Wong C S, Shen T T, Liaw W J, Cherng C H, Ho S T
Department of Anesthesiology, National Defense Medical Center, Taipei, Taiwan, R.O.C.
Acta Anaesthesiol Sin. 1996 Sep;34(3):151-5.
The N-methyl-D-aspartate (NMDA) receptor system plays an important role in nociceptive signal modulation in the central nerve system. There is considerable evidence that NMDA receptor antagonists can abolish hypersensitivity of nociceptors in animal models. In this case report, we described a patient who suffered post-herpetic neuralgia with severe pain, allodynia, and hyperesthesia over right side T2 to T8 dermatomes. Treatment with conventional doses of non-steroid anti-inflammatory drug (NSAID), antidepressant, anticonvulsant and benzodiazepine failed to provide satisfactory pain relief. With the patient's consent, we administered subanalgesic doses of ketamine (10 mg), morphine (1 mg), and 6 ml bupivacaine (0.1%) through the thoracic epidural route. After the treatment, hyperalgesia and allodynia improved dramatically, and the receptive field also reduced. After four weeks' treatment, satisfactory pain relief was achieved with conventional analgesics treatment. The combination of relatively low doses of morphine, ketamine and bupivacaine epidurally provides effective pain relief in this case. The result strongly suggests a synergy from this combination that warrants a formal study of the dose-response relationship involved in this treatment and the mechanism by which this effect is achieved. This regimen provides a promising treatment for the neuropathic pain with limited side effects.
N-甲基-D-天冬氨酸（NMDA）受体系统在中枢神经系统伤害性信号调制中起重要作用。有大量证据表明，NMDA受体拮抗剂可消除动物模型中伤害感受器的超敏反应。在本病例报告中，我们描述了一名患有带状疱疹后神经痛的患者，其右侧T2至T8皮节出现严重疼痛、痛觉过敏和感觉异常。使用常规剂量的非甾体抗炎药（NSAID）、抗抑郁药、抗惊厥药和苯二氮䓬类药物治疗未能提供满意的疼痛缓解。在患者同意下，我们通过胸段硬膜外途径给予亚镇痛剂量的氯胺酮（10毫克）、吗啡（1毫克）和6毫升布比卡因（0.1%）。治疗后，痛觉过敏和痛觉异常显著改善，感觉野也缩小。经过四周治疗，使用常规镇痛药治疗取得了满意的疼痛缓解。硬膜外给予相对低剂量的吗啡、氯胺酮和布比卡因的联合用药在本病例中提供了有效的疼痛缓解。结果强烈提示这种联合用药具有协同作用，值得对该治疗中涉及的剂量反应关系以及实现这种效果的机制进行正式研究。这种治疗方案为副作用有限的神经性疼痛提供了一种有前景的治疗方法。
