Ludzkie koronawirusy - autor: Krzysztof Pyrć z Zakładu Mikrobiologii, Wydział Biochemii, Biofizyki i Biotechnologii, Uniwersytet Jagielloński, Kraków

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© Borgis - Postępy Nauk Medycznych 5/2014, s. 317-322
*Małgorzata Malec-Milewska1, Iwona Kolęda1, Agnieszka Sękowska1, 2, Hanna Kucia1, 2, Dariusz Kosson1, 3, 4
Zastosowanie termolezji w leczeniu bólu przewlekłego opornego na farmakoterapię
Radiofrequency ablation for the management of pharmacotherapy – resistant chronic pain
1Department of Anaesthesiology and Intensive Care, Medical Centre of Postgraduate Education, Warszawa
Head of Department, a.i.: Małgorzata Malec-Milewska, MD, PhD
22-nd Department of Obstetric and Gynecology, Medical Centre of Postgraduate Education, Warszawa
Head of Department: Romuald Dębski, MD, PhD
3Department of Anaesthesiology and Intensive Care, Medical University of Warsaw
Head of Department: Dariusz Kosson, MD, PhD
4Emergency Medicine College of Rehabilitation, Warszawa
Head of Department: Andrzej Kański, MD, PhD
Streszczenie
Wstęp. Międzynarodowe Stowarzyszenie Badania Bólu IASP (The International Association for the Study of Pain) zaleca wielodyscyplinarne leczenie chorych z bólem przewlekłym, z uwzględnieniem zastosowania inwazyjnych metod leczenia w przypadku bólu opornego na farmakoterapię. Jedną z inwazyjnych metod leczenia, stosowanych w Poradni Leczenia Bólu Kliniki Anestezjologii i Intensywnej Terapii CMKP, jest termolezja, czyli zniszczenie struktur układu nerwowego przy pomocy wysokiej temperatury.
Cel pracy. Celem badania była ocena skuteczności i bezpieczeństwa prezentowanej terapii.
Materiał i metody. Autorzy dokonali wstępnej oceny wyników leczenia chorych, u których zastosowano technikę termolezji. Badanie prowadzono w latach 2009-2011 w trzech grupach pacjentów. Pierwszą grupę stanowili chorzy z zespołem bolesnego barku, u których wykonano termolezję nerwu nadłopatkowego (20 chorych), drugą chorzy z neuralgią trójdzielną, u których wykonano termolezję zwoju Gassera (19 chorych), a trzecią chorzy z neuralgią potyliczną, u których wykonano termolezję nerwów potylicznych (33 chorych). W ocenie zwrócono szczególną uwagę na skuteczność i bezpieczeństwo omawianej metody.
Wyniki. Termolezja okazała się skuteczną metodą leczenia bólu przewlekłego w omawianych grupach pacjentów. Pozytywny efekt zabiegu obserwowano u 18/20 (90%) chorych z grupy I, 18/19 (94,73%) chorych z grupy II i 31/33 (93,93%) chorych z grupy III.
Wnioski. Dzięki swoim właściwościom, a przede wszystkim przewidywalności rozmiaru uszkodzenia, termolezja ma przewagę nad innymi technikami neurodestrukcji fizycznej i chemicznej. Poprawnie zastosowana technika i ścisłe przestrzeganie zasad ustalania wskazań i przeciwwskazań powodują, że częstość występowania powikłań jest niewielka. Dalsze badania i obserwacja stale rosnącej grupy chorych wymagających leczenia bólu przy pomocy termolezji będą tematem kolejnych opracowań.
Summary
Introduction. The International Association for the Study of Pain recommends interdisciplinary approach to the treatment of patients with chronic pain, including interventional methods in cases of pain resistant to pharmacotherapy. One of those methods, applied in our Pain Clinic, is thermolesion which utilizes high temperature to destroy structures of the nervous system.
Aim. The aim of the study was to assess the effectiveness and safety of the presented therapy.
Material and methods. The authors performed a preliminary evaluation of the results of the treatment among patients scheduled for thermolesion. Between 2009-2011 three groups of patients were examined. Suprascapular nerve thermolesion was performed in 20 patients with the painful shoulder syndrome (group I). The Gasser ganglion thermolesion was applied in 19 patients with the trigeminal nerve neuralgia (group II). Occipital nerve thermolesion was carried out in 33 patients with occipital neuralgia (group III).
