Postoperative neuropathic kurwadziwa idambudziko rinowanzoitika, kunyangwe murwere ari mumamiriro akanakisa.Kufanana nedzimwe mhando dzemarwadzo ekukuvara kwetsinga, kurwadziwa kweuropathic mushure mekuvhiyiwa kwakaoma kurapa uye kazhinji kunovimba neadjuvant analgesics, senge antidepressants uye anticonvulsants, uye nerve blockers.Ndakagadzira mushonga uchishandisa inotengeswa inowanika cross-linked hyaluronic acid (Restylane neJuvéderm), iyo inopa zororo rinogara kwenguva refu, rakakosha pasina mhedzisiro.
Muchinjikwa-yakabatanidzwa hyaluronic acid yakashandiswa kwekutanga kurapa marwadzo europathic paMusangano Wegore ra2015 weAmerican Academy of Pain Medicine muNational Harbor, Maryland.1 Mumwedzi we34 retrospective chart review, 15 neuropathic pain varwere (7 vakadzi, 8 varume) uye 22 pain syndromes yakadzidzwa.Avhareji yezera revarwere yaive makore 51 uye avhareji yenguva yekurwadziwa yaive mwedzi ye66.Avhareji yekuona analog scale (VAS) marwadzo ekurwadziwa kusati kwaitwa 7.5 points (kunze kwe10).Mushure mekurapa, VAS yakaderera kusvika ku10 points (kunze kwe1.5), uye nguva yenguva yekuregererwa yaiva mwedzi 7.7.
Kubva pandakasuma basa rangu rekutanga, ndakabata varwere makumi manomwe nevashanu vane marwadzo akafanana (kureva, post-herpetic neuralgia, carpal tunnel uye tarsal tunnel syndrome, Bell's paralytic tinnitus, musoro, nezvimwewo).Pamusana pezvinogoneka nzira yekuita basa, ndakasarudza kurapwa uku se-cross-linked neural matrix analgesia (XL-NMA).2 Ini ndinopa nyaya yenyaya yemurwere ane mutsipa unoramba uchirwadza uye kurwadziwa kwemaoko mushure mekuvhiyiwa kwekervical spine.
Hyaluronic acid (HA) is proteoglycan, linear anionic polysaccharide 3 inoumbwa nekudzokorora zvikamu zve glucuronic acid uye N-acetylglucosamine.Izvo zvinowanzoitika mu extracellular matrix (ECM) (56%) yeganda, 4 connective tissue, epithelial tissue uye nerve tissue.4,5 Muzvinyama zvine hutano, huremu hwayo hwema molecular i5 kusvika ku10 mamiriyoni daltons (Da)4.
Muchinjikwa-yakabatana HA ndeyekutengesa cosmetic inobvumidzwa neFDA.Inotengeswa pasi pemhando dzeJuvéderm6 (yakagadzirwa neAllergan, HA yemukati 22-26 mg/mL, molecular uremu 2.5 miriyoni daltons)6 uye Restylane7 (yakagadzirwa naGalderma), uye iyo HA yemukati ndeye 20 mg/Milliliters, iyo molecular uremu 1 mamiriyoni eDaltons.8 Kunyangwe iyo yakasikwa isina-crosslinked fomu yeHA imvura uye yakagadziriswa mukati mezuva, ma molecular crosslinks eHA anosanganisa ega ega polymer cheni uye kugadzira viscoelastic hydrogel, saka hupenyu hwayo hwesevhisi (6 kusvika 12 Mwedzi) uye hunyoro hwekunyudza. inogona kusveta zvakapetwa ka1,000 kurema kwayo kwemvura.5
Mumwe murume ane makore 60 akauya kuhofisi yedu muna April 2016. Mushure mokugamuchira C3-C4 uye C4-C5 posterior cervical decompression, posterior fusion, local autotransplantation uye posterior segmental internal fixation, mutsipa wakaenderera mberi Uye kurwadziwa kwemaoko maviri.Masikiru emhando paC3, C4, uye C5.Kukuvara kwemutsipa wake kwakaitika muna Kubvumbi 2015, paakadonha negotsi kubasa paakarova mutsipa wake nemusoro uye akanzwa mutsipa wake uchirova.
