Intlungu ye-neuropathic ye-postoperative yingxaki eqhelekileyo, nokuba isigulane sikwimeko engcono kakhulu.Njengezinye iintlobo zentlungu yokulimala kwe-nerve, intlungu ye-neuropathic emva kokuhlinzwa kunzima ukuyiphatha kwaye ngokuqhelekileyo ixhomekeke kwi-adjuvant analgesics, njenge-antidepressants kunye ne-anticonvulsants, kunye ne-nerve blockers.Ndenze unyango usebenzisa i-hyaluronic acid (i-Restylane kunye ne-Juvéderm) efumaneka ngokurhweba, enika isiqabu esihlala ixesha elide, esibonakalayo ngaphandle kwemiphumo emibi.
I-Cross-linked hyaluronic acid isetyenziswe okokuqala ngqa ukunyanga intlungu ye-neuropathic kwiNtlanganiso yoNyaka ye-2015 ye-American Academy of Pain Medicine kwi-National Harbour, eMaryland.I-1 Kwinyanga ye-34 yokuphononongwa kwetshathi ye-retrospective, izigulane ze-15 zentlungu ye-neuropathic (abafazi be-7, amadoda e-8) kunye nee-syndromes ze-22 zentlungu zafundwa.Umyinge weminyaka yezigulane yiminyaka eyi-51 kwaye ubude bexesha leentlungu ziinyanga ze-66.I-avareji ye-analog scale ebonakalayo (VAS) inqaku lentlungu phambi kokuba unyango lube ngamanqaku e-7.5 (ngaphandle kwe-10).Emva kokonyango, i-VAS yehla kumanqaku e-10 (ngaphandle kwe-1.5), kwaye umyinge wexesha lokuxolelwa ziinyanga ezi-7.7.
Ukususela ekubeni ndazisa umsebenzi wam wokuqala, ndinyange izigulane ze-75 ezineentlungu ezifanayo (oko kukuthi, i-post-herpetic neuralgia, i-carpal tunnel kunye ne-tarsal tunnel syndrome, i-Bell's paralytic tinnitus, intloko, njl.).Ngenxa yendlela enokwenzeka yokusebenza emsebenzini, ndityumbe olu nyango njenge-cross-linked neural matrix analgesia (XL-NMA).2 Ndinikezela ngengxelo yecala lesigulane esinentamo eqhubekayo kunye nentlungu yesandla emva kokuhlinzwa komlomo wesibeleko.
I-Hyaluronic acid (HA) i-proteoglycan, i-anionic polysaccharide ye-3 eyenziwe ngokuphindaphindiweyo yeeyunithi ze-glucuronic acid kunye ne-N-acetylglucosamine.Ngokwemvelo ikhona kwi-matrix ye-extracellular (ECM) (56%) yesikhumba, i-4 izicubu ezidibeneyo, izicubu ze-epithelial kunye nezicubu ze-nerve.I-4,5 Kwizicubu ezinempilo, ubunzima bayo be-molecular yi-5 kwi-10 yezigidi zeedaltons (Da)4.
I-HA ye-Cross-linked yi-cosmetic yorhwebo evunywe yi-FDA.Ithengiswa phantsi kwee-brand Juvéderm6 (eyenziwe ngu-Allergan, umxholo we-HA 22-26 mg / mL, ubunzima be-molecular 2.5 yezigidi zeedaltons) i-6 kunye ne-Restylane7 (eyenziwe yi-Galderma), kunye ne-HA umxholo we-20 mg / Milliliters, ubunzima be-molecular is I-1 yezigidi zeeDaltons.8 Nangona uhlobo lwendalo lwe-HA olungenasiphambano lwendalo lulwelo kwaye lufakwe kwi-metabolized ngaphakathi kosuku, i-molecular crosslinks ye-HA idibanisa i-polymer chain chain kwaye yenze i-viscoelastic hydrogel, ngoko ubomi bayo benkonzo (iinyanga ezi-6 ukuya kwezi-12) kunye nomthamo wokufunxa umswakama. inokufunxa amanzi aphindwe kangangama-1 000.5
Indoda eneminyaka eyi-60 yeza kwiofisi yethu ngo-Aprili 2016. Emva kokufumana i-C3-C4 kunye ne-C4-C5 ukuchithwa kwe-posterior yomlomo wesibeleko, i-posterior fusion, i-autotransplantation yendawo kunye ne-posterior segmental yangaphakathi ukulungiswa kwangaphakathi, intamo yaqhubeka Kwaye intlungu yezandla zombini.Izikrufu zomgangatho kwi-C3, C4, kunye ne-C5.Ukwenzakala kwakhe entanyeni kwenzeka ngo-Epreli 2015, xa wawa ngomqolo emsebenzini xa wabetha intamo yakhe ngentloko kwaye weva intamo yakhe ibetha.
