Ubuhlungu be-postoperative neuropathic yinkinga evamile, ngisho noma isiguli sisesimweni esihle kakhulu.Njengezinye izinhlobo zobuhlungu bokulimala kwezinzwa, ubuhlungu be-neuropathic ngemva kokuhlinzwa kunzima ukuyelapha futhi ngokuvamile buthembele kuma-adjuvant analgesics, njengama-antidepressants nama-anticonvulsants, nama-nerve blockers.Ngasungula indlela yokwelapha esebenzisa i-hyaluronic acid etholakala emakethe (i-Restylane ne-Juvéderm), enikeza ukukhululeka okuhlala isikhathi eside, okuphawulekayo ngaphandle kwemiphumela emibi.
I-hyaluronic acid exhunywe esiphambanweni yasetshenziswa okokuqala ngqa ukuphatha ubuhlungu be-neuropathic eMhlanganweni Wonyaka we-2015 we-American Academy of Pain Medicine e-National Harbor, eMaryland.I-1 Ekubuyekezweni kweshadi lezinyanga ze-34, iziguli ezibuhlungu ze-neuropathic ze-15 (abesifazane be-7, amadoda angu-8) kanye ne-syndromes yobuhlungu be-22 yafundwa.Isilinganiso seminyaka yeziguli sasiyiminyaka engu-51 kanti ubude besikhathi sobuhlungu kwakuyizinyanga ezingu-66.Isilinganiso sesilinganiso sobuhlungu be-analog scale (VAS) ngaphambi kokwelashwa kwakungamaphuzu angu-7.5 (ku-10).Ngemuva kokwelashwa, i-VAS yehla yaba amaphuzu angu-10 (ku-1.5), kanti ubude besikhathi sokuxolelwa kwakuyizinyanga ezingu-7.7.
Kusukela ngethula umsebenzi wami wokuqala, ngelaphe iziguli ezingama-75 ezinezinhlungu ezifanayo (okungukuthi, i-post-herpetic neuralgia, umhubhe we-carpal kanye ne-tarsal tunnel syndrome, i-Bell's paralytic tinnitus, ikhanda elibuhlungu, njll.).Ngenxa yendlela yokusebenza okungenzeka ngayo emsebenzini, ngikhethe lokhu kwelashwa njenge-cross-linked neural matrix analgesia (XL-NMA).I-2 Nginikeza umbiko wecala wesiguli esinentamo eqhubekayo kanye nobuhlungu besandla ngemva kokuhlinzwa komgogodla womlomo wesibeletho.
I-Hyaluronic acid (HA) iyi-proteoglycan, i-anionic polysaccharide 3 ehambisanayo eyakhiwe ngamayunithi aphindaphindayo e-glucuronic acid ne-N-acetylglucosamine.Kungokwemvelo ku-matrix ye-extracellular (ECM) (56%) yesikhumba, izicubu ezixhunyiwe ze-4, izicubu ze-epithelial kanye nezicubu zezinzwa.4,5 Ezicutshini ezinempilo, isisindo sayo se-molecular singama-dalton ayizigidi ezingu-5 kuya kwezingu-10 (Da)4.