Results. The thermolesion ensured good pain relief in the examined groups of patients. A positive effect of the therapy was observed among 18/20 (90%) patients in group I, 18/19 (94.73%) patients in group II, among 31/33 (93.93%) patients in group III.
Conclusions. Due to its characteristic features, and above all the predictability of the extension of destruction, thermolesion shows clinically relevant advantages and seems to be superior to other physical or chemical methods of neurodestruction. Accuracy in assigning patients to the procedure and precision in the performing of thermolesion results in low incidence of serious complications. Further investigations of the ever-increasing group of patients requiring interventional methods of therapy are planned to be conducted in the future.
Introduction
Chronic pain has a complex mechanism of formation and is often resistant to pharmacotherapy. The International Association for the Study of Pain recommends multidisciplinary approach including interventional techniques: local blockades and neurodestructive procedures. Neurodestructive procedures can be carried out using chemical (neurolysis), physical (temperature) or mechanical (surgical cutting) agents. Thermolesion is one of the invasive techniques which utilizes high temperature as a neurodestructive agent. It is a method based on controlled use of temperature above 45°C which is produced by radio waves spreading in tissues generated by RHF device. The procedure is enabled by a suitable device which preciously measures temperature and impedance and produces two kind of stimulation: sensory at a frequency of 50-100 Hz and motor at a frequency of 2-5 Hz. Th device is also equipped with a high frequency waves generator which produces accordingly programmed temperature in a strictly fixed time on the electrode tip. Measuring the impedance and two kinds of stimulation facilitate precise placing of the active electrode tip. The rest of the electrode is insulated by a synthetic material. Uninsulatd tip of the needle serves as an active electrode. Conducting thermolesion at temperatures 45-65°C enables selective lesion in mixed nerves, thin sensory fibres A delta and C without impairment of the functions of thicke motor nerves, resistant to this range of temperature. The indications for thermolesion are established when other noninvasive procedures failed especially when the effect of the diagnostic – prognostic blockade is possitive. Patients abusing drugs or alcochol and those whoe pain perception can be influenced by psychological and social agents are not elligible for the procedure. Thermolesion is carried out in such syndromes of chronic pain as: trigeminal neuralgia, cluster headaches, facet joint syndrome, occipital neuralgia, cancer pain, intercostal neuralgia, vascular pain, sympathetically maintained pain, stump limb pain (1, 2). The following analysis concerns the effect of thermolesion treatment of the pain in: painful shoulder syndrome, trigeminal and occipital neuralgia in the years 2009-2011.
Aim
The aim of the study was to assess the effectiveness and safety of the presented therapy.
Group I: Supraclavicular nerve thermolesion
Introduction
Painful shoulder syndrome is a set of clinical symptoms related to the shoulder girdle characterized by pain, motor deficiency and impairment of the functions of the upper limb. It is often treatment resistant and inadequate therapy can lead to permanent motor impairment of the upper limb. The treatment of the painful shoulder syndrome ancompasses: noninvasive methods pharmacotherapy and physiotherapy and interventional procedures (supraclavicular nerve blockades, thermolesion, and surgery).
Material and methods
The study was conducted among the patients of Pain Clinic of Department of Anaesthesiology and Intensive Therapy of the Medical Center of Postgraduate (Education/Studies) in Warsaw in 2009-2011 diagnosed with a painful shoulder syndrome with intensity of pain > 6 in numerical rating scale NRS (11 points scale in which 0 – means no pain, and 10 – worst pain imaginable). After series of blockade of the supraclavicular nerve with positive but transient effect, thermolesion of supraclavicular nerve was performed. 20 patients (13 women, 7 man) aged 56-82 years were enrolled into the study. The chronic pain had lasted from one to 8 years. The written informed consent was obtained from the all patients. The thermolesion was applied ambulatorily with the use of Neuro-Therm RDG R/JK2C device and the electrode Top Nekropole Needle (EQUIPP MEDIKEY B.V.) the lenght of 6 cm (lentght of the uninsulated tip 5 mm). Th correct positioning of the active electrode tip was verified by means of sensory (50 Hz) and motor (2-5 Hz) stimulation. The place of lesion was anaesthetized by injection of 1 ml 2% lignocaine (ASTRA ZENECA). The time of lesion was 60s, voltage 21 mV, intensity 50 mA. The current characterized by such parameters generates a temperature of 65°C at the tip of active electrode. After application, 1 ml (20 mg) of pentoxyphylline was given. The efficacy of the procedure was evaluated on the basis of NRS in chosen time points (before the procedure, 14, 30, 60 days after the procedure). The duration of pain reduction and the occurence of side effects was also estimated.
