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超声引导下星状神经节阻滞治疗头颈部带状疱疹爆发痛1例

2019-05-22 周红梅 张建楠 裴燕芳 中国医药导报

患者,女,64岁,因“左侧耳垂、枕部疼痛4d伴左颈部红斑、疱疹1d”于2017年6月16日入院。既往有高血压病史,平时口服“氢氯噻嗪片”“螺内酯”“乐卡地平”,血压控制尚可。患者入院前3d因耳垂、枕部阵发性刀绞般疼痛来我科门诊就诊,当时行颈椎间盘CT示无明显异常,予加巴喷丁胶囊0.3g口服,3次/d,洛芬待因片200mg口服,3次/d,对症治疗,嘱门诊随诊。

急性带状疱疹(acute herps zoster)是由水痘—带状疱疹病毒(varicella zoster virus,VZV)感染引起的一种疾病,其特征为沿感染神经分布的节段性、成束状簇集性水泡,并伴有剧烈疼痛。临床上针对该疾病的主要治疗方法为:①综合药物治疗,包括抗病毒药物、能量合剂、止痛药物等;②神经阻滞;③物理疗法及中医中药疗法。对于头颈部带状疱疹,星状神经节阻滞(stellate ganglion block,SGB)亦具有良好疗效。本文研究对象为1例左侧头颈部带状疱疹爆发痛患者,疼痛剧烈,予超声引导下左侧SGB后取得了满意的效果。现报道如下:
 
1.病历资料
 
患者,女,64岁,因“左侧耳垂、枕部疼痛4d伴左颈部红斑、疱疹1d”于2017年6月16日入院。既往有高血压病史,平时口服“氢氯噻嗪片”“螺内酯”“乐卡地平”,血压控制尚可。患者入院前3d因耳垂、枕部阵发性刀绞般疼痛来我科门诊就诊,当时行颈椎间盘CT示无明显异常,予加巴喷丁胶囊0.3g口服,3次/d,洛芬待因片200mg口服,3次/d,对症治疗,嘱门诊随诊。
 
患者疼痛第4天左侧颈肩部出现红斑、疱疹,门诊复诊,因疼痛剧烈,视觉模拟评分(VAS)10分,严重影响饮食睡眠,服药效果不显著,要求住院治疗。入院后查:左侧颈肩部散在成片、成簇的粟粒样大小丘疹,周围伴红肿,皮肤触痛(+/-),不过正中线,耳部、枕部头皮无疱疹。双侧肢体肌张力未见增高,Babinski征(-),脑膜刺激征(-)。爆发痛时VAS评分10分,间歇期VAS评分4分,间隔时间8~15min。综合此患者临床表现,考虑为带状疱疹爆发痛,疱疹在颈部成披肩样分布,为颈丛受累。见图1、2。

 图1 左侧颈胸部大量疱疹


 图2 背部疱疹
 
疼痛受累的神经是耳大神经和枕小神经,发自C2/3,属于颈浅丛分支。予盐酸伐昔洛韦片0.3g口服,2次/d,喷昔洛韦乳膏适量外用,甲钴胺注射液0.5mg肌肉注射,1次/d,恩再适(Analgecine,牛痘疫苗致炎兔皮提取物注射液)3.6U静脉滴注,2次/d,及继续服用加巴喷丁胶囊、洛芬待因片,行抗病毒、营养神经、止痛综合治疗。
 
在入院后4h,完成血常规、凝血常规、心电图、胸片等检查后,于胸锁乳突肌后缘平环状软骨上极水平行超声引导下左侧颈浅丛神经阻滞,用药:0.1%布比卡因+复方倍他米松1mg,共6mL,阻滞完毕后,患者左侧耳垂及枕部疼痛无显著缓解,左颈肩部较右侧略有麻木感,阻滞治疗后4h随访,患者左侧耳垂、枕部疼痛有反复,爆发痛时VAS评分8分,间歇期VAS评分4分,间隔时间约15min。阻滞治疗后10h,患者疼痛加重,难以入睡,予酮络酸氨丁三醇肌肉注射对症处理。入院第2天,与患者及家属沟通后,予超声引导下C6颈椎水平左侧星状神经节阻滞,药物:1%利多卡因5mL。
 
操作经过:患者平卧位,左侧肩下垫薄枕,超声探头先置于锁骨上方并向上平移依次寻找斜坡状的C7横突及“双驼峰图像”的C6横突,C6横突位于环状软骨切迹的水平,其特点为于颈椎横突前后结节超声显像成“双驼峰图像”,而神经根位于两个驼峰中间。在此超声影像下,可清晰分辨C6椎体和横突包括突出的前结节、较短的后结节和第6颈神经根。在此超声影像下,可清晰分辨胸锁乳突肌、前中斜角肌、颈长肌、颈动脉、颈内静脉、第6颈椎横突前结节、后结节、第6颈神经根。见图3。颈中神经节或者颈交感神经组织位于颈长肌表面,颈动脉旁。采用线性探头,10MHz,探头方向与颈部矢状位呈30°角左右,可以在超声下实时监控进针路径,达颈长肌表面,回抽无血,推注1%利多卡因5mL,观察药物扩散范围。见图4。患者出现Horner综合征,则是阻滞成功的标志。
 
