去神经化治疗腰椎关节突关节源性腰痛的有效性与安全性研究

Efficacy and safety of using denervation to treat the low back pain due to lumbar joint origin

目的:探讨脊神经后内侧支阻滞模拟去神经化治疗腰椎关节突关节源性腰痛的有效性与安全性。方法:自2009年3月至2010年10月,采用脊神经后内侧支阻滞模拟去神经化治疗腰椎关节突关节源性腰痛患者10例,男6例,女4例;年龄41～68岁,平均56.4岁;病程0.5～3年,平均1.2年。每例患者分别进行脊神经后内侧支单支阻滞、双支阻滞、三支阻滞、四支阻滞(分别在C形臂X线透视引导下行病变腰椎关节突关节和(或)上下邻近几个关节行腰脊神经后内侧支阻滞),其中5例双支阻滞时行同位脊神经后内侧支及上位神经阻滞,5例行同位及下位神经阻滞。以相应上关节突与横突根部交界处为靶点。用药均为:0.5%盐酸利多卡因15ml加入确炎舒松-A1ml(10mg/ml)、甲钴铵注射液1ml(500μg)。评价患者阻滞前、阻滞腰脊神经后内侧支单支、双支、3支、4支后腰背部疼痛的VAS评分、致痛关节突关节水平多裂肌表面肌电信号及腰部背伸肌力。多裂肌表面肌电信号用表面肌电测定仪记录,背部肌力采用背力计测定。结果:所有患者脊神经阻滞后腰背疼痛VAS评分、多裂肌平均肌电(averageEMG,AEMG)均低于阻滞前(阻滞前VAS评分为6.85±1.55,肌电值为69.25±2.13)。腰脊神经后内侧支单支、双支、3支、4支阻滞后腰背部的VAS评分分别为5.80±1.05、3.65±1.20、2.80±1.10、2.75±1.15,肌电值分别为62.15±1.85、51.25±1.28、47.30±1.85、45.96±1.98。腰背伸肌力:腰脊神经后内侧支阻滞前和单支、双支、3支、4支阻滞后分别为60、55、48、44、43kg。VAS评分:3支阻滞后<双支阻滞后<单支阻滞后;腰背伸力:3支阻滞后<双支阻滞后<单支阻滞后。4支阻滞后的VAS评分、腰背伸力与3支阻滞后差异无统计学意义。同位脊神经后内侧支及上位双支阻滞VAS评分及背伸力下降幅度明显大于同位及下位双支阻滞。结论:脊神经后内侧支去神经化治疗腰椎关节突关节源性腰痛是有效的,单支、双支去神经化治疗是相对安全的;双支阻滞首选同位脊神经后内侧支及上位双支阻滞,其疗效明显。3支、4支去神经化治疗有一定风险,应谨慎使用。

Objective：To explore efficacy and safety of using denervation of dorsal medial branch to treat the low back pain due to lumbar joint origin. Methods：From March 2009 to October 2010,10 patients with the low back pain due to lumbar joint origin were enrolled in this study including 6 males and 4 females with an average age of 56.4 years old （41 to 68）. The average disease duration was 1.2 years （0.5 to 3）. All patients were operated by blocking the dorsal medial branch. Single branch （dorsal medial branch of the involved level）,dual branches （dorsal medial branches of the involved and the upper or lower level,5 with the upper level,5 with the lower level）,three branches （dorsal medial branches of the involved and the upper and lower levels）,four branches （dorsal medial branches of the involved and the upper two and lower levels） were blocked by 0.5% lidocaine 15 ml compounded with betamethasone injection 1 ml （10 mg/ml） and a cobalt ammonium injection 500 μg at the junction of the superior articular process and the transverse process. Low back pain VAS,average EMG of multifidus of the involved level and low back muscle strength were assessed and statistically compared. Low back muscle strength was measured by the back power meter. Results：The mean low back pain VAS of the 10 patients in the preoperation was 6.85±1.55,in single branch blocked group was 5.80±1.05,in dual branches blocked group was 3.65±1.20,in three branches blocked group was 2.80±1.10 and in four branches blocked group was 2.75±1.15. Average EMG of multifidus was 69.25±2.13 in the preoperation,in single branch blocked group was 62.15±1.85,in dual branches blocked group was 51.25±1.28,in three branches blocked group was 47.30±1.85 and in four branches blocked group was 45.96±1.98. The mean low back muscle strength was 60 kg in the preoperation,in single branch blocked group was 55 kg,in dual branches blocked group was 48 kg,in three branches blocked group was 44 kg and in four branches blocked group was 43 kg. Among the dual branches blocked group,low back pain VAS and low back muscle strength in the dorsal medial branches of the involved and the upper level blocked showed great decline compared with those in the dorsal medial branches of the involved and the lower level blocked. Conclusion：It is effective by denervation of dorsal medial branch to treat the low back pain due to lumbar joint origin. There are significant difference in low back pain VAS between every two among the preoperation,single branch blocked group,dual branches blocked group and three branches blocked group. There is no significant difference between four branches blocked group and three branches blocked group. In low back muscle strength and average EMG of multifidus,compared with the preoperation group,there is no significant decline in single branch blocked and dual branches blocked group,and there is significant decline in three branches blocked and four branches blocked group. Therefore,single or dual dorsal medial branch blocked is safety. Among the dual branches blocked group,dorsal medial branches of the involved and the upper level blocked should be given priority to. There is a certain risk in three or four dorsal medial branches blocked which should be used with caution.