I-Cross-linked HA iyimonyo yezentengiso egunyazwe yi-FDA.Ithengiswa ngaphansi kohlobo lwe-Juvéderm6 (ekhiqizwe i-Allergan, okuqukethwe kwe-HA okungu-22-26 mg/mL, isisindo samangqamuzana angama-dalton ayizigidi ezingu-2.5)6 kanye ne-Restylane7 (ekhiqizwe yi-Galderma), kanti okuqukethwe kwe-HA kungu-20 mg/Milliliters, isisindo samangqamuzana 1 million amaDaltons.8 Nakuba uhlobo lwe-HA lwemvelo olungaxhunywanga luwuketshezi futhi lwenziwa i-metabolized phakathi nosuku, i-molecular crosslinks ye-HA ihlanganisa amaketanga e-polymer ngayinye futhi yakhe i-viscoelastic hydrogel, ngakho-ke impilo yayo yesevisi (Izinyanga eziyisi-6 kuye kweziyi-12) namandla okumunca umswakama. ingamunca amanzi aphindwe izikhathi ezingu-1 000.5
Indoda eneminyaka engu-60 ubudala yafika ehhovisi lethu ngo-April 2016. Ngemva kokuthola i-C3-C4 kanye ne-C4-C5 ukuchithwa komlomo wesibeletho ngemuva, ukuhlanganiswa kwe-posterior, i-autotransplantation yendawo kanye ne-posterior segmental fixation yangaphakathi, intamo iqhubekile Futhi ubuhlungu bezandla zombili.Izikulufu zekhwalithi ku-C3, C4, kanye ne-C5.Ukulimala kwakhe entanyeni kwenzeka ngo-Ephreli 2015, ngesikhathi ewa emuva emsebenzini ngesikhathi eshaya intamo yakhe ngekhanda futhi wezwa intamo yakhe ishaya.
Ngemva kokuhlinzwa, izinhlungu nokuba ndikindiki kwakhe kwaba kubi nakakhulu, futhi kwaba nobuhlungu obuqhubekayo bokusha obungapheli ngemuva kwezandla nentamo yakhe (Umfanekiso 1).Ngesikhathi enyakaziswa intamo yakhe, ukushaqeka kukagesi okunamandla kwakuphuma entanyeni nasemgogodleni kuye ezithweni zakhe ezingenhla nezingaphansi.Uma ulele ngakwesokudla, ukuba ndikindiki kwezandla kubi kakhulu.
Ngemuva kokwenza ukuhlolwa kwe-computed tomography (CT) i-myelography kanye ne-radiography (CR), izilonda zesigaba somlomo wesibeletho zitholwe ku-C5-C6 kanye ne-C6-C7, okuzosekela ubuhlungu obuqhubekayo ezandleni kanye nemvelo yemishini ye-neck flexion Pain (okungukuthi, i-secondary neuropathic kanye ne-spinal pain states kanye ne-C6-C7 acute radiculopathy).
Izilonda ezithile zithinta izimpande zezinzwa ezimbili kanye nezingxenye ezihlobene zomgogodla ngaphambili, okuhlanganisa:
Udokotela ohlinza umgogodla wakwamukela ukubonisana naye, kodwa waba nomuzwa wokuthi akukho lutho ayengalunikeza ngokunye ukuhlinzwa.
Ekupheleni kuka-April 2016, isandla sokudla sesiguli sathola ukwelashwa kwe-Restylane (0.15 mL).Umjovo wenziwa ngokubeka imbobo enenaliti yegeji engu-20, bese ufaka i-27 gauge microcannula (DermaSculpt) enethiphu elibuthuntu.Uma kuqhathaniswa, isandla sokunxele saphathwa ngengxube ye-lidocaine emsulwa engu-2% (2 mL) kanye ne-0.25% ye-bupivacaine emsulwa (4 mL).Umthamo endaweni ngayinye ngu-1.0 kuya ku-1.5 mL.(Ukuze uthole imiyalelo yesinyathelo ngesinyathelo kule nqubo, bheka ibha eseceleni.) 9
Ngokushintshwa okuthile, indlela yokujova ifana ne-nerve block evamile ezingeni lesihlakala se-nerve median (MN), i-ulnar nerve (UN), kanye ne-superficial radial nerve (SRN) ezingeni le-anatomical.Ibhokisi lesinemfu-indawo engunxantathu yesandla eyakhiwe phakathi kwesithupha nomunwe ophakathi.Emahoreni angamashumi amabili nane ngemva kokuhlinzwa, isiguli sathola ukuba ndikindiki okuqhubekayo ezintendeni zezandla zomunwe wesine nowesihlanu wesandla sokudla kodwa abukho ubuhlungu.Iningi lokundikindiki emunweni wokuqala, wesibili nowesithathu lanyamalala, kodwa kwakusenobuhlungu eminweni.Isilinganiso sobuhlungu, 4 kuya ku-5).Ukuzwa ukushisa ngemuva kwesandla kwehle ngokuphelele.Sekukonke, uzizwe ethuthuka ngo-75%.
