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病例漫谈103:腰椎间盘突出诱发严重疼痛的治疗 [复制链接]

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ABSTRACT
Lumbar intervertebral disk protrusion can cause excruciating pain in severe cases, which can be exacerbated by activity such as sitting down and straining at stool. Acute sciatica due to disk rupture will improve within 1 to 3 months. The efficacy of drugs used for the management of sciatica in primary care is unclear. Severe cases can require opioid analgesia, however people taking opioids for pain relief frequently present with opioid-induced bowel dysfunction. The use of transforaminal steroid injections is a controversial issue and repeat steroid injections should be considered in light of the risk-benefit profile of the individual patient.
摘要
一些严重病例中,腰椎间盘突出症引起剧烈疼痛,这种疼痛可因活动而加剧,如落坐和用力排便。椎间盘破裂引起的急性坐骨神经痛在1-3个月内会有所改善。坐骨神经痛初级治疗的药物疗效尚不明确。严重的病例需服用阿片类药物镇痛,然而患者服用阿片类药物缓解疼痛的同时常伴随阿片类药物诱导的肠功能紊乱。椎间孔类固醇注射治疗仍有争议,个别患者应当在权衡风险-利益后才考虑再次接受类固醇注射。

BACKGROUND
This article describes a case where strong opioid medication was required to relieve pain and where prolonged release oral oxycodone/naloxone presented the advantage of limiting situations where opioid-induced constipation would cause exacerbation of existing pain.
背景
本文报道了一例需服用强力阿片类药物镇痛的病例,此病例中患者服用口服缓释羟考酮/纳洛酮,此方案的优势是能控制阿片类药物诱导的便秘,这种便秘加重现有的疼痛。

DISCUSSION
This case illustrates that many patients with lumbar disk protrusion complain of a significant exacerbation of their back and radicular pain as a consequence of coughing, straining at stool and so on. Many of these patients require opioid medication to control their pain; however, the ever-present problem of opioid-induced constipation can exacerbate their pain. The use of prolonged release oral oxycodone/naloxone in this situation could therefore be beneficial.
讨论

此病例证明了多数腰椎间盘突出患者主诉的情况,即咳嗽、用力大便等会引起背部和神经根疼痛明显加剧。这些患者中的大多数需服用阿片类药物镇痛;然而,始终存在的问题是阿片类药物诱导的便秘会加剧患者疼痛。因此,在这种情况下,口服缓释羟考酮/纳洛酮是有益的。

CASE ASSESSMENT
A 40-year-old male sales representative was referred acutely to the pain clinic by his family doctor. He had been previously diagnosed with type 2 diabetes mellitus. He had severe right-sided low back pain radiating to his right buttock and down the lateral aspect of his right thigh and calf. This pain occurred suddenly 2 weeks prior to review. His family doctor had prescribed diclofenac 50 mg three times daily and pregabalin 75 mg 12 hourly. The pain did not settle, so his doctor had prescribed prolonged release oxycodone 10 mg twice daily and this was increased to 10 mg three times daily 2 days later, in addition to immediate release oxycodone 10 mg 2-4 hourly for acute exacerbations of pain.
病例评估
一例40岁男性患者,其工作是销售代表,因急性疼痛由其家庭医生送到了疼痛门诊部。  之前,患者已被诊断出患有II型糖尿病。患者右侧下腰背疼痛已经放射到右臀部,以及右大腿和小腿的外侧。此疼痛于就诊检查前2周突发。患者的家庭医生开具的处方为双氯芬酸50 mg(每日三次),普瑞巴林75 mg(每12h一次)。但该处方没有减轻疼痛,随后医生让其服用口服缓释羟考酮,每次10 mg,每日两次,2天后服药剂量增加到每次10 mg,每日三次,同时服用速释羟考酮以避免急性疼痛加重,每次10 mg,每2 - 4 h服用一次。

The patient complained that sitting down and, in particular, straining at stool exacerbated his pain.He stated that this exertion increased his pain score to “20/10” on the visual analog scale. He did not have any symptoms associated with cauda equine syndrome, or other “red flag” symptoms.
患者主诉其坐下,尤其是用力大便时疼痛会加剧,这一负荷使得患者疼痛的视觉模拟评分值增加到了“20/10”。患者无任何尾马综合征症状或其他“危险信号”症状。

