Hampton Hunter, Kalava Arun
Anesthesiology, University of Central Florida College of Medicine, Orlando, USA.
Cureus. 2023 Aug 30;15(8):e44377. doi: 10.7759/cureus.44377. eCollection 2023 Aug.
The pudendal nerve is situated deep within the pelvis and is a challenge to target for pain interventions due to the theoretical risk of incontinence with manipulation. The management of pudendal neuralgia using cryoablation is currently limited as it has historically required computed tomography (CT) guidance by interventional radiologists. Through this report, we describe a safe, reproducible, ischiorectal fossa approach to pudendal nerve cryoablation with a handheld device utilizing anatomical landmarks, nerve stimulation, and fluoroscopy. Two patients with longstanding pelvic pain and positive response to diagnostic pudendal nerve blocks underwent bilateral cryoablation of the pudendal nerves. This procedure was performed with the patients in prone positioning and percutaneous insertion of a cryoablation probe medial to the ischial tuberosity and lateral to the rectum. Correct positioning on the pudendal nerve was achieved with nerve stimulation eliciting visible anal sphincter contraction, and fluoroscopic imaging of the probe relative to the ischial spine. The probe was set to -88 Celsius for 108 seconds and a total of two cycles were performed. Pain reduction was reported for 3-4 months and repeat cryoablation was similarly efficacious with no evidence of incontinence. This technique, we believe minimizes risks and simplifies cryoablation to be performed on an outpatient basis by more pain physicians.
阴部神经位于骨盆深处，由于操作存在理论上的尿失禁风险，因此针对疼痛干预进行靶向治疗具有挑战性。目前，使用冷冻消融治疗阴部神经痛受到限制，因为从历史上看，这需要介入放射科医生进行计算机断层扫描（CT）引导。通过本报告，我们描述了一种安全、可重复的坐骨直肠窝入路，使用手持设备，利用解剖标志、神经刺激和荧光透视进行阴部神经冷冻消融。两名长期患有盆腔疼痛且对诊断性阴部神经阻滞有阳性反应的患者接受了双侧阴部神经冷冻消融。该手术在患者俯卧位时进行，经皮将冷冻消融探头插入坐骨结节内侧和直肠外侧。通过神经刺激引起可见的肛门括约肌收缩以及探头相对于坐骨棘的荧光透视成像，实现了在阴部神经上的正确定位。探头设置为-88摄氏度，持续108秒，共进行两个周期。据报告疼痛减轻持续3至4个月，重复冷冻消融同样有效，且没有尿失禁的迹象。我们认为，这种技术将风险降至最低，并简化了冷冻消融操作，使其能够由更多疼痛科医生在门诊进行。