Ezinyangeni ze-4, isiguli sabona ukuthi ubuhlungu esandleni sakhe sokunene busathuthukisiwe ngo-75% kuya ku-85%, futhi uhlangothi oluhlangene lweminwe 1 no-2 lwalubekezeleleka.Akukho ukusabela okubi noma imiphumela.Qaphela: Noma yikuphi ukukhululeka okuvela ku-anesthesia yendawo esandleni sobunxele kwaxazululwa isonto le-1 ngemuva kokuhlinzwa, futhi ubuhlungu bakhe babuyela ezingeni lokuqala laleso sandla.Ngokuthakazelisayo, isiguli saphawula ukuthi nakuba ubuhlungu obushisayo nokuba ndikindiki phezulu kwesandla sokunxele ngemva kokujova umuthi obulala izinzwa wendawo kwase kudambile, kwathathelwa indawo ukuba ndikindiki okungajabulisi kakhulu nokucasulayo.
Njengoba kushiwo ngaphambili, isiguli sabika ukuthi ngemva kokuthola i-XL-NMA, ubuhlungu be-neuropathic esandleni sokunene buthuthukisiwe kakhulu.Isiguli savakashela futhi ngasekupheleni kuka-Agasti 2016, lapho ebika ukuthi ukuthuthukiswa kwaqala ukuncipha ngasekupheleni kukaJulayi 2016. Uhlongoze ukungenelela okuthuthukisiwe kwe-XL-NMA kwesandla sokunene, kanye nokwelashwa kwe-XL-NMA kwesandla sobunxele kanye nomlomo wesibeletho. -indawo ye-brachial-bilateral, ihlombe eliseduze, indawo ye-C4 kanye nezinga le-C5-C6.
Isiguli savakashela futhi maphakathi no-Okthoba 2016. Ubike ukuthi ngemva kokungenelela ngo-Agasti 2016, ubuhlungu bakhe obuvuthayo kuzo zonke izindawo ezibuhlungu bugcinwe futhi bukhululekile ngokuphelele.Izikhalo zakhe eziyinhloko ubuhlungu obunzima/obunzima ebusweni bentende nangemuva kwesandla (imizwa yobuhlungu ehlukene-ezinye zibukhali kanti ezinye zibuthuntu, kuye ngokuthi imicu yezinzwa ehilelekile) kanye nokucinana esihlakaleni.Ukucindezeleka kwakungenxa yokulimala kwezimpande zemizwa yomgogodla wakhe womlomo wesibeletho, okwakuhilela imicu eyakha zonke izinzwa eziyinhloko ze-3 (SRN, MN, ne-UN) esandleni.
Isiguli sabona ukwanda kwe-50% kuhlu lokujikeleza komgogodla womlomo wesibeletho (ROM), nokunciphisa kwe-50% ebuhlungu bomlomo wesibeletho kanye nengalo endaweni ye-C5-C6 ne-C4 eseduze.Uphakamise i-XL-NMA yokwengezwa kwe-MN yamazwe amabili kanye ne-SRN-i-UN kanye nendawo ye-neck-brachial ihlale ithuthukisiwe ngaphandle kokwelashwa.
Ithebula 1 lifingqa indlela yokusebenza ehlongozwayo enezici eziningi.Zibalwa ngokuvumelana nokusondelana kwazo ne-anti-nociception eguquguqukayo yesikhathi-kusukela emthelela oqondile kakhulu emizuzwini yokuqala ye-10 ngemuva kokujova ekuphumuleni okuhlala njalo nokude okubonwa kwezinye izimo ngonyaka noma ngaphezulu.