Emva kokuhlinzwa, intlungu yakhe kunye ne-numbness yaba yinto enzima kakhulu, kwaye kwakukho intlungu evuthayo eqhubekayo emva kwezandla zakhe nentamo (Umfanekiso 1).Ngethuba lokujikwa kwentamo yakhe, ukutshatyalaliswa kombane okunamandla kwakuphuma entanyeni yakhe kunye nomqolo ukuya kumalungu akhe aphezulu nangaphantsi.Xa ulele ngecala lasekunene, ukuba ndindisholo kwezandla kubi kakhulu.
Emva kokwenza i-computed tomography (CT) i-myelography kunye ne-radiography (CR) iimvavanyo, izilonda zecandelo lomlomo wesibeleko zifunyenwe kwi-C5-C6 kunye ne-C6-C7, eya kuxhasa intlungu eqhubekayo kwizandla kunye ne-mechanic mechanical nature of neck flexion Intlungu (okt, I-neuropathic yesibini kunye neentlungu zomgogodla kunye neentlungu ze-C6-C7 ze-radiculopathy).
Izilonda ezikhethekileyo zichaphazela iingcambu ze-nerve ze-bilateral kunye nezahlulo ezinxulumene nentambo yomgogodla ngaphambili, kubandakanya:
Ugqirha wotyando womqolo walwamkela olu thethwano, kodwa wavakalelwa kukuba akukho nto inokunikela ngolunye utyando.
Ekupheleni kuka-Aprili 2016, isandla sokunene sesigulane safumana unyango lwe-Restylane (0.15 mL).I-injection yenziwa ngokubeka i-port kunye nenaliti ye-gauge ye-20, kwaye emva koko ifake i-27 gauge microcannula (i-DermaSculpt) nge-tip blunt.Ukuthelekisa, isandla sasekhohlo sasiphathwa ngomxube we-2% ye-lidocaine ecocekileyo (2 mL) kunye ne-0.25% ye-bupivacaine ecocekileyo (4 mL).Idosi kwisiza ngasinye yi-1.0 ukuya kwi-1.5 mL.(Ukufumana imiyalelo yenyathelo nenyathelo kule nkqubo, bona ibar esecaleni.) 9
Ngolunye uhlengahlengiso, indlela yokujova ifana ne-nerve yesiqhelo kwi-wrist level ye-nerve median (MN), i-nerve ye-ulnar (UN), kunye ne-radial nerve (SRN) kwinqanaba le-anatomical.Ibhokisi yesnuff-indawo engunxantathu yesandla eyenziwe phakathi kobhontsi kunye nomnwe ophakathi.Emva kweeyure ezingamashumi amabini anesine emva kokuhlinzwa, isigulane safumana i-numbness eqhubekayo entendeni yeminwe yesine neyesihlanu yesandla sokunene kodwa akukho ntlungu.Ubuninzi bobundindisholo kwiminwe yokuqala, yesibini neyesithathu yanyamalala, kodwa kwakusekho iintlungu kwiminwe.Amanqaku entlungu, i-4 ukuya kwi-5).Ukuvutha komlilo ngasemva kwesandla kuye kwaphela ngokupheleleyo.Lilonke, waziva ephucuka ngama-75%.
