Ciwon neuropathic bayan tiyata shine matsala na kowa, koda kuwa mai haƙuri yana cikin yanayin mafi kyau.Kamar sauran nau'o'in ciwon ciwon jijiya, ciwon neuropathic bayan tiyata yana da wuya a bi da shi kuma yawanci ya dogara da analgesics adjuvant, irin su antidepressants da anticonvulsants, da masu hana jijiya.Na haɓaka magani ta amfani da siyayyar hyaluronic acid mai haɗin gwiwa (Restylane da Juvéderm), wanda ke ba da ɗorewa, babban taimako ba tare da lahani ba.
An yi amfani da hyaluronic acid mai alaƙa da haɗin gwiwa a karon farko don magance ciwon neuropathic a taron shekara-shekara na 2015 na Cibiyar Nazarin Ciwon Magunguna ta Amurka a Harbour National Harbor, Maryland.1 A cikin bita na sake dubawa na watanni 34, 15 marasa lafiya na ciwon neuropathic (matan 7, 8 maza) da kuma 22 ciwon ciwo sun yi nazari.Matsakaicin shekarun marasa lafiya shine shekaru 51 kuma matsakaicin tsawon lokacin zafi shine watanni 66.Matsakaicin ma'auni na gani na gani (VAS) zafin ciwo kafin jiyya shine maki 7.5 (daga 10).Bayan jiyya, VAS ya ragu zuwa maki 10 (daga 1.5), kuma matsakaicin tsawon lokacin gafara shine watanni 7.7.
Tun da na gabatar da aikina na asali, na yi jinyar marasa lafiya 75 masu irin wannan ciwon ciwo (wato, post-herpetic neuralgia, ramin carpal da ciwon ramin tarsal, Bell's paralytic tinnitus, ciwon kai, da sauransu).Saboda yuwuwar tsarin aiki a wurin aiki, na sanya wannan jiyya azaman analgesia na matrix mai alaƙa da haɗin gwiwa (XL-NMA).2 Ina bayar da rahoton shari'ar mai haƙuri tare da wuyan wuyansa da ciwo na hannu bayan tiyata na kashin baya na mahaifa.
Hyaluronic acid (HA) proteoglycan ne, madaidaiciyar anionic polysaccharide 3 wanda ya ƙunshi maimaita raka'a na glucuronic acid da N-acetylglucosamine.Yana da ta halitta a cikin matrix extracellular (ECM) (56%) na fata, 4 connective tissue, epithelial tissue da jijiyoyi.4,5 A cikin kyallen jikin lafiya, nauyin kwayoyin sa shine 5 zuwa 10 daltons miliyan (Da)4.
Cross-linked HA kayan kwaskwarima ne na kasuwanci wanda FDA ta amince da shi.Ana sayar da shi a ƙarƙashin nau'ikan Juvéderm6 (wanda Allergan ya kera, abun ciki na HA 22-26 mg / mL, nauyin kwayoyin 2.5 daltons miliyan) 6 da Restylane7 (wanda Galderma ke ƙera), kuma abun ciki na HA shine 20 mg / Milliliters, nauyin kwayoyin shine Dalton miliyan 1.8 Kodayake nau'in HA ba tare da haɗin kai ba ruwa ne kuma yana daidaitawa a cikin rana ɗaya, hanyoyin haɗin kwayoyin halitta na HA sun haɗu da sarƙoƙi na polymer na kowane mutum kuma suna samar da hydrogel viscoelastic, don haka rayuwar sabis ɗin sa (6 zuwa watanni 12) da ƙarfin ɗaukar danshi. zai iya sha sau 1,000 nauyinsa na ruwa.5
Wani mutum mai shekaru 60 ya zo ofishinmu a watan Afrilu 2016. Bayan karbar C3-C4 da C4-C5 na baya-bayan nan na mahaifa, haɗuwa na baya, autotransplantation na gida da na baya-bayan nan na ciki na ciki, wuyansa ya ci gaba Kuma ciwo na hannu biyu.Kyakkyawan sukurori a C3, C4, da C5.Raunin wuyansa ya faru ne a watan Afrilun 2015, lokacin da ya koma baya a wurin aiki lokacin da ya bugi wuyansa da kansa kuma ya ji wuyansa ya buga.