An MRI of the lumbar spine confirmed the presence of an annular tear at L4-5 and a broad-based right posterolateral disk protrusion at L5-S1, with impingement of the exiting L5 spinal nerve. Because of difficulties arranging a day case admission for a therapeutic right-sided transforaminal epidural injection of steroid, the patient was commenced on prolonged release oxycodone 20 mg/naloxone 10 mg combined tablet twice daily in conjunction with a fecal softener/stimulant, two capsules at night.
腰椎MRI检查证实L4-5存在环形撕裂,L5-S1右后侧存在范围较大的椎间盘突出并对L5脊神经造成碰撞。由于每天接受右侧椎间孔硬膜外类固醇注射治疗很困难,患者开始服用缓释羟考酮20mg和纳洛酮10mg,每日均两次,同时联合服用大便软化剂/兴奋剂,每晚两粒。                

There was a 4 day delay in gaining admission to hospital for treatment, however the treatment regimen described above was successful in controlling the patient’s pain and there were no exacerbations of pain due to straining at stool.
患者拖延了4天才入院治疗,不过上述治疗方案还是有效控制了疼痛,因用力大便导致的痛苦也没有加重。        

The patient underwent a successful transforaminal injection under radiological screening and he was referred for neurosurgical opinion. As his pain was well controlled and there were no further complications, surgery was deferred and the patient was scheduled for a repeat transforaminal injection of steroid. His oxycodone/naloxone dosage was decreased to 10/5 mg twice daily immediately post-procedure and this achieved adequate pain control. It is envisaged to discontinue the oxycodone/naloxone immediately following the repeat injection.
患者成功接受了影像引导下的椎间孔注射,同时听取了神经外科的相关意见。因患者疼痛控制良好,且无进一步并发症,暂缓了手术,并再次接受了椎间孔类固醇注射。椎间孔注射后立即减少羟考酮/纳洛酮服药量至10/5mg,仍每日两次,这有效控制了疼痛。患者希望再次接受注射后停止服用羟考酮/纳洛酮。

COMMENTARY FROM SWEDEN
Annica Rhodin

This patient has a few weeks history of severe pain due to right posterolateral disk protrusion with impingement on the L5 spinal nerve but no signs of cauda equina impact. He also has type 2 diabetes. His pain mechanism, as described, would be mixed nociceptive-neuropathic. There is inadequate pain relief with diclofenac 50 mg three times daily and pregabalin 75 mg twice daily. Prolonged release oxycodone 10 mg three times daily and immediate release oxycodone 10-40 mg as needed is added. However, constipation and straining at stool increases the pain.
来自瑞典的评论
Annica Rhodin
该患者因右后侧椎间盘突出对L5脊神经的撞击,造成剧烈疼痛持续了数周,但马尾神经未受影响。患者同时患有II型糖尿病。此痛苦机制为混合型疼痛(伤害性疼痛联合神经性疼痛)。双氯芬酸(50 mg,每日三次)联合普瑞巴林(75 mg,每12h一次)没有达到止痛的效果。然而,缓释羟考酮(10mg,每日三次)联合速释羟考酮(根据需要在处方中增加,10-40mg),便秘和用力大便会使疼痛加剧。

In the case described, oxycodone is switched to prolonged release oxycodone 20 mg/naloxone 10 mg together with a fecal stool softener/stimulant, relieving the problem with constipation contributing to the pain experience. This certainly improves the situation for the patient. However, the invasive procedure of transforaminal injection of steroid in a patient with acute pain is a controversial issue. Even if there is a low risk of complications as cited in many reviews, there are cases of neuronal damage, bleeding and infection. Repeat steroid injections should be carefully considered in respect of the risk-benefit profile of this patient with diabetes. Also, this procedure is not easily accessible in most hospitals.
正如病例中所描述的,将羟考酮改为缓释羟考酮20mg/纳洛酮羟考酮10mg,同时服用大便软化剂/兴奋剂以缓解因便秘引起的疼痛。这确实改善了患者病情。然而,行椎间孔类固醇注射这种具有侵入性的手术治疗急性疼痛患者仍有争议。即使许多综述性文章都提到该手术诱发并发症的风险较低,但仍有出现神经损伤,出血和感染的病例。这名同时患有糖尿病的患者应该在详细权衡风险–利益后才考虑再次注射类固醇药物。另外,该手术在多数医院都较难实施。

