Locher Stephan, Burmeister Helge, Böhlen Thomas, Eichenberger Urs, Stoupis Christophoros, Moriggl Bernhard, Siebenrock Klaus, Curatolo Michele
Department of Anesthesiology, Division of Pain Therapy, University Hospital of Bern, Bern, Switzerland.
Pain Med. 2008 Apr;9(3):291-8. doi: 10.1111/j.1526-4637.2007.00353.x.
A previous study of radiofrequency neurotomy of the articular branches of the obturator nerve for hip joint pain produced modest results. Based on an anatomical and radiological study, we sought to define a potentially more effective radiofrequency method.
Ten cadavers were studied, four of them bilaterally. The obturator nerve and its articular branches were marked by wires. Their radiological relationship to the bone structures on fluoroscopy was imaged and analyzed. A magnetic resonance imaging (MRI) study was undertaken on 20 patients to determine the structures that would be encountered by the radiofrequency electrode during different possible percutaneous approaches.
The articular branches of the obturator nerve vary in location over a wide area. The previously described method of denervating the hip joint did not take this variation into account. Moreover, it approached the nerves perpendicularly. Because optimal coagulation requires electrodes to lie parallel to the nerves, a perpendicular approach probably produced only a minimal lesion. In addition, MRI demonstrated that a perpendicular approach is likely to puncture femoral vessels. Vessel puncture can be avoided if an oblique pass is used. Such an approach minimizes the angle between the target nerves and the electrode, and increases the likelihood of the nerve being captured by the lesion made. Multiple lesions need to be made in order to accommodate the variability in location of the articular nerves.
The method that we described has the potential to produce complete and reliable nerve coagulation. Moreover, it minimizes the risk of penetrating the great vessels. The efficacy of this approach should be tested in clinical trials.
先前一项关于闭孔神经关节支射频神经切断术治疗髋关节疼痛的研究效果一般。基于一项解剖学和放射学研究，我们试图确定一种可能更有效的射频方法。
对10具尸体进行研究，其中4具为双侧研究。用金属丝标记闭孔神经及其关节支。对其在荧光镜下与骨结构的放射学关系进行成像和分析。对20例患者进行磁共振成像（MRI）研究，以确定在不同经皮穿刺路径中射频电极会遇到的结构。
闭孔神经的关节支位置在很大范围内变化。先前描述的使髋关节去神经支配的方法没有考虑到这种变化。此外，它是垂直接近神经的。由于最佳的凝固需要电极与神经平行，垂直进针可能仅产生最小的损伤。此外，MRI显示垂直进针很可能会穿刺股血管。如果采用斜行进针可以避免血管穿刺。这种进针方式可使目标神经与电极之间的角度最小化，并增加神经被所造成的损伤捕获到的可能性。为了适应关节神经位置的变化，需要进行多个损伤。
我们所描述的方法有可能实现完全且可靠的神经凝固。此外，它将穿透大血管的风险降至最低。这种方法的疗效应在临床试验中进行检验。