Bayan an yi masa tiyata, ciwonsa da raɗaɗinsa sun ƙara tsananta, kuma ana ci gaba da samun zafi mai tsanani a bayan hannunsa da wuyansa (Hoto na 1).A lokacin jujjuyawar wuyansa, mugunyar wutar lantarki ta taso daga wuyansa da kashin bayansa zuwa gaɓoɓinsa na sama da ƙasa.Lokacin kwance a gefen dama, kuncin hannaye ya fi tsanani.
Bayan yin lissafin ilimin lissafi (CT) myelography da gwaje-gwaje na rediyo (CR), an sami raunuka na mahaifa a C5-C6 da C6-C7, wanda zai goyi bayan ci gaba da ciwo a cikin hannaye da kuma yanayin injiniya na lokaci-lokaci na wuyan wuyansa Pain (watau, na biyu neuropathic da kuma jihohin zafi na kashin baya da C6-C7 radiculopathy mai tsanani).
Takamaiman raunuka suna shafar tushen jijiya na gefe biyu da sassan kashin baya masu alaƙa a gaba, gami da:
Likitan kashin baya ya yarda da shawarwarin, amma yana jin cewa babu wani abin da zai bayar don wani aiki.
A ƙarshen Afrilu 2016, hannun dama na majiyyaci ya karɓi magani Restylane (0.15 ml).Ana yin allurar ta hanyar sanya tashar jiragen ruwa tare da allurar ma'aunin ma'auni 20, sannan a saka microcannula ma'auni 27 (DermaSculpt) tare da baƙar fata.Don kwatanta, an bi da hannun hagu tare da cakuda 2% lidocaine mai tsabta (2 ml) da 0.25% bupivacaine mai tsabta (4 ml).Matsakaicin kowane rukunin yanar gizon shine 1.0 zuwa 1.5 ml.(Don umarnin mataki-mataki akan wannan tsari, duba madaidaicin labarun gefe.) 9
Tare da wasu gyare-gyare, hanyar allura tana kama da toshewar jijiyoyi na al'ada a matakin wuyan hannu na jijiyar tsaka-tsaki (MN), jijiyar ulnar (UN), da jijiyar radial na sama (SRN) a matakin anatomical.Akwatin Snuff-yankin hannu triangular da aka kafa tsakanin yatsan yatsa da na tsakiya.Sa'o'i 24 bayan tiyata, majiyyacin ya sami ci gaba da lanƙwasa a cikin tafin hannun yatsu na huɗu da na biyar na hannun dama amma babu ciwo.Yawancin ƙumburi a cikin yatsu na farko, na biyu da na uku sun ɓace, amma har yanzu akwai ciwo a cikin yatsa.Ciwon zafi, 4 zuwa 5).Jin zafi a bayan hannun ya lafa gaba ɗaya.Gabaɗaya, ya ji haɓakar 75%.
A cikin watanni 4, mai haƙuri ya lura cewa ciwo a hannun damansa har yanzu yana inganta ta 75% zuwa 85%, kuma ƙananan yatsa na 1 da 2 sun kasance masu jurewa.Babu wani sakamako mara kyau ko tasiri.Lura: Duk wani taimako daga maganin sa barci a hannun hagu an warware mako 1 bayan tiyata, kuma ciwonsa ya koma matakin asali na wannan hannun.Abin sha'awa, majiyyacin ya lura cewa ko da yake ƙonawa da ƙonawa a saman hannun hagu bayan allurar maganin sa barci ya ragu, amma an maye gurbin shi da rashin jin dadi da damuwa.
Kamar yadda aka ambata a baya, mai haƙuri ya ruwaito cewa bayan karbar XL-NMA, ciwon neuropathic a hannun dama ya inganta sosai.Mai haƙuri ya sake ziyartar a ƙarshen Agusta 2016, lokacin da ya ba da rahoton cewa haɓakawa ya fara raguwa a ƙarshen Yuli 2016. Ya ba da shawarar inganta haɓakar XL-NMA don hannun dama, da kuma maganin XL-NMA na hannun hagu da kuma mahaifa. -yankin brachial-bilateral, proximal kafada, yankin C4 da matakin C5-C6.
