Transdermal spinal endoscopy lower spinal nerve root cut-off surgery to treat cancer pain 1 case

Malignant tumors of the digestive tract can be metastasized and affected by the abdominal wall, although the incidence rate is low, but the prognosis is poorWhen the abdominal wall metastatic tumor invades the interribal nerve, it can cause tumor-related interribal nerve painFor patients with persistent nerve pain, oral medications have poor analgesic effects, and most of them are unable to tolerate surgery due to physical weaknessThere is no safe, small-impact, and positive treatment for such patientsthe current development of spinal endoscopy technology can make the intervertebral hole area a new therapeutic target areaAfter full preparation we explore the transdermal spinal endoscopic endoscopic intervertebral hole after the enlarged thoracic spinal nerve cut-off successfultreatment of abdominal wall cancer pain 1 case, achieved good resultsThe following reports are as follows:1Method1) General informationpatient Zhu, male, 62 years old, in March 2011 diagnosed as "B colon malignancies", in our hospital tumor treatmentPostoperative conventional pathology tips "B-type colon malignancies, ulcer-soaked type, medium differentiation adenocarcinoma, cancerous tissue invasion and slurry membrane layer, lymphatic recidivism (-), PTNM staging: Phase II (T3N0M0), postoperative assisted chemotherapyIn 2013, the patient developed right upper abdominal palpitations, diagnosed with "tumor hepatic metastasis" and "left liver internal lobe excision"A 2014 patient review found "tumor abdominal wall metastasis" and "abdominal wall particle implantation." In June 2016, the patient's left lower abdomen and right upper abdomen each touched a block, occasionally hidden pain, check PET-CT prompt "two-sided abdominal wall FDG metabolism increased", line "skin metastasis cancer microwave ablation."January 2017 the patient felt a tingling right upper abdominal wall, gradually aggravated, the area is mainly located in the upper right right of the umbilical cord (see Figure 1), Oscandin gradually increased to 100mg, 1 2 hours 1 time, the joint gabba dincapsule 600mg, 3 times a day, oral, pain numerical score (rating scale, NRS) score control 6 points, the patient wakes up at night and severely dizzy and severeThe doctor then sought surgery to discontinue or reduce the use of analgesicdrugs Figure 1 Right metastatic abdominal wall tumor 2) Selective nerve root blocking according to the pain area shown by the patient, physical examination positioning is mainly tadgentity area of T9 nerve, in order to further clarify the responsibility of nerve root and judge the effect of nerve cut-off, the right side OfT9 nerve root blocking technique under the guidance of the ct The puncture needle is positioned at the right T9 nerve root outlet, injected with contrast agent (iodine seaalcohol) 0.2 ml, CT contrast agent wrapped around the T9 nerve root, did not enter the vertebral tube (see Figure 2), and then 2% Lidoca in 0.2 ml, the patient felt the right upper abdominal pain site symptoms significantly reduced, NRS1, the effect is accurate, confirmed to be T9 spine nerve Figure 2 Selective T9 Nerve Root Block
3) The mode of surgery the patient to take the position of the lower, chest and abdomen cushionth pillow, continuous electrocardiogram monitoring Regular disinfection of the towel, through the C-arm perspective to locate the T9 vertebral level, and mark in the body table (see Figure 3) In the image guide to determine the needle route, 1% of Lidoca because of the success of layer-by-layer partial immersion anesthesia, first of all the needle puncture to the T9 right side of the vertebral plate outside the lower, equivalent to the lower joint protrusion and transverse junction, follow the puncture needle by the skin with dilation casing step-by-step expansion of soft tissue, placed in Working casing (see Figure 4), placement of the intervertebral perforation system and flushing system flushing, adjusting the appropriate water flow and pressure to continue physiological saline flushing, with a grinding drill and mirror ring saw to polish the vertebrae plate to widen the window widening the intervertebral hole, gradually separating the intervertebral hole surrounding the tissue to clearly display the right-hand T9 nerve root Close the flushing system, inject 2% Lidoca in the nerve root around 5 ml, wait a few minutes after full blocking the nerve root after the endoscope straight under the blue pliers bite the T9 ridge nerve (see Figure 5), bipolar radiofrequency scalphead on the nerve break end of the thermal coagulation, and finally through the working channel to thoroughly stop the work area after the wound disinfection stitching Figure 3 Image confirmation and body table marking puncture points Figure 4 put into the working channel Figure 5 T9 nerve root cut-off 2 Results patients in the T9 nerve-dominant area of abdominal wall pain significantly eased Gradually reduced to 50mg, 1 time for 12 hours, 200mg of gaba dincapsules, 3 times a day, oral, systemic pain control can be, NRS 3 minutes, no obvious drug side effects occurred A review of thoracic CT and 3D reconstruction images showed limitations of thoracic vertebral damage and small trauma (see Figure 6) After the operation of January, March and June, patients were followed up, the abdominal wall T9 nerve-dominant area NRS score was 2, 2, 2, 3, until the patient died in July after surgery, did not appear serious pain, accompanied by mild numbness Figure 6 Ct imaging 3 Discussion of malignant abdominal wall tumor pathology of a wide variety, can be divided into primary and metastasis, to metastasis Metastatic abdominal wall malignancies can come from various parts of the body, mostly due to advanced metastasis of abdominal gastrointestinal malignancies, or can be caused by tumor cell shedding and planting during abdominal surgery or laparoscopic surgery In recent years, with the progress of diagnosis and treatment technology, the