Mushure mekuvhiyiwa, kurwadziwa kwake uye chiveve zvakawedzera zvakanyanya, uye pakanga paine marwadzo ekupisa anoramba achipisa kumashure kwemaoko ake nemutsipa (Mufananidzo 1).Panguva yekutenderedzwa kwemutsipa wake, kuvhunduka kwemagetsi kwakakura kubva pamutsipa wake nemuzongoza kusvika kumakumbo ake epamusoro uye ezasi.Kana wakarara nerutivi rworudyi, chiveve chemaoko chinonyanya kuoma.
Mushure mekuita computed tomography (CT) myelography uye radiography (CR) miedzo, cervical segmental maronda akawanikwa paC5-C6 uye C6-C7, iyo ichatsigira marwadzo anoramba ari mumaoko uye dzimwe nguva mechanical nature yemutsipa flexion Pain (kureva, yechipiri neuropathic uye spinal pain states uye acute C6-C7 radiculopathy).
Maronda chaiwo anobata bilateral nerve midzi uye ane hukama nepinal cord zvikamu kumberi, kusanganisira:
Chiremba wemuzongoza akabvuma kubvunza, asi akanzwa kuti pakanga pasina chekupa kune kumwe kuvhiyiwa.
Mukupera kwaApril 2016, ruoko rworudyi rwemurwere rwakagamuchira Restylane (0.15 mL) kurapwa.Jekiseni rinoitwa nekuisa chiteshi chine 20 gauge tsono, uye wozoisa 27 gauge microcannula (DermaSculpt) ine blunt tip.Kuenzanisa, ruoko rworuboshwe rwakabatwa nemusanganiswa we2% pure lidocaine (2 mL) uye 0.25% pure bupivacaine (4 mL).Chiyero pasaiti ndeye 1.0 kusvika 1.5 mL.(Kuti uwane mirairo-nhanho pamaitiro aya, ona bhara reparutivi.) 9
Nekumwe kugadziridzwa, nzira yejekiseni yakafanana neyakajairika nerve block pawrist level ye median nerve (MN), ulnar nerve (UN), uye superficial radial nerve (SRN) padanho reanatomical.Snuff bhokisi-nzvimbo ine katatu yeruoko yakaumbwa pakati pechigunwe chechigunwe chepakati.Maawa makumi maviri nemana mushure mekuvhiyiwa, murwere akawana chiveve chisingaperi mumaoko emunwe wechina nechishanu cheruoko rwerudyi asi pasina kurwadziwa.Kuwanda kwechiveve muminwe yekutanga, yechipiri neyechitatu yakanyangarika, asi pakanga pachine marwadzo muminwe.Pain mamakisi, 4 kusvika ku5).Kunzwa kupisa kuseri kweruoko kwapera zvachose.Pakazara, akanzwa kuvandudzwa kwe75%.
Pamwedzi ye4, murwere akaona kuti marwadzo ari muruoko rwake rworudyi akanga achiri kuvandudzwa ne75% kusvika ku85%, uye rutivi rwekunzwa kweminwe 1 uye 2 yakanga inoshivirira.Iko hakuna maitiro akaipa kana mhedzisiro.Cherechedza: Chero zororo kubva kune anesthesia yemunharaunda muruoko rworuboshwe yakagadziriswa 1 vhiki mushure mekushanda, uye kurwadziwa kwake kwakadzokera kunheyo yekutanga yeruoko irworwo.Sezvineiwo, murwere akacherechedza kuti kunyange zvazvo kurwadziwa kunopisa uye chiveve pamusoro peruoko rworuboshwe pashure pejekiseni rekutindivadza kwomunharaunda kwapera, kwakatsiviwa nechiveve chisingafadzi zvikuru uye chinogumbura.
Sezvambotaurwa, murwere akataura kuti mushure mekugamuchira XL-NMA, kurwadziwa kweuropathic muruoko rworudyi kwakavandudzwa zvakanyanya.Murwere akashanyira zvakare pakupera kwaAugust 2016, paakashuma kuti kuvandudzwa kwakatanga kuderera pakupera kwaJuly 2016. Akaronga kupindira kweXL-NMA yerudyi, pamwe chete neXL-NMA kurapwa kweruoko rworuboshwe uye cervical. -brachial area-bilateral, proximal shoulder, C4 area uye C5-C6 level.