Mai haƙuri ya sake ziyartar tsakiyar Oktoba 2016. Ya bayar da rahoton cewa bayan shiga tsakani a watan Agusta 2016, zafi mai zafi a duk wurare masu zafi ya ci gaba kuma ya sami sauƙi.Babban koke-kokensa shine maras nauyi / zafi mai tsanani a saman tafin hannu da bayan hannu (masu zafi daban-daban-wasu suna da kaifi wasu kuma maras nauyi, dangane da zaruruwan jijiyar da ke ciki) da kuma matsewa a kusa da wuyan hannu.Tashin hankali ya faru ne saboda lalacewar tushen jijiya na kashin mahaifansa, wanda ya haɗa da zaruruwan da ke samar da dukkanin manyan jijiyoyi 3 (SRN, MN, da UN) a hannu.
Mai haƙuri ya lura da haɓakar 50% a cikin kewayon jujjuyawar motsi na mahaifa (ROM), da raguwar 50% a cikin mahaifa da ciwon hannu a cikin yankin C5-C6 da C4 kusa da kafada.Ya ba da shawarar haɓaka XL-NMA na MN biyu da SRN- Majalisar Dinkin Duniya da yankin wuyan wuyansa sun kasance sun inganta ba tare da magani ba.
Tebu 1 yana taƙaita tsarin aiwatar da abubuwa da yawa da aka tsara.An jera su bisa ga kusancinsu zuwa anti-nociception-sanya-daga mafi tasiri kai tsaye a cikin mintuna 10 na farko bayan allura zuwa taimako mai ɗorewa da dadewa da aka gani a wasu lokuta shekara ɗaya ko fiye.
CL-HA yana aiki azaman shinge na kariya ta jiki, yana samar da ɗaki, yana rage kunna ayyukan da ba a so ba a cikin C fiber da Remak bundle afferents, da duk wani ɓoyayyen ɓoyayyen ɓoyayyen ɓoyayyiyar cuta.10 Saboda yanayin polyanionic na CL-HA, manyan kwayoyin halittarsa (500 MDA zuwa 100 GDa) na iya kawar da yuwuwar aikin gaba daya saboda girman cajinsa mara kyau kuma ya hana duk wani watsa sigina.LMW/HMW gyare-gyaren rashin daidaituwa yana haifar da TNFa-ƙarfafa tsarin tsarin furotin 6 kumburi yanki.Wannan yana daidaitawa da kuma dawo da rashin lafiyar jijiyoyi na rigakafi a matakin matrix na jijiyoyi na waje, kuma yana hana abubuwan da aka yi imani da su suna haifar da ciwo mai tsanani.11-14
Mahimmanci, bayan raunin matrix na jijiyoyi (ECNM) ko rauni, za a sami wani lokaci na farko na kumburi na asibiti, tare da kumburi na nama da kunna Aδ da C fiber nociceptors.Koyaya, da zarar wannan yanayin ya zama na yau da kullun, kumburin nama da maganganun jijiya na rigakafi zasu zama na dindindin amma na ƙasa.Chronicization zai faru ta hanyar sake shigarwa da madaidaicin ra'ayi mai kyau, don haka kiyayewa da kuma kiyaye pro-inflammatory, pre-pain state, da hana shiga cikin waraka da farfadowa (Table 2).Saboda rashin daidaituwar LMW/HMW-HA, yana iya zama mai dogaro da kai, wanda zai iya zama sakamakon ɓarnawar halittar CD44/CD168 (RHAMM).
A wannan lokacin, allurar CL-HA na iya gyara kuskuren LMW / HMW-HA kuma ya haifar da katsewar jini, barin interleukin (IL) -1β da TNFα don haifar da TSG-6 don daidaita kumburi, ta hanyar daidaitawa da daidaitawa LMW- HA da CD44.Wannan yana ba da damar ci gaba na al'ada zuwa ECNM anti-inflammatory da analgesic lokaci, saboda CD44 da RHAMM (CD168) yanzu suna iya yin hulɗa tare da HMW-HA daidai.Don fahimtar wannan tsarin, duba Table 2, wanda ke kwatanta cytokine cascade da neuroimmunology hade da raunin ECNM.
