本文選題：射頻 + 疼痛　； 參考：《北京中醫(yī)藥大學(xué)》2015年碩士論文

【摘要】：射頻是交流變化頻率超過10000次的高頻電流,射頻交變電流在工作電極尖端產(chǎn)生變化磁場,使得在磁場范圍內(nèi)的靶點(diǎn)組織的離子發(fā)生震蕩,通過運(yùn)動摩擦生熱,使目標(biāo)組織或者神經(jīng)發(fā)生蛋白變性凝固,造成毀損。射頻熱凝技術(shù)被大量的用來治療疼痛性疾病。射頻能在C形臂或CT指引下,配合特殊電極用于椎間盤內(nèi)病變組織的射頻熱凝治療,使得病變椎間盤被毀損,從而解除突出的椎間盤對于脊神經(jīng)的壓迫,緩解患者的腰腿疼痛。射頻熱凝技術(shù)也被用來高選擇性的毀損痛覺神經(jīng)纖維的傳導(dǎo)支,阻斷疼痛信號向上位的神經(jīng)進(jìn)行傳導(dǎo),從而破壞疼痛傳導(dǎo)通路,達(dá)到控制疼痛的目的。膝關(guān)節(jié)骨性關(guān)節(jié)炎是老年人常見的一種退行性關(guān)節(jié)疾病。以軟骨退化變性、關(guān)節(jié)邊緣形成骨刺、滑膜肥厚為主要病理變化,以膝關(guān)節(jié)疼痛、功能障礙和畸形為主要臨床表現(xiàn)。骨關(guān)節(jié)炎的患病率隨著年齡的增大而升高,由于膝關(guān)節(jié)疼痛,嚴(yán)重影響了患者的關(guān)節(jié)功能,引起心理困擾,造成生活質(zhì)量下降。膝關(guān)節(jié)骨性關(guān)節(jié)炎的疼痛治療需要結(jié)合病人自身情況,如年齡、性別、體重、病變部位及程度等選擇合適的治療方案。對于常規(guī)口服藥治療效果不理想,或長期使用藥物產(chǎn)生胃腸道等副作用,導(dǎo)致患者不能耐受的早中期膝關(guān)節(jié)骨性關(guān)節(jié)炎患者,以及不宜接受截骨術(shù)和膝關(guān)節(jié)置換等手術(shù)治療的患者；另外,還有膝關(guān)節(jié)骨性關(guān)節(jié)炎中晚期患者合并癥多,不能耐受較大手術(shù)的的患者。射頻技術(shù)為患者提供了有效的治療手段,避免了長期服用藥物的副作用,也減輕了其對常規(guī)膝關(guān)節(jié)手術(shù)的心理負(fù)擔(dān)和經(jīng)濟(jì)負(fù)擔(dān)。目前,針對膝關(guān)節(jié)骨性關(guān)節(jié)炎的射頻治療,根據(jù)部位可分為：膝關(guān)節(jié)腔內(nèi)的射頻治療和針對隱神經(jīng)的射頻治療。在關(guān)節(jié)鏡下對膝關(guān)節(jié)骨性關(guān)節(jié)炎的射頻治療主要是通過等離子射頻汽化棒進(jìn)行的,是低溫消融,通過100KHz的強(qiáng)射頻電場,使等離子體薄層中的自由帶電粒子獲得足夠動能,打斷分子鍵,使靶組織細(xì)胞以分子為單位解體,在低溫下形成切割和消融效果。等離子射頻汽化棒可以在關(guān)節(jié)鏡的幫助下清理多種病變組織,包括：滑膜、軟骨等。等離子射頻汽化采用雙極技術(shù),電流不直接流經(jīng)組織,創(chuàng)面損傷小,深層組織仍保持健康狀態(tài)。膝關(guān)節(jié)骨性關(guān)節(jié)炎時,膝關(guān)節(jié)周圍的滑囊發(fā)炎、骨質(zhì)增生等引起膝周疼痛。同時,發(fā)炎的滑囊及增生的骨贅會刺激局部炎性滲出,粘連,造成隱神經(jīng)髕下支機(jī)械性卡壓或炎性損害,從而引起膝關(guān)節(jié)周圍疼痛加劇。另外,隱神經(jīng)髕下支由縫匠肌和股薄肌之間淺出,分布于膝關(guān)節(jié)內(nèi)下方及髕腱的前方,在下行途中,可能與膝內(nèi)、前、下部的深筋膜粘連,其外包裹大量的纖維組織,此處皮下脂肪層薄,緩沖力欠佳,易受勞損或外傷,而導(dǎo)致局部滲出粘連,造成神經(jīng)機(jī)械性卡壓或炎性損害。這種疼痛比較頑固,局部臨床表現(xiàn)為股骨內(nèi)側(cè)髁、脛骨內(nèi)側(cè)髁、內(nèi)側(cè)關(guān)節(jié)囊處有壓痛,皮膚針刺樣疼痛或痛覺減退,還可表現(xiàn)為酸痛或脹痛。單純玻璃酸鈉膝關(guān)節(jié)內(nèi)注射的效果不理想。在玻璃酸鈉關(guān)節(jié)內(nèi)注射的基礎(chǔ)上,有效地針對隱神經(jīng)進(jìn)行治療,能緩解隱神經(jīng)卡壓等引起的疼痛。隱神經(jīng)阻滯能解除膝關(guān)節(jié)疼痛,主要通過使用激素類藥物消除炎癥并軟化纖維組織,解除對隱神經(jīng)的壓迫來改善癥狀,減輕疼痛。由于射頻技術(shù)的不斷推廣,近年來,很多研究人員在臨床上對隱神經(jīng)射頻治療膝關(guān)節(jié)周圍疼痛做了新的嘗試,并且都取得了滿意的療效針對隱神經(jīng)的射頻治療,通過高選擇性的毀損痛覺神經(jīng)纖維的傳導(dǎo)支,阻斷疼痛信號向上位神經(jīng)傳導(dǎo),而破壞痛覺傳導(dǎo)通路,達(dá)到控制疼痛的目的。作用于隱神經(jīng)的射頻手術(shù)模式：包括射頻定位的電刺激 (Stimulation)、標(biāo)準(zhǔn)射頻損毀模式(SL:Standard Lesioning).脈沖射頻損毀模式(PL:Puse lesioning)。目前第一種方法主要是用于治療前后的測試和確定射頻針的位置。針對隱神經(jīng)的射頻治療一般采用標(biāo)準(zhǔn)射頻損毀模式和脈沖射頻損毀模式。標(biāo)準(zhǔn)射頻損毀模式臨床常采用的設(shè)定參數(shù)為溫度70～90℃,工作時間80-120 s,工作頻率10 Hz,每周期工作時間是100 ms,是連續(xù)工作,無間歇期,溫度上升模式為線性上升。脈沖射頻損毀模式臨床常采用的參數(shù)設(shè)定為：溫度42℃,時間120 s,工作頻率為2 Hz,每周期工作時間為20s,時間間歇是480 ms,溫度上升模式為階梯式上升。本研究隱神經(jīng)射頻采用的標(biāo)準(zhǔn)射頻參數(shù)為：溫度75℃,工作時間90s,工作頻率10 Hz。隱神經(jīng)射頻僅針對感覺神經(jīng),干擾疼痛信號由隱神經(jīng)向中樞神經(jīng)系統(tǒng)的傳輸。在射頻治療隱神經(jīng)時,通過射頻定位模式,保證了對感覺神經(jīng)的選擇無誤。其次,可以借助超聲引導(dǎo),有效提高神經(jīng)定位的準(zhǔn)確性。還可以通過診斷性測試,確定是否為隱神經(jīng)的確切定位。另外,標(biāo)準(zhǔn)射頻損毀模式的溫度設(shè)定在75-C以下；而脈沖射頻損毀模式的溫度設(shè)定在42℃,一般都不會毀損運(yùn)動神經(jīng)纖維。因而,隱神經(jīng)射頻治療是比較安全的治療手段。隱神經(jīng)射頻治療,定位確切,創(chuàng)傷小,并發(fā)癥少,安全性高,可重復(fù),避免了長期服用藥物的副作用,減輕了患者對常規(guī)膝關(guān)節(jié)手術(shù)的心理負(fù)擔(dān)和經(jīng)濟(jì)負(fù)擔(dān)。WOMAC骨關(guān)節(jié)炎指數(shù)(Western Ontario and McMaster Universities Osteoarthritis Index西安大略和麥克馬斯特大學(xué)關(guān)節(jié)炎指數(shù))是美國風(fēng)濕性關(guān)節(jié)炎臨床研究組創(chuàng)建的測量工具。該測量工具也用于評估髖或膝關(guān)節(jié)骨關(guān)節(jié)炎。由受試者如實填寫,只對病變膝關(guān)節(jié)評分,從軀體功能、僵硬、疼痛程度三方面以0-100毫米評分。