Results
The intensity of pain before the thermolesion was 7-10 point in NRS score. The pain relief was observed in 18 out of 20 patients (90%). In 13 patients (65%) the intensity of pain decreased to 2-4 points in NRS in all time points after the procedure. In 5 patients (25%) complete pain relief was achieved. In 2 patients (10%) no improvement was observed after the thermolesion. The average time of pain reduction was 5 moths. The complications observed in our patients, such as hyperaesthesia and increased muscle tension retreated spontaneously in 2 weeks. The thermolesion was carried out again in 7 patients (35%) with recurrance of complaints.
Discussion
The thermolesion of the supraclavicular nerve has been carried out in our Pain Clinic since 2008. Previously we had treated the painful shoulder syndrome with blockades of supraclavicular nerve with the use of local anaesthetic agent and with steroid addition in chosen patients. The efficacy of thermolsion was high in our material. In 18 out of 20 patients (90%) treated with the discussed method significant improvement was achieved. In similar studies decrease of pain about 95% and improvement of motor function of the limb is reported. Technical precision in performing thermolesion and accuracy in assigning patients to the procedure results in low incidence of serious complications. Hyperaesthesia and increased muscle tension observed in our patients subsided spontaneously in 2 weeks. We didn’t observed decrease of muscle strength. No serious side effects have been observed in similar studies either. Only transient sensitive disorders appeared (3, 4). The preferable method in this technique of thermolesion is now pulsative thermolesion. It is our plan in the nearest future to also use this method of treatment after the purchase of suitable device.
Conclusions
The positive effect of the procedure in 18 out of 20 patients confirms the efficacy of the supraclavicular nerve thermolesion in the complex treatment of the painful shoulder syndrome. Low incidence of complications and their spontaneous retreat proves that the procedure is safe. Due to the long time of clinical improvement (5 months average) thermolesion is a useful alternative to the supraclavicular nerve blockades with the use of local anaesthetic agent in the complex treatment of painful shoulder syndrome.
Group II: The Gasserian ganglion thermolesion
Introduction
The facial pain is a diffiult diagnostic and therapeutic problem because of it’s complicated patomechanism and many different causes. Rare occurance, lack of objective diagnostic tests and a wide range of causes and symptoms render an accurate recognition and an adequate therapy difficult. According to epidemiology studies, trigeminal neuralgia (NNT) is one of frequent causes of the unilateral facial pain. The incidence of trigeminal neuralgia is reported to to be approximately 3-5 per 100 000 persons per year. Nowadays the widely preferable and accepted theory regarding ethiopatology of NNT is the theory of peripheral and central mechanism of NNT proposed by Rappaport and Devor 1994. They presumed that the lesion caused by the pressure on the root of trigeminal nerve leads to hiperactivity of a small group of neurons in the trigeminal nerve ganglion which consequently creates a kind of trigger. The choice of the therapy depends on its efficacy and influence on other later methods of treatment. Therapy has to be individual. Some patients are resistant to any kind of therapy or they experience side effects which preclude the continuation of the treatment. Clinical procedures are also very often determined by the clinical status and age of the patients. Unfortunately in all the methods, even the most radical ones, there is a percent of failure. The therapy is multistage from the least to the most invasive methods. Pharmacotherapy is the first step which is effective in 80% of the patients. The patients refractory to the medical therapy are subjected to invasive treatment options (5). The invasive methods are: surgical procedures among which we destinguish destructive methods (with a high percentage of complications), microsurgical decompression of the nerve root pressed by the vessel, and neurodestructive procedure (5, 6). The most of neurodestructive techniques concern the Gassserian ganglion. Among which the thermolesion of the Gassserian ganglion is the most often performered procedure (7, 8).
Material and methods

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otrzymano: 2014-02-19
zaakceptowano do druku: 2014-03-26

Adres do korespondencji:
*Małgorzata Malec-Milewska
Department of Anaesthesiology and Intensive Care Medical Centre of Postgraduate Education
ul. Czerniakowska 231, 00-416 Warszawa
tel. +48 502-622-052
lmilewski@post.pl

Postępy Nauk Medycznych 5/2014
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