A taƙaice, CL-HA ana iya ɗaukarsa azaman babban-giant Dalton nau'i na HA.Sabili da haka, ya ci gaba da haɓakawa da kiyaye HMW-HA na jiki da kuma warkar da daidaitattun ayyuka na ilimin halitta, gami da:
Lokacin da nake tattaunawa game da wannan rahoto tare da abokan aiki na, ana yawan tambayata, "Amma ta yaya tasirin ya canza a cikin jiyya mai nisa daga wuyan wuyansa?"A wannan yanayin, sanannun raunuka na kowane CR da CT myelography Recognition a matakin ƙananan sassan C5-C6 da C6-C7 (C6 da C7 tushen jijiya, bi da bi).Wadannan raunuka suna lalata tushen jijiya da kuma sashin gaba na kashin baya, don haka suna kusa da tushen tushen tushen jijiya na radial da kashin baya (watau C5, C6, C7, C8, T1).Kuma, ba shakka, za su goyi bayan ciwon ƙonawa akai-akai a bayan hannayen hannu.Duk da haka, don ƙara fahimtar wannan, dole ne a yi la'akari da manufar mai shigowa.16
Afferent neuralgia shine kawai, "... Duk da ragewa ko rashin jin dadi ga abubuwan da ba su da kyau na waje (hypoalgesia ko analgesia) zuwa sashin jiki, ciwo mai tsanani na kwatsam a cikin sashin jiki mai nisa na rauni."16 Yana iya haifar da kowace lahani ga tsarin jijiya, na tsakiya da na gefe, gami da kwakwalwa, kashin baya, da jijiyoyi na gefe.Ana tsammanin jijiyar afferent ta kasance saboda asarar bayanai daga kewaye zuwa kwakwalwa.Musamman ma, akwai katsewa a cikin bayanan azanci mai ban sha'awa wanda ya kai ga cortex ta hanyar spinothalamic.Yankin wannan tarin ya haɗa da watsa ciwo ko shigarwar nociceptive da aka mayar da hankali ga thalamus.Ko da yake har yanzu ba a fahimci ainihin tsarin ba, samfurin ya dace sosai da halin da ake ciki (watau waɗannan tushen jijiya da sassan kashin baya ba su da alaƙa da jijiyar radial).
Sabili da haka, yin amfani da shi zuwa zafi mai zafi a baya na hannun mai haƙuri, bisa ga tsarin 3 a cikin Table 1, rauni dole ne ya faru don fara pro-inflammatory, pre-mummunan yanayin cytokine cascade (Table 2).Wannan zai zo daga lalacewa ta jiki ga tushen jijiya da aka shafa da sassan kashin baya.Duk da haka, tun da ECNM ci gaba ne kuma mai watsawa neuroimmune mahaɗan da ke kewaye da duk tsarin jijiyoyi (watau gaba ɗaya ne), ƙananan ƙwayoyin jijiya da suka shafi tushen jijiya na C6 da C7 da kuma sassan kashin baya suna ci gaba da ci gaba da haɗin gwiwa da haɗin gwiwar neuroimmune akan. bayan hannaye biyu.
Sabili da haka, lalacewa a cikin nesa shine ainihin sakamakon sakamako mai ban mamaki na ECNM na kusa a cikin nesa.15 Wannan zai haifar da CD44, CD168 (RHAMM) don gano HATΔ, da kuma saki IL-1β, IL-6 da TNFa cytokines mai kumburi, wanda ke kunnawa da kuma kula da kunnawar C fibers da Aδ nociceptors lokacin da ya dace (tebur 2, #3) .Tare da lalacewar ECNM a kusa da SRN mai nisa, XL-NMA yanzu za a iya samun nasarar amfani da shi don shiga tsakani don cimma CL-HA LMW / HMW-HA rashin daidaituwa da kuma ICAM-1 (CD54) tsarin kumburi (Table 2, # 3-). #5 zagayowar).
Duk da haka, hakika abin farin ciki ne a dogara da samun sauƙi mai ɗorewa daga cututtuka masu tsanani da taurin kai ta hanyar lafiyayyen jiyya marasa ƙarfi.Dabarar galibi tana da sauƙin aiwatarwa, kuma mafi ƙalubale al'amari na iya zama gano jijiyoyi masu azanci, hanyoyin sadarwa na jijiyoyi, da kuma abin da za a yi allura a kusa da abin da ake hari.Duk da haka, tare da daidaitawar fasaha bisa ga bayyanar cututtuka na kowa, wannan ba shi da wahala.
Lokacin aikawa: Agusta-12-2021