SF-36是美國波士頓健康研究所研制的簡明健康調(diào)查問卷,主要用于普通人群的生存質(zhì)量測定、臨床試驗效果評價和衛(wèi)生政策評估。SF-36從生理機(jī)能、生理職能、軀體疼痛、一般健康狀況、精力、社會功能、情感職能以及精神健康共8個方面,通過36個具體問題,全面概括了受試者的生存質(zhì)量,可以全面地評價被調(diào)查者的身體和精神兩方面的健康狀況。本研究采用WOMAC疼痛、僵硬和功能三方面評分,以及SF-36生理機(jī)能、精力兩個方面評分,評價隱神經(jīng)射頻治療后膝關(guān)節(jié)功能、患者生存質(zhì)量改善情況,具有全面、準(zhǔn)確的特點(diǎn)。本研究共分為兩個部分：第一部分玻璃酸鈉關(guān)節(jié)內(nèi)注射復(fù)合隱神經(jīng)射頻治療緩解膝關(guān)節(jié)疼痛目的：觀察玻璃酸鈉關(guān)節(jié)內(nèi)注射復(fù)合隱神經(jīng)射頻治療膝關(guān)節(jié)疼痛的有效性。方法：將60例膝關(guān)節(jié)骨性關(guān)節(jié)炎患者隨機(jī)分成實驗組(C組,n=30)和對照組(H組,n=30),實驗組給予玻璃酸鈉復(fù)合隱神經(jīng)射頻治療緩解膝關(guān)節(jié)疼痛；對照組給予玻璃酸鈉膝關(guān)節(jié)內(nèi)注射,但是不給予有效地射頻治療,評價治療前,治療后5分鐘,1周,2周和4周時的WOMAC評分和SF-36生活質(zhì)量評分(PF和VT),并記錄治療中和治療后的并發(fā)癥。結(jié)果：實驗組和對照組在WOMAC疼痛改善,晨僵,身體功能和SF-36生活質(zhì)量評分(PF和VT)的平均改變有差異,P0.05,兩組差異存在統(tǒng)計學(xué)意義。結(jié)論：玻璃酸鈉關(guān)節(jié)內(nèi)注射復(fù)合隱神經(jīng)射頻治療膝關(guān)節(jié)疼痛的療效優(yōu)于單純玻璃酸鈉關(guān)節(jié)內(nèi)注射治療膝關(guān)節(jié)疼痛的療效。第二部分玻璃酸鈉關(guān)節(jié)內(nèi)注射分別聯(lián)合隱神經(jīng)射頻及隱神經(jīng)阻滯治療膝關(guān)節(jié)疼痛的療效對比目的：觀察玻璃酸鈉關(guān)節(jié)內(nèi)注射分別聯(lián)合隱神經(jīng)射頻與隱神經(jīng)阻滯治療膝關(guān)節(jié)疼痛的療效對比。方法：將50例膝關(guān)節(jié)疼痛患者,隨機(jī)分成玻璃酸鈉關(guān)節(jié)內(nèi)注射聯(lián)合隱神經(jīng)射頻組(C組,n=25)和玻璃酸鈉關(guān)節(jié)內(nèi)注射聯(lián)合隱神經(jīng)阻滯組(H組,n=25),C組給予玻璃酸鈉關(guān)節(jié)內(nèi)注射聯(lián)合隱神經(jīng)射頻；H組給予玻璃酸鈉關(guān)節(jié)內(nèi)注射聯(lián)合隱神經(jīng)阻滯,評價治療前,治療后1周和4周時的WOMAC評分和SF-36生活質(zhì)量評分與基礎(chǔ)值的差值,同時記錄治療中和治療后的并發(fā)癥及不良反應(yīng)。結(jié)果：實驗組和對照組在WOMAC疼痛改善,晨僵,身體功能和SF-36生活質(zhì)量評分(PF和VT)的平均改變有差異,P0.05,兩組差異存在統(tǒng)計學(xué)意義。結(jié)論：玻璃酸鈉關(guān)節(jié)內(nèi)注射聯(lián)合隱神經(jīng)射頻治療膝關(guān)節(jié)疼痛的療效優(yōu)于玻璃酸鈉關(guān)節(jié)內(nèi)注射復(fù)合隱神經(jīng)阻滯治療的療效。
[Abstract]:Radio frequency is a high frequency current with alternating frequency of more than 10000 times. The radio frequency alternating current produces a changing magnetic field at the tip of the working electrode, making the ion of the target tissue in the range of the magnetic field oscillates. The target tissue or neurogenic protein is solidified by the movement friction and causes damage. The radiofrequency thermocoagulation technology is used in a large amount. To treat pain disease. Radiofrequency can be used with a C arm or CT, combined with a special electrode for radiofrequency thermocoagulation in the diseased tissue of the intervertebral disc, causing diseased intervertebral discs to be damaged, thus relieving the compression of the spinal nerve and alleviating the pain of the lumbago and legs. The conduction branch of the nerve fibers, which blocks the pain signal conduction to the upper nerve, destroys the pain conduction path and controls the pain. Osteoarthritis of the knee is a common degenerative joint disease of the elderly. The degeneration of cartilage, the edge of the joint, the main pathological changes of the synovial hypertrophy, and the knee closure. Pain, dysfunction and malformation are the main clinical manifestations. The incidence of osteoarthritis increases with age. Due to knee pain, it seriously affects the joint function of the patients, causes psychological distress and causes a decline in quality of life. The treatment of knee osteoarthritis needs to be combined with the patient's own condition, such as age and sex, It is not ideal for the treatment of conventional oral medicine, or the long-term use of the side effects of the gastrointestinal tract, which leads to the