Kwiinyanga ze-4, isigulane saqaphela ukuba intlungu esandleni sakhe sokunene isaphuculwe ngu-75% ukuya kwi-85%, kwaye i-numbness yecala yeminwe 1 kunye ne-2 yayinyamezeleka.Akukho ziphumo zibi okanye iziphumo.Qaphela: Naluphi na uncedo oluvela kwi-anesthesia yendawo esandleni sasekhohlo yasombululwa kwiveki ye-1 emva kokusebenza, kwaye intlungu yakhe yabuyela kwinqanaba elisisiseko leso sandla.Okubangel’ umdla kukuba, isigulana saphawula ukuba nangona iintlungu ezitshisayo kunye nokuba ndindisholo phezulu kwesandla sasekhohlo emva kokutofwa kweyeza lendawo yokuthomalalisa iintlungu, kwathatyathelw’ indawo yindindisholo engathandekiyo necaphukisayo.
Njengoko kushiwo ngaphambili, isigulane sabika ukuba emva kokufumana i-XL-NMA, intlungu ye-neuropathic kwisandla sokunene yaphuculwa kakhulu.Isigulane sivakatye kwakhona ekupheleni kuka-Agasti 2016, xa wachaza ukuba ukuphuculwa kwaqala ukuncipha ekupheleni kukaJulayi 2016. Ucebise ukungenelela kwe-XL-NMA ephuculweyo yesandla sokunene, kunye nonyango lwe-XL-NMA yesandla sokunxele kunye nomlomo wesibeleko. -indawo ye-brachial-bilateral, ihlombe elisondeleyo, indawo ye-C4 kunye nenqanaba le-C5-C6.
Isigulane satyelela kwakhona phakathi ko-Oktobha 2016. Wachaza ukuba emva kokungenelela ngo-Agasti 2016, intlungu yakhe evuthayo kuzo zonke iindawo ezibuhlungu zigcinwe kwaye zikhululekile ngokupheleleyo.Izikhalazo zakhe eziphambili ziyintlungu ebuhlungu / ebuhlungu ebusweni besandla nasemva kwesandla (iintlungu ezahlukeneyo-ezinye zibukhali kwaye ezinye zibuhlungu, kuxhomekeke kwimicu ye-nerve echaphazelekayo) kunye nokuqina okujikeleze isihlahla.Uxinzelelo lwalubangelwa kumonakalo kwiingcambu zemithambo-luvo yomqolo wesibeleko sakhe, ezibandakanya iifibers ezenza zonke ii-3 eziphambili (SRN, MN, kunye ne-UN) esandleni.
Isigulane sabona ukwanda kwe-50% kwinqanaba lokujikeleza komlomo wesibeleko (i-ROM), kunye nokunciphisa i-50% kwintlungu yomlomo wesibeleko kunye nengalo kwi-C5-C6 kunye ne-C4 yendawo yegxalaba.Ucebise i-XL-NMA yokwandiswa kwe-MN yamazwe amabini kunye ne-SRN-i-UN kunye nommandla wentamo-brachial yahlala iphuculwe ngaphandle kwonyango.
Uluhlu loku-1 lushwankathela indlela ecetywayo yokwenza izinto ezininzi.Zibekwe ngokuhambelana nokusondela kwexesha elichasene ne-nociception-ukusuka kwisiphumo esithe ngqo kwimizuzu yokuqala ye-10 emva kwesitofu ukuya kwixesha elide kunye nexesha elide lokukhululeka okubonwa kwezinye iimeko ngonyaka okanye ngaphezulu.