I-CL-HA isebenza njengesithiyo sokuzivikela ngokomzimba, yenza i-compartment, inciphisa ukusebenza kwemisebenzi ezenzakalelayo ku-C fiber kanye ne-Remak bundle afferents, kanye nanoma iyiphi i-nociceptive ephapse engavamile.10 Ngenxa yemvelo ye-polyanionic ye-CL-HA, ama-molecule ayo amakhulu (500 MDA kuya ku-100 GDa) angase ahlehlise ngokuphelele amandla esenzo ngenxa yobukhulu bokushajwa kwayo okungekuhle futhi avimbele noma yikuphi ukudluliswa kwesignali.Ukulungiswa kokungafani kwe-LMW/HMW kuholela ekuvuvukeni kwendawo yokulawula amaprotheni e-TNFα.Lokhu kuzinza futhi kubuyisele i-immune neural crosstalk disorder ezingeni le-extracellular neural matrix, futhi ngokuyisisekelo kuvimbela izici okukholelwa ukuthi zibangela ubuhlungu obungapheli.11-14
Ngokuyinhloko, ngemva kokulimala noma ukulimala kwe-extracellular neural matrix (ECNM), kuzoba nesigaba sokuqala esibucayi sokuvuvukala okusobala komtholampilo, okuhambisana nokuvuvukala kwezicubu nokusebenza kwe-Aδ kanye ne-C fiber nociceptors.Kodwa-ke, uma lesi simo sesihlala isikhathi eside, ukuvuvukala kwezicubu kanye ne-immune nerve crosstalk kuzoba okuphikelelayo kodwa kuncane.Ukuhlala isikhathi eside kuzokwenzeka ngokungena kabusha kanye ne-loop yempendulo enhle, ngaleyo ndlela kugcinwe futhi kugcinwe isimo se-pro-inflammatory, pre-pain state, nokuvimbela ukungena esigabeni sokuphulukisa nokululama (Ithebula 2).Ngenxa yokungafani kwe-LMW/HMW-HA, ingakwazi ukuziphilisa, okungaba umphumela wokuphambuka kofuzo lwe-CD44/CD168 (RHAMM).
Ngalesi sikhathi, umjovo we-CL-HA ungalungisa ukungafani kwe-LMW/HMW-HA futhi ubangele ukuphazamiseka kokujikeleza kwegazi, okuvumela i-interleukin (IL) -1β ne-TNFα ukuthi yenze i-TSG-6 ilawule ukuvuvukala, ngokulawula nokwehlisa i-LMW- I-HA kanye ne-CD44.Lokhu bese kuvumela ukuqhubekela phambili okuvamile kusigaba se-ECNM sokunqanda ukuvuvukala ne-analgesic, ngoba i-CD44 ne-RHAMM (CD168) manje sebeyakwazi ukusebenzisana ne-HMW-HA ngendlela efanele.Ukuze uqonde le nqubo, bheka Ithebula 2, elibonisa i-cytokine cascade kanye neuroimmunology ehambisana nokulimala kwe-ECNM.