patients' intolerance of the patients with early and middle knee osteoarthritis, and the patients who are not suitable for osteotomy and knee replacement. There are more patients with middle and advanced osteoarthritis of the knee joint, which can not tolerate large surgery. Radiofrequency technology provides effective treatment for patients, avoids the side effects of long-term medication, and reduces the psychological burden and financial burden on conventional knee surgery. Radiofrequency therapy is divided into radiofrequency therapy in the knee joint and radiofrequency therapy for the saphenous nerve. Radiofrequency therapy for osteoarthritis of the knee under arthroscopy is mainly carried out by plasma radiofrequency vaporization rod, which is cryogenic ablation, and the free charged particles in the plasma thin layer are made through a strong radiofrequency electric field of 100KHz. To get enough kinetic energy to break the molecular keys to disintegrate the cells of the target tissue and disintegrate the molecules in a unit and to form a cutting and ablation effect at low temperatures. The plasma radiofrequency vaporization rod can clean up a variety of pathological tissues under the help of the arthroscope, including the synovium, cartilage, etc. plasma radiofrequency vaporization uses bipolar technique, the current does not flow directly through the tissue, and the wound is wound. The injury is small and the deep tissue remains healthy. During the osteoarthritis of the knee, the inflammation of the sac around the knee, the hyperosteogeny, and so on, causes the pain of the knee. At the same time, the inflammatory cysts and proliferating osteophyte will stimulate the local inflammatory exudation, adhesion, and cause the mechanical entrapment or inflammatory damage of the inferior patellar branch, causing the pain around the knee joint. In addition, the Subpatellar branch of the saphenous nerve is shallow between the sartorius and the gracilis muscle, distributed in the lower knee and front of the patellar tendon. In the downlink, it is possible to adhere to the deep fascia in the knee, front and lower part of the knee, and encapsulate a large number of fibrous tissue. The subcutaneous fat layer is thin, the buffer force is poor, and it is vulnerable to strain or trauma, which leads to partial exudation. Adhesion, causing neuromechanical compression or inflammatory damage. This pain is relatively stubborn. Local clinical manifestations are the medial condyle of the femur, the medial tibia, the inner condyle of the tibia, the pain of the medial articular capsule, the needling pain of the skin or the hypoalgesia, and the pain or sore pain. The effect of intralamna injection of sodium hyaluronate is not ideal. On the basis of intrapele injection, effective treatment of the saphenous nerve can relieve the pain caused by the pressure of the hidden nerve. The saphenous nerve block can relieve the pain of the knee joint. It is mainly through the use of hormone drugs to eliminate inflammation and soften the fibrous tissue, relieve the pressure of the hidden nerve to improve the symptoms and relieve the pain. In recent years, many researchers have made a new attempt to treat the pain around the knee by radiofrequency therapy, and have achieved a satisfactory therapeutic effect on the radiofrequency therapy of the saphenous nerve. Through