An alternative conservative treatment would be to try a different anti-inflammatory drug to diclofenac, as individual patients may respond differently to different NSAIDs. Furthermore, amitriptyline 10-50 mg could be started at night together with physiotherapy and TENS. Most cases of acute sciatica resolve within 1-3 months.
一种可选的保守治疗是服用另一种不同的抗炎药双氯芬酸,因为患者对不同非甾体类抗炎药的反应各不相同。此外,可在晚上服用阿米替林10-50mg,并接受理疗和TENS治疗。多数急性坐骨神经痛病例是在1到3个月内治愈的。

COMMENTARY FROM ISRAEL
Elon Eisenberg

This case raises three important issues: first, the majority of patients with acute sciatica due to disk rupture will improve within 1-3 months; only a small proportion of patients, typically those with intractable pain or with significant neurological deficits, require surgery. 1 This means that the majority of the patients with sciatica should be managed in the primary care/pain clinic setting, rather than being referred to spine surgeons. Primary care practitioners should therefore be capable of diagnosing and managing patients with uncomplicated acute sciatica.
来自以色列的评论
Elon Eisenberg
此病例指出了三个重要问题:一、多数椎间盘断裂引起急性坐骨神经痛的患者在1-3个月内病情能得到改善;仅有少数患者需进行手术,通常这些患者都出现了顽固性疼痛或明显神经功能缺损。这意味着多数坐骨神经痛患者应该由初级保健/疼痛门诊部治疗,而不是脊柱外科部。对于无并发症的急性坐骨神经痛患者,初级保健从业者应当具有诊断和治疗的能力。

Second, although sciatica is the most common form of neuropathic pain, a recent systematic review on drugs for the relief of sciatic pain concluded that “ the efficacy and tolerability of drugs commonly prescribed for the management of sciatica in primary care is unclear.” 2 No wonder therefore that the selection of analgesics prescribed for this condition is often arbitrary. Nonetheless, if pain is severe and image-guided steroid injections are not readily available, the use of a “strong” opioid in combination with an adjuvant drug (anticonvulsants, antidepressants or steroids) or an anti-inflammatory drug may make sense.
二、尽管坐骨神经痛是神经性疼痛中最常见的形式,但是近期系统文献回顾对缓解坐骨疼痛的药物总结认为“坐骨神经痛初级保健中常用的处方药疗效和耐受性仍不明确。”因此,在这种情况下,止痛药的处方选择常具有随意性也就不奇怪了。尽管如此,如果疼痛剧烈且影像引导下类固醇注射又难以实现时,给予“强力”阿片类药物结合辅助类药物(抗惊厥药、抗抑郁药或类固醇)或抗炎药可能是有意义的。          

Third, studies show that, on average, approximately 40% of patients who consume opioids are constipated. Reduced mobility associated with the acute or subacute phases of severe sciatic pain may also be expected to cause constipation. Constipation, in turn, often exacerbates sciatic pain around strained bowel movements, as seen in the presented patient. Hence, the use of oxycodone/naloxone combination for acute sciatica (and perhaps for additional forms of acute exacerbations of chronic pain) seems reasonable.
三、研究表明,服用阿片类药物的患者中平均约40%出现了便秘。严重坐骨神经痛急性或亚急性期的活动能力下降也可能导致便秘。便秘反过来又会使排便用力时出现坐骨疼痛,此患者即出现了这种情况。因此,联合使用羟考酮和纳洛酮治疗急性坐骨神经痛(或者慢性疼痛急性加剧的其他形式)似乎是合理的。

由Medicool医库软件 王露黔 编译

原文来自 Journal of Pain &Palliative Care Pharmacotherapy

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