Kafushane, i-CL-HA ingathathwa njengefomu elikhulu le-Dalton le-HA.Ngakho-ke, iye yathuthukisa futhi yagcina ukuvuselelwa komzimba kwe-HMW-HA kanye nemisebenzi evamile yebhayoloji yokuphulukisa yamangqamuzana, okuhlanganisa:
Lapho ngixoxa ngalo mbiko wecala nozakwethu, ngangivame ukubuzwa, “Kodwa ushintsha kanjani umphumela ekwelashweni okukude kude nesilonda sentamo?”Kulesi simo, izilonda ezaziwayo ze-CR kanye ne-CT myelography Ukuqashelwa ezingeni lezingxenye zomgogodla we-C5-C6 kanye ne-C6-C7 (izimpande ze-C6 ne-C7, ngokulandelana).Lezi zilonda zilimaza impande yezinzwa kanye nengxenye yangaphambili yomgogodla, ngakho-ke ziyingxenye eseduze yomthombo owaziwayo we-radial nerve root kanye nomgogodla (okungukuthi, C5, C6, C7, C8, T1).Futhi-ke, bazosekela ubuhlungu obuvuthayo obuqhubekayo ngemuva kwezandla.Nokho, ukuze kuqondwe kabanzi lokhu, kufanele kubhekwe umqondo wokungenayo.16
I-afferent neuralgia imane nje, “…Naphezu kokuncipha noma ukungazweli ekushukumiseni okuyingozi kwangaphandle (i-hypoalgesia noma i-analgesia) esithweni somzimba, ubuhlungu obukhulu obuzenzakalelayo engxenyeni ekude yomzimba yokulimala.”16 Kungase Kubangelwe yinoma imuphi umonakalo esimisweni sezinzwa, kokubili enkabeni nasemkhunjini, okuhlanganisa ubuchopho, umgogodla, nezinzwa eziseceleni.I-afferent nerve kucatshangwa ukuthi ibangelwa ukulahlekelwa kolwazi olusuka ku-periphery ukuya ebuchosheni.Ngokucacile, kukhona ukuphazamiseka olwazini lwezinzwa oluhlangene olufinyelela ku-cortex ngepheshana le-spinothalamic.Isizinda salesi sikhwama sihlanganisa ukudluliselwa kobuhlungu noma okokufaka kwe-nociceptive okugxilwe kuthalamus.Nakuba indlela eqondile ingakaqondwa kahle, imodeli ifaneleka kakhulu esimweni esiseduze (okungukuthi, lezi zimpande zemizwa kanye nezingxenye zomgogodla azihambelani ngokuphelele ne-radial nerve).
Ngakho-ke, ukuyisebenzisa ebuhlungu obuvuthayo ngemuva kwesandla sesiguli, ngokusho komshini we-3 kuThebula 1, ukulimala kufanele kwenzeke ukuze kuqalwe isimo esibucayi, esibi kakhulu se-cytokine cascade (Ithebula 2).Lokhu kuzovela ekulimaleni ngokomzimba ezimpandeni zezinzwa ezithintekile kanye nezingxenye zomgogodla.Kodwa-ke, njengoba i-ECNM iyinhlangano ye-neuroimmune eqhubekayo nesabalalayo ezungeza zonke izakhiwo ze-neural (okungukuthi, iyonke), ama-neuron athintekile ezimpande ze-C6 ne-C7 ezithintekile kanye nezingxenye zomgogodla ziyaqhubeka futhi ukuthintana kwe-Limb kanye ne-neuroimmune contact on. ngemuva kwezandla zombili.
Ngakho-ke, ukulimala okukude empeleni kuwumphumela womphumela ongavamile we-ECNM eseduze ebangeni.I-15 Lokhu kuzokwenza ukuthi i-CD44, i-CD168 (RHAMM) ithole i-HATΔ, futhi ikhulule i-IL-1β, i-IL-6 ne-TNFα i-cytokines evuthayo, eyenza futhi igcine ukusebenza kwe-distal C fibers kanye ne-Aδ nociceptors uma kufaneleka (ithebula 2, #3) .Ngokulimala kwe-ECNM ezungeze i-distal SRN, i-XL-NMA manje isingasetshenziswa ngempumelelo ukungenelela endaweni ukuze kuzuzwe ukulungiswa okungalungile kwe-CL-HA LMW/HMW-HA kanye nomthetho wokuvuvukala we-ICAM-1 (CD54) (Ithebula 2, # 3- #5 umjikelezo).
Noma kunjalo, kuyajabulisa ngempela ukuthola impumuzo ehlala njalo ezimpawini ezinzima nezinenkani ngokwelashwa okuphephile nokungangeneleli kancane.Indlela yokusebenza ngokuvamile ilula ukuyenza, futhi isici esiyinselele kakhulu kungase kube ukuhlonza imizwa yezinzwa, amanethiwekhi emizwa, kanye ne-substrate okumele ijovwe eduze kwalapho kuhlosiwe.Kodwa-ke, ngokumiswa kobuchwepheshe ngokusekelwe ekubonakalisweni komtholampilo okuvamile, lokhu akunzima.
Isikhathi sokuthumela: Aug-12-2021