high selective damage to the conduction branch of the painful nerve fibers, it blocks the conduction of the pain signal to the upper nerve, and destroys the pain conduction pathway. To control the pain, the radiofrequency operation mode of the saphenous nerve: radio frequency stimulation (Stimulation), standard radio frequency damage model (SL:Standard Lesioning). Pulse radio frequency damage model (PL:Puse lesioning). The first method is mainly used to test and determine the location of the radiofrequency needle before and after treatment. The radiofrequency radiofrequency therapy for saphenous nerve generally adopts the standard radio frequency damage model and pulse radio frequency damage model. The standard radiofrequency damage mode is often used as the setting parameters of 70~90 C, working time 80-120 s, working frequency 10 Hz, working time of 100 ms per cycle, continuous work, no interval, and temperature rising mode linear rise. The parameters of the radiofrequency ablation model are: temperature 42 C, time 120 s, working frequency 2 Hz, working time of 20s, time interval of 480 MS, and rising mode of temperature rise. The standard radiofrequency parameters used in this study are: temperature 75, working time 90s, working frequency 10 Hz. hidden God Radiofrequency is only for the sensory nerve, which interferes with the transmission of the pain signal from the saphenous nerve to the central nervous system. In the radiofrequency treatment of the saphenous nerve, the selection of the sensory nerve is ensured by the radiofrequency positioning mode. Secondly, the accuracy of the neural location can be improved effectively by the ultrasound guidance. It can also be determined by diagnostic test to determine whether or not. For the exact location of the saphenous nerve. In addition, the temperature of the standard radiofrequency damage model is set below 75-C; and the temperature of the pulse radio frequency damage mode is set at 42 degrees C, and generally does not damage the motor nerve fibers. Therefore, radiofrequency therapy is a safer treatment. High safety, repeatable, avoiding side effects of long-term use of drugs, alleviating the psychological burden and economic burden of patients on conventional knee surgery.WOMAC Osteoarthritis Index (Western Ontario and McMaster Universities Osteoarthritis Index Xi'an and McMaster University arthritis index) is American rheumatoid arthritis The measurement tool created by the clinical research group is also used to assess the osteoarthritis of the hip or knee. The subjects were filled out, and only 0-100 millimeters of.SF-36, the three aspects of the somatic function, stiffness and pain, were the concise health questionnaire developed by the Boston Health Research Institute in the United States. The quality of life of the general population, the clinical trial effect evaluation and the health policy evaluation.SF-36 from the physiological function, the physiological function, the physical pain, the general health condition, the energy, the social function, the emotional function and the mental health. Through 36 specific problems, the quality of life of the subjects can be fully summarized, and the.SF-36 can be comprehensively evaluated. The two aspects of physical and mental health of the investigators. The study adopted the score of WOMAC pain, stiffness and function in three