Murwere akashanyira zvakare pakati paOctober 2016. Akarondedzera kuti mushure mekupindira muna August 2016, kurwadziwa kwake kunopisa munzvimbo dzose dzinorwadza kwakatsigirwa uye kusunungurwa zvachose.Kunyunyuta kwake kukuru kunorwadza / kurwadza kwakanyanya pamusoro pechanza uye kumashure kweruoko (kunzwa kwakasiyana-siyana-kumwe kwakapinza uye kumwe kwakagomara, zvichienderana netsinga dzetsinga dzinobatanidzwa) uye kusimba kwakatenderedza wrist.Kushushikana uku kwakakonzerwa nekukuvadzwa kumidzi yetsinga yemutsipa wake wekervical, iyo yaisanganisira mafibers anoumba ese 3 main nerves (SRN, MN, uye UN) muruoko.
Murwere akacherechedza 50% kuwedzera kwekervical spine rotational range of motion (ROM), uye kuderedzwa kwe50% mumutsipa wekervical uye kurwadziwa kwemaoko muC5-C6 uye C4 proximal shoulder area.Akakurudzira XL-NMA kuwedzera kweBilateral MN uye SRN-iyo UN uye mutsipa-brachial nzvimbo yakaramba yakagadziridzwa pasina kurapwa.
Tafura 1 inopfupisa iyo yakarongwa multifactorial nzira yekuita.Vanorongerwa maererano nekuswedera kwavo kune nguva-yakasiyana-siyana ye-anti-nociception-kubva pane yakanyatsogadzirisa mumaminitsi ekutanga e10 mushure mejojo kusvika kune runyararo runogara uye rurefu rwakaonekwa mune dzimwe nguva gore kana kupfuura.
CL-HA inoshanda sechidziviriro chekudzivirira chemuviri, kuumba kamuri, kuderedza kushandiswa kwezviitiko zvinongoerekana zvaitika muC fiber uye Remak bundle afferents, uyewo chero ipi zvayo isina kujairika nociceptive ephapse.10 Nekuda kwechimiro chepolyanionic cheCL-HA, mamorekuru ayo makuru (500 MDA kusvika 100 GDa) anogona kukanganisa zvachose kugona kwekuita nekuda kwehukuru hwechaji yayo yakaipa uye kudzivirira chero kutapurirana kwechiratidzo.LMW/HMW kusawirirana kururamiswa kunotungamira kuTNFα-inosimudzira gene 6 protein regulation nzvimbo kuzvimba.Izvi zvinogadzirisa uye zvinodzorera immune neural crosstalk disorder pamwero we extracellular neural matrix, uye inodzivirira zvakanyanya zvinhu zvinotendwa zvinokonzera kurwadziwa kusingaperi.11-14
Chaizvoizvo, mushure mekukuvadzwa kwe extracellular neural matrix (ECNM) kana kukuvara, pachava nechikamu chekutanga chechirwere chekiriniki chakajeka, pamwe chete nekuzvimba kwenyama uye kushandiswa kweAδ uye C fiber nociceptors.Nekudaro, kana chirwere ichi chave chisingaperi, kuzvimba kwetishu uye immune nerve crosstalk inoenderera asi subclinical.Kugara kwenguva refu kuchaitika kuburikidza nekupinda zvakare uye yakanaka mhinduro loop, nekudaro kuchengetedza nekuchengetedza pro-kuzvimba, pre-pain state, nekudzivirira kupinda muchikamu chekuporesa nekudzorera (Table 2).Nekuda kwekusawirirana kweLMW/HMW-HA, inogona kuzviriritira, ingave mhedzisiro yeCD44/CD168 (RHAMM) gene aberrations.
Panguva ino, jekiseni reCL-HA rinogona kugadzirisa kusawirirana kweLMW/HMW-HA uye kukonzera kukanganiswa kweropa, zvichibvumira interleukin (IL) -1β uye TNFα kuita kuti TSG-6 igadzirise kuzvimba, nekugadzirisa uye pasi-kugadzirisa LMW- HA uye CD44.Izvi zvinobva zvabvumira kufambira mberi kwakajairika kuECNM anti-inflammatory and analgesic phase, nekuti CD44 neRHAMM (CD168) vave kukwanisa kudyidzana neHMW-HA nemazvo.Kuti unzwisise nzira iyi, ona Tafura 2, iyo inoratidzira cytokine cascade uye neuroimmunology yakabatana nekukuvara kweECNM.