I-CL-HA isebenza njengesithintelo somzimba sokukhusela, ukwenza i-compartment, ukunciphisa ukusebenza kwemisebenzi ezenzekelayo kwi-C fiber kunye ne-Remak bundle afferents, kunye nayo nayiphi na i-nociceptive ephapse engaqhelekanga.I-10 Ngenxa yobume be-polyanionic ye-CL-HA, iamolekyu zayo ezinkulu (i-500 MDA ukuya kwi-100 GDa) inokutshabalalisa ngokupheleleyo amandla esenzo ngenxa yobukhulu bentlawulo yayo embi kwaye ithintele naluphi na ukuhanjiswa komqondiso.Ukulungiswa kwe-LMW / HMW engafanelekanga kukhokelela kwi-TNFα-evuselelwe i-gene ye-6 yeprotheyini yokulawula indawo yokuvuvukala.Oku kuzinzisa kwaye kubuyisele i-immune neural crosstalk disorder kwinqanaba le-extracellular neural matrix, kwaye ngokusisiseko ikhusela izinto ezikholelwa ukuba zenza intlungu engapheliyo.11-14
Ngokusisiseko, emva kokulimala okanye ukulimala kwe-extracellular neural matrix (ECNM), kuya kubakho isigaba esinzima sokuvuvukala okucacileyo kweklinikhi, ehamba kunye nokuvuvukala kwezicubu kunye nokusebenza kwe-Aδ kunye ne-C fiber nociceptors.Nangona kunjalo, yakube le meko ingapheliyo, ukudumba kwezicubu kunye ne-immune nerve crosstalk kuya kuzingisa kodwa kuncinci.I-Chronicization iya kwenzeka ngokungena kwakhona kunye ne-feedback loop, ngaloo ndlela kugcinwe kwaye kugcinwe i-pro-inflammatory, pre-pain state, kunye nokuthintela ukungena kwisigaba sokuphulukisa kunye nokubuyisela (Itheyibhile 2).Ngenxa yokungahambelani kwe-LMW/HMW-HA, iyakwazi ukuzixhasa, enokuba sisiphumo se-CD44/CD168 (RHAMM) gene aberrations.
Ngeli xesha, i-injection ye-CL-HA inokulungisa ukungahambi kakuhle kwe-LMW / HMW-HA kwaye ibangele ukuphazamiseka kokujikeleza kwegazi, ukuvumela i-interleukin (IL) -1β kunye ne-TNFα ukuba yenze i-TSG-6 ukulawula ukuvuvukala, ngokulawula kunye nokunciphisa i-LMW- I-HA kunye ne-CD44.Oku ke kuvumela ukuqhubela phambili okuqhelekileyo kwisigaba se-ECNM esichasayo kunye ne-analgesic, kuba i-CD44 kunye ne-RHAMM (CD168) ngoku ziyakwazi ukusebenzisana ne-HMW-HA ngokuchanekileyo.Ukuqonda le ndlela, jonga iThebhile 2, ebonisa i-cytokine cascade kunye ne-neuroimmunology ehambelana nokulimala kwe-ECNM.
Isishwankathelo, i-CL-HA inokuthathwa njenge-super-giant Dalton form of HA.Ke ngoko, iye yaphucula ngokuphindaphindiweyo kwaye yagcina i-HMW-HA yomzimba yokubuyisela kunye nokuphilisa imisebenzi esemgangathweni yebhayoloji yebhayoloji, kubandakanya:
Xa ndixoxa ngale ngxelo yetyala kunye nabalingane bam, ndandisoloko ndibuzwa, "Kodwa ingaba isiphumo sitshintsha njani kunyango lwe-peripheral kude ne-neck lesion?"Kule meko, izilonda ezaziwayo ze-CR nganye kunye ne-CT myelography Ukuqaphela kwinqanaba leengqungquthela ze-spinal cord C5-C6 kunye ne-C6-C7 (i-C6 kunye neengcambu ze-C7 ze-nerve, ngokulandelanayo).Ezi zilonda zonakalisa ingcambu ye-nerve kunye nenxalenye yangaphambili yentambo yomgogodla, ngoko ke ziyinxalenye esondeleyo yomthombo owaziwayo we-radial nerve root kunye nentambo yomgogodla (okt, C5, C6, C7, C8, T1).Kwaye, ngokuqinisekileyo, baya kuxhasa intlungu evuthayo rhoqo ngasemva kwezandla.Nangona kunjalo, ukuze uqonde ngakumbi oku, ingcamango yokufika engenayo kufuneka ithathelwe ingqalelo.16
