关节镜手术和非手术治疗在处理颞下颌关节病患者中的关系(英文)

The relationship between arthroscopic surgery of the temporomandibular joint and non- surgical therapies in the management of patients with temporomandibular joint pathology

作者结合文献复习和临床经验,全面论述了非手术治疗和关节镜手术在处理常见颞下颌关节病变中的价值,其主要观点是:非手术治疗和手术治疗并非互相排斥,而是相辅相成。非手术治疗适用于病变较轻者,而且是手术治疗患者手术前后的必要辅助治疗。目前对颞下颌关节病变的认识,不支持对病变的关节盘进行复位或替代;关节盘复位术总体上是失败的,因为不改变关节盘的位置,患者的症状也会得到显著改善。而通过关节盘复位术改变关节的解剖结构,对引起患者疼痛和功能紊乱的生物化学和生物机械过程的作用不大。过去15年间积累的临床、影像学和滑液分析资料足以证明,内紊乱理论存在很大缺陷,然而遗憾的是,迄今临床医生仍在强调内紊乱和关节盘复位的重要性。对颞下颌关节病变的成功处理,必须基于治疗内在的生物化学改变和组织异常。正常的滑膜和软骨组织具有很强的耐受机械负荷的适应能力,以维持组织的完整性。当关节所承受的慢性负荷超过组织的耐受力时,就会出现关节疼痛、运动受限和关节杂音。在这一过程的早期,旨在减轻关节负荷、缓解炎症和增加运动的非手术干预,加上组织本身的自然愈合能力,完全能够使组织的结构和功能恢复正常。如引起过度负荷和运动受限的病因持续存在,则病变加重,必须进行手术干预。非手术治疗的原则和目的是:减轻关节负荷,通过被动开口锻炼增加而不是限制关节运动,采用非类固醇类消炎药物如芬必得和奈普生缓解炎症和疼痛,改善患者睡眠(必要时辅以药物如benzodiazepine)。由滑膜炎、骨关节炎和黏连导致的颞下颌关节疾病的手术治疗适应证为:(1)严重疼痛和(或)功能障碍,(2)疼痛或功能紊乱系由关节内病变引起,(3)正规疗程的非手术治疗未能改善症状。手术原则是:(1)尽量微创,手术创伤越大,组织损伤和瘢痕形成的几率越大;(2)手术的目的是清除和(或)治疗已经存在的病变组织,如松解黏连,清除病变的骨关节纤维化组织;(3)辅助减轻滑膜炎症,如内镜下分离滑膜炎症组织,直视下注入高浓度的消炎药物;(4)尽量保留滑膜、关节软骨和关节盘,因为研究表明,保留穿孔的关节盘不会带来任何危害。

The guiding principles of patient management include the establishment of an accurate diagnosis, and providing treatment based on the diagnosis and an understanding of the pathogenesis of the disease process. Furthermore, therapeutic interventions should begin with the least invasive therapies with the highest benefit： risk ratio. When a patient responds to a minimal level of treatment, this usually is an indication that the pathology present is minor in nature and is reversible. Patients who do not respond to appropriate non-surgical therapies often have more complex pathology that may require invasive therapies. Management of the most common temporomandibular joint disorders requires a thorough understanding of the pathogenesis of synovitis, osteoarthritis and adhesions. These conditions represent tissue responses to external factors that exceed the adaptive capacity of the joint tissues. When the functional capacity of the joint tissues is exceeded, this leads to joint pain, limited range of motion and an inability of the joint to tolerate normal physiologic loads, leading to mandibular dysfunction. The principles of management of these conditions involve reduction of joint loading, restoring mandibular mobility and reduction of inflammation and pain. Non-surgical management of temporomandibular joint disorders is guided by these principles and will often result in decreased pain and improved mandibular function. When patients respond to non-surgical therapies, this is a reflection of the ability of the tissues to recover and heal. However, a failure of the patient to respond to a full course of non-surgical therapy is often a reflection of the magnitude of the pathology and represents an inability of the tissues to recover the structure and function necessary for normal mandibular loads. Arthroscopic temporomandibular joint surgery is a minimally invasive operative technique that enables the surgeon to directly visualize and treat intra-articular pathology. Operative arthroscopy permits maximum preservation of the structure and function of intra-articular tissues consistent with the removal and treatment of pathologic tissues such as synovitis, osteoarthritis and adhesions. Following surgical treatment, the postoperative rehabilitation regimen is required to continue to reduce joint loading, maximize mandibular mobility and reduce inflammation and pain while the joint tissues heal and regain function. Therefore, comprehensive treatment of patients with temporomandibular joint pathology involves a thorough understanding of the principles of non-surgical and surgical therapies, which are not mutually exclusive. To the contrary, both non-surgical and surgical therapies represent a continuum in the management of the patient suffering from temporomandibular joint pathology. Fortunately, most patients respond to treatment when the clinician has a thorough knowledge of the principles of non-surgical and surgical therapy.