Muchidimbu, CL-HA inogona kutorwa seyakanyanya-hofori yeDalton fomu yeHA.Naizvozvo, yakaramba ichivandudza nekuchengetedza muviri HMW-HA kupora uye kuporesa molecular biology standard mabasa, anosanganisira:
Pakukurukura nyaya iyi nevamwe vandaishanda navo, ndaiwanzobvunzwa kuti, "Asi mhedzisiro inoshanduka sei mukurapwa kweparutivi kure neronda remutsipa?"Muchiitiko ichi, maronda anozivikanwa ega ega CR uye CT myelography Kuzivikanwa pamwero wepelinha zvikamu C5-C6 uye C6-C7 (C6 uye C7 nerve midzi, maererano).Aya maronda anokuvadza midzi yetsinga uye chikamu chepamberi chemuzongoza, saka inhengo yepedyo yenzvimbo inozivikanwa yeradial nerve root uye spinal cord (kureva, C5, C6, C7, C8, T1).Uye, zvechokwadi, ivo vachatsigira marwadzo anoramba achipisa pamusana pemaoko.Nekudaro, kuti uwedzere kunzwisisa izvi, iyo pfungwa yeinouya inofanirwa kutariswa.16
Afferent neuralgia inongova, "... Pasinei nekuderedzwa kana kusanzwa kune kunze kune zvinokuvadza zvinokurudzira (hypoalgesia kana analgesia) kune chikamu chemuviri, kurwadziwa kwakanyanya kunongoerekana kwaitika muchikamu chemuviri chiri kure chekukuvara."16 Inogona Kukonzerwa nekukuvadzwa kupi zvako kwetsinga dzetsinga, pakati nepakati, kusanganisira uropi, musana, uye tsinga dzeparutivi.Iyo afferent nerve inofungidzirwa kuve nekuda kwekurasikirwa neruzivo kubva kunharaunda kuenda kuuropi.Kunyanya kunyanya, pane kukanganisa mune afferent sensory information inosvika kune cortex kuburikidza ne spinothalamic tract.Domain yebundle iyi inosanganisira kutapurirana kwemarwadzo kana nociceptive input yakanangidzirwa kune thalamus.Kunyange zvazvo nzira chaiyo ichiri kusanyatsonzwisiswa, muenzaniso wacho wakanyatsokodzera mamiriro ezvinhu aripo (kureva kuti, idzi midzi yetsinga uye zvikamu zvepinal cord hazvina kuwirirana zvachose kune radial nerve).
Nokudaro, kuishandisa kumarwadzo anopisa pamusana peruoko rwemurwere, maererano nemaitiro 3 muTebhu 1, kukuvadzwa kunofanira kuitika kuti kutange pro-inflammatory, pre-noxious state ye cytokine cascade (Table 2).Izvi zvinouya kubva mukukuvadzwa kwemuviri kune yakakanganisika nerve midzi uye spinal cord zvikamu.Zvisinei, sezvo ECNM inoramba ichienderera uye inopararira neuroimmune entity iyo inopoteredza zvose neural structures (kureva, iyo yakazara), iyo yakakanganiswa sensory neurons yeC6 yakakanganiswa uye C7 nerve midzi uye spinal cord segment zvinopfuurira uye Limb kusangana uye neuroimmune kusangana pa. kumashure kwemaoko maviri.
Naizvozvo, kukuvadzwa kuri kure ndiko mhedzisiro yekushamisa kweiyo proximal ECNM iri kure.15 Izvi zvichaita kuti CD44, CD168 (RHAMM) ione HATΔ, uye isunungure IL-1β, IL-6 uye TNFα inflammatory cytokines, iyo inoshandisa uye inochengetedza kushandiswa kwe distal C fibers uye Aδ nociceptors kana zvakakodzera (tafura 2, #3) .Nekukuvara kweECNM yakatenderedza distal SRN, XL-NMA ikozvino inogona kushandiswa zvakabudirira in situ kupindira kuti iwane CL-HA LMW/HMW-HA mismatch kururamiswa uye ICAM-1 (CD54) kuzvimba mutemo (Tafura 2, # 3- #5 kutenderera).
Zvakadaro, zvinofadza zvechokwadi kuwana zororo risingaperi kubva kuzviratidzo zvakakomba uye zvakasindimara kuburikidza nemishonga yakachengetedzeka uye ine zvishoma.Iyo tekinoroji inowanzo kuve nyore kuita, uye iyo yakanyanya kunetsa inogona kunge iri kuzivisa tsinga dzekunzwa, neural network, uye substrate yekubaiwa yakatenderedza chinangwa.Nekudaro, nekumisikidza tekinoroji kunoenderana neyakajairwa kiriniki zviratidzo, izvi hazvina kuoma.
Nguva yekutumira: Aug-12-2021