I-afferent neuralgia ilula nje, "... Nangona kuncitshisiwe okanye ukungabi naluvelwano kwi-stimuli enobungozi yangaphandle (i-hypoalgesia okanye i-analgesia) kwindawo yomzimba, iintlungu ezibuhlungu ezizenzekelayo kwindawo ekude yokulimala."16 Isenokubangelwa ngawo nawuphi na umonakalo kwinkqubo yemithambo-luvo, embindini kunye neperipheral, kuquka ubuchopho, umnqonqo kunye nemithambo-luvo.I-afferent nerve kucingelwa ukuba ibangelwa kukulahleka kolwazi olusuka kwiperiphery ukuya ebuchotsheni.Ngokukodwa ngakumbi, kukho ukuphazamiseka kolwazi lwe-sensory afferent olufikelela kwi-cortex ngephecana le-spinothalamic.Ummandla wale ngxowa uquka ukuhanjiswa kweentlungu okanye igalelo le-nociceptive eligxininiswe kwi-thalamus.Nangona indlela echanekileyo ayikaqondwa kakuhle, imodeli ifanelekile kakhulu kwimeko ekhoyo (oko kukuthi, ezi ngcambu zemithambo-luvo kunye namacandelo e-spinal cord azihambelani ngokupheleleyo ne-radial nerve).
Ngoko ke, ukuyisebenzisa kwiintlungu ezivuthayo ngasemva kwesandla somgulane, ngokwendlela ye-3 kwiThebhile 1, ukulimala kufuneka kwenzeke ukuqalisa i-pro-inflammatory, pre-noxious state of the cytokine cascade (Itheyibhile 2).Oku kuya kuvela kumonakalo womzimba kwiingcambu ze-nerve ezichaphazelekayo kunye namacandelo entambo yomgogodla.Nangona kunjalo, ekubeni i-ECNM yinto eqhubekayo kwaye isasaza i-neuroimmune entity ejikeleze zonke izakhiwo ze-neural (oko kukuthi, iyonke), i-neurons ye-sensory echaphazelekayo ye-C6 kunye ne-C7 yeengcambu ze-nerve kunye ne-spinal cord segment ziyaqhubeka kwaye i-Limb contact kunye ne-neuroimmune contact on. umva wezandla zozibini.
Ke ngoko, umonakalo kumgama ngokusisiseko sisiphumo sesiphumo esingaqhelekanga se-ECNM esondeleyo kumgama.15 Oku kuya kubangela ukuba i-CD44, i-CD168 (RHAMM) ibone i-HATΔ, kwaye ikhulule i-IL-1β, i-IL-6 kunye ne-TNFα i-cytokines evuthayo, eyenza isebenze kwaye igcine ukusebenza kwe-distal C fibers kunye ne-Aδ nociceptors xa kufanelekile (itafile 2, #3) .Ngomonakalo we-ECNM malunga ne-distal SRN, i-XL-NMA ngoku ingasetyenziselwa ngempumelelo ukungenelela kwi-situ ukufezekisa i-CL-HA LMW / HMW-HA yokulungiswa kwe-mitch kunye ne-ICAM-1 (CD54) umgaqo wokuvuvukala (Itheyibhile 2, # 3- #5 umjikelo).
Nangona kunjalo, kuyonwabisa ngokwenene ukufumana isiqabu esihlala sihleli kwiimpawu eziqatha nezinenkani ngonyango olukhuselekileyo noluncinci.Ubuchwephesha buhlala bulula ukwenza, kwaye owona mba ucelomngeni unokuba kukuchonga imithambo-luvo, uthungelwano lwe-neural, kunye ne-substrate ekufuneka itofwe malunga nethagethi.Nangona kunjalo, ngokumiswa kwetekhnoloji esekelwe kwiimpawu eziqhelekileyo zeklinikhi, oku akunzima.
Ixesha lokuposa: Aug-12-2021