图3 超声下星状神经节附近解剖影像。A:颈动脉;V:颈内静脉;LCo:颈长肌;N6:颈六神经根;ASM:前斜角肌
 
图4 星状神经节所在位置及穿刺路径。小五角星为星状神经节所在位置;箭头所指为穿刺针位置
 
星状神经节阻滞后,患者即感到头枕部及耳垂附近疼痛缓解,4h后随访,患者Horner综合征持续约3.5h,爆发痛时VAS评分降至7分,间歇期3分,间隔时间20~30min。10h后随访,爆发痛时VAS评分降至4分,间歇期2分,间隔时间30min左右。入院后第3天因患者颈部疱疹严重,穿刺部位有影响,暂停星状神经节阻滞治疗。继续前述抗病毒、营养神经、止痛综合治疗,患者虽疼痛仍有反复,但夜间睡眠无明显影响。
 
2.讨论
 
带状疱疹是沿单侧周围神经分布的簇集性水泡,疼痛剧烈为特征的皮肤病。急性期一般予以抗病毒、营养神经、止痛治疗,对于体质虚弱、疱疹皮损范围大的患者往往不能完全缓解疼痛。本例患者疼痛非常剧烈,VAS评分10分,为阵发性刀绞般疼痛,主要位于左侧耳垂、枕部,剧烈疼痛,而大面积的皮肤疱疹主要位于颈下部和肩部,疼痛受累神经和疱疹受累的神经看似并不完全一致,其实均属于颈丛的分支,亦有文献报道过类似病例。
 
带状疱诊急性期的重度疼痛是后遗神经痛的高危因素之一,带状疱疹急性期是治愈的最佳时期,故神经阻滞治疗尽可能在疱疹后立即进行(最好3d内)。有研究表明,在抗病毒、营养神经、镇痛的基础上尽早予神经阻滞治疗可以积极止痛,同时还能有效地预防或降低后遗神经痛发生率以及后遗神经痛严重程度。
 
本例采用超声引导下左侧颈浅丛神经阻滞疗效甚微,即耳大神经、枕小神经未被完全浸润,可能是由于所阻滞神经在神经解剖上邻近末梢分支分布较分散,麻醉效果随患者解剖结构的变异相差较大。而次日的1次SGB却取得了意想不到的效果。SGB用于头颈部带状疱疹的应用报道广泛,虽然无指南推荐,但通过长时间的临床观察,SGB治疗带状疱疹后遗神经痛有效而医疗成本相对较低。
 
SGB缓解疼痛机制可能与改善头颈部的血液供应、抑制交感神经的过度兴奋、减少一氧化氮和前列腺素等缩血管物质的合成与释放有关。SGB可减少患者恐惧、不安、焦虑等症状,同时,减少对交感神经的刺激,提高免疫功能,增强抗炎作用。SGB联合药物治疗头颈部带状疱疹后神经痛效果确切,能显著缓解患者的疼痛强度,改善生活质量,且不良反应较少。
 
本例SGB采用C6横突水平进针,Gofeld等于尸体标本C6水平的椎前筋膜下和颈长肌表面之间注射亚甲蓝,证实颈交感干位于椎前筋膜之下、颈长肌表面。超声引导下穿刺又增加了成功率和安全性,从而进一步提高了治疗效果和患者的依从性,值得临床推广使用。本例在超声引导下行SGB,可以实时监控进针路线和针尖位置,已达到精准治疗的目的,故患者予1%利多卡因5mLHorner综合征持续约3.5h。
 
Sinofsky等指出,通过阻滞星状神经节,可阻断疼痛的恶性循环,切断疼痛传导,可使血管扩张,改善血运,从而纠正神经营养状况,有效缓解带状疱疹后遗神经痛。此外,多项研究证实,根据所用局麻药浓度不同,一般Horner综合征持续2~4h可完全恢复,而交感神经阻滞作用可持续6~8h。
 
亦有一项随机对照研究发现,严重创伤患者行SGB后,24~72h内治疗组的血清白细胞介素1β,白细胞介素6和肿瘤坏死因子-α浓度显著低于对照组,这提示SGB通过抑制促炎细胞因子白细胞介素1β,白细胞介素6和肿瘤坏死因子-α的表达来调节早期全身炎性反应。故本例患者10h随访的VAS评分显著低于4h,以上亦为本例1次SGB在缓解头颈部带状疱疹爆发痛方面提供了理论支持。
 
综上所述,本研究提示超声引导下星状神经节阻滞对于头颈部带状疱疹爆发痛的治疗是有效的,可以为疼痛科医生在日常的诊治过程中提供借鉴。
 
原始出处:

周红梅,张建楠,裴燕芳,蔡靓羽.超声引导下星状神经节阻滞治疗头颈部带状疱疹爆发痛1例[J].中国医药导报,2018,15(18):147-149.

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    2019-05-24 wshxjq
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