prognosis of malignant tumors in the digestive tract has been significantly improved, and the survival time of some patients with tumors has been significantly extended However, once the digestive tract tumor abdominal wall attack metastasis, that is, the patient is considered to be in the late stage of the tumor, more than active tumor removal surgery, to treatment of the disease, chemotherapy and other systemic treatment, many patients have poor symptom control, poor quality of life Abdominal wall malignant tumor aggression of interribal nerve-induced cancer-related nerve pain (cancer-induced neuropathic pain, CINP), can be caused by the direct immersion of the tumor or the compression of nerves, can also be indirectly caused by changes in the neural environment, such as tumor growth, local and systemic inflammatory reactions caused by increased tissue acidity, release inflammatory factors such as tumor necrosis, and so on, and then lead to the sensitivity of the injury receptor It can also be caused by surgical treatment, radiotherapy and chemotherapy and other related treatmentmethods cancerous neuropathological pain is an important type of cancer pain, compared with injury sensory pain, its etiology and mechanism is more complex, often difficult to distinguish in clinical, less targeted treatment measures, poor tolerance of basic drug treatment, many patients pain control is insufficient, so comprehensive treatment is an effective treatment for cancer-related nerve pain, and minimally invasive interventional treatment has become one of the effective methods to control cancer-related nerve pain this case of b-shaped colon malignancy with abdominal wall metastasis patients, the effect of drug joint analgesia is not good, the side reaction is heavy, the patient is very painful, strong lying for nerve damage treatment At present, the rapid development of spinal endoscopy technology and skilled endoscopy operation technology, can now use this technology to solve more clinical problems, not only intervertebral disc removal or nerve root relief, endoscopy can be a target for surgery consider the shortcomings of past neuro-damage dissonance techniques, such as the risk of transvertebral drug damage may seep into the vertebral tube and the instability of the rfertic thermocosisation part, after careful discussion, this study initially developed a surgical plan for the cutting of nerves between the ribs under the spinal endoscopy, and obtained the consent of the patient and the family Before surgery to clarify the responsibility of the nerve is very critical, the relationship between the surgical operation site and the success of the post-operative, in the CT downstream diagnostic block positioning clearly affected nerve T9 spine nerve, CT guidance to make the puncture site more accurate, while the use of contrast agent can clarify the spread of hemp drug For patients whose tumor suing multiple rib nerves, the condition needs to be evaluated in detail before surgery, the effect of de-nerve control on the body, and the need to consider the length of surgery and the patient's tolerance for surgery surgical puncture operation is similar to spinal endoscopic thoracic disc removal, because the puncture point is closer to the middle line, so the puncture angle is more vertical, the puncture target is located in the lower joint sudden and transverse junction of the vertebrae plate The enlarged tube behind the pleural hole in the surgery reduces the damage to the pleural body and improves the safety and simplicity of the operation When grinding the thoracic vertebrae, care should be paid to protect the joint protrusions, while avoiding the damage of nerve roots, spinal cord, blood vessels, etc After fully revealing the nerve root, in order to avoid severe pain when the nerve is cut off, the nerve root is blocked first, but the correlation experience of applying local anaesthetic concentration and capacity, etc is lacking Considering that the surgical area of the Water Environment Bureau drug is easy to be diluted, and the excessive capacity of local anaesthetic easily into the vertebral tube to expand anesthesia and increase the risk, first injected 2% Lidoca in 5 ml, the performance of anesthesia in the operation is satisfactory Neuroma is the result of the failure of the cut-off nerve break autonomic reconstruction of nerve continuity, most nerve fractures will form a neuroma, but only a few produce pain Abnormal autonomic discharge of painful neuromas, patients often have needles, fire samples and other unbearable pain Studies such as Ramanavarapu have shown that thermal coagulation can denature neuromyelin Therefore, in order to avoid the occurrence of residual neuroma and nerve pain after nerve separation, we used a double-click radiofrequency scalpel head for thermal coagulation treatment of nerve breaks At the same time, the inflammatory reaction caused by surgery is also an important factor in the development of neuropathic pain, and the continuous flushing of physiological saline under the spinal endoscopic mirror reduces the accumulation of local inflammatory substances After the operation, we give patients the oral treatment of gabadin, on the one hand, can control the cancerous neuropathological pain, on the other hand, voltage-gated Ca2-channel blocker is also effective for painful neuromas through follow-up, patients did not experience painful neuromatic symptoms during their lifetime The clinical practice of this case shows that the neuro-cutting technique of spinal endoscopy is an effective, safe and minimally invasive method for patients with cancerous neuropathic pain who are poorly controlled by conservative treatment of spinal nerve severance At the same time, this technique may be applied to patients with rib pain after stubborn shingles, inter-rib pain after opening chest surgery, etc As this case is a cancerpatient with a short survival period, it remains to be seen whether patients with long-lived patients will have residual nerve pain