aspects, as well as the score of the physiological function of SF-36 and energy in two aspects. It evaluated the knee joint function after the radiofrequency therapy of the hidden nerve, and the improvement of the quality of life of the patients. This study was divided into two parts: The first part of sodium hyaluronate injection combined with saphenous nerve radiofrequency therapy to relieve the pain of knee joint: To observe the effectiveness of radiofrequency treatment for knee joint pain by intraarticular injection of sodium hyaluronate. Methods: 60 patients with osteoarthritis of the knee joint were randomly divided into experimental group (group C, n=30) and control group (group H, n=30), and the experimental group was given. Radiofrequency therapy with sodium hyaluronate combined with saphenous nerve was used to relieve knee pain. The control group was given intraarticular injection of sodium hyaluronate, but no effective radiofrequency therapy was given. The WOMAC score and SF-36 quality of life score (PF and VT) were evaluated at 5, 1, 2 and 4 weeks before treatment, and the complications after treatment and treatment were recorded. Results: in the experimental group and the control group, the WOMAC pain improvement, the morning stiffness, the body function and the SF-36 quality of life score (PF and VT) were different, P0.05, the two groups were statistically significant. Conclusion: the effect of sodium hyaluronate intraarticular injection of compound saphenous nerve for the pain of knee joint is better than that of sodium hyaluronate intra-articular injection. Curative effect of knee joint pain. Comparison of the curative effect of second part sodium hyaluronate combined with saphenous nerve block and radiofrequency and saphenous nerve block in the treatment of knee pain. Objective: To observe the curative effect of intraarticular injection of sodium hyaluronate combined with saphenous nerve block and saphenous nerve block in the treatment of knee pain. Method: 50 cases of knee joint pain were treated with sodium hyaluronate. The pain patients were randomly divided into sodium hyaluronate intra-articular injection combined with saphenous nerve radio frequency group (group C, n=25) and sodium hyaluronate joint injection combined with hidden nerve block group (group H, n=25). Group C was given intra-articular injection of sodium hyaluronate combined with saphenous nerve radiofrequency, and group H was given intra-articular injection of sodium hyaluronate combined with saphenous nerve block, before the treatment, 1 weeks after the treatment. The difference between the WOMAC score and the SF-36 quality of life score and the base value at the 4 week, and the complications and adverse reactions after treatment and treatment were recorded. Results: there were differences in the improvement of WOMAC pain, morning stiffness, physical function and SF-36 quality of life score (PF and VT) in the experimental group and the control group, and the differences in the P0.05 and the two groups were statistically significant. Conclusion: the curative effect of sodium hyaluronate combined with intra-articular injection of saphenous nerve in the treatment of knee pain is better than that of intra-articular injection of sodium hyaluronate.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R684

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