r HQC VI$T NAM THANG 9 - s6 2/2012
NHAN X £ T T I N H HlNH DliU TRj OAU THAN KINH HONG TO DO THOAT Vj DiA Dim COT SONG THAT LUNG TAI KHOA CO XUIDNG KHOIP BENH VIEN BACH MAI
Nguyen Thj Ngpc Lan*, Nguyin Thj Hiln*
T6MTAT
Oau thin kinh hdng to do thoit v| dia df m eft sdng thit luYig thudng gfp va cd nhieu phuUng phip d i u trj. M|jc tISu: (1). Nhan xet cac phudng phip dieu trj dau than kinh hdng to do thoat vj dia dfm eft sdng thit lung tai khoa Of XUdng Khdp Bfnh vien B^ch Mai nim 2010- 2011.(2). Dinh gii hifu qua v i tinh an toan cua
<ic phudng phip dddc ap dpng. Ddi tu'dng:
gSm 60 bfnh nhan dau than kinh toa do thoat vj dia dem eft sdng thit Idng dieu tri ndi tru tai kiioa Cd xuting khdp bfnh vifn Bach Mai td ngay 06/01/2010 den ngay 01/04/2011 duHc chan doan xac dinh qua trifu chiing lam sang v i ket qua diup cpng hudng tir eft sdng that Idng.
Phu'dng phip: Md t i cit ngang. Ket qua: (1).
Co ba phudng phap dieu trj la dung thudc, bao gSm thudc chdng viem khdng steroid; thudc giam dau va thuoc gian cd (100%), dem ngoai mang cutig (90%), phgc hoi chiic ning (60%).
Co 56,7% benh nhan dudc ket hop c i ba phddng phap. So ngiy dieu tri trung binh: 11,27 ± 3,19 ngiy. (2). Phic do dat hifu qui d 93,3% sd bfnh nhin. Blem sd VAS: dat VAS 2,08 ± 1,05 diem so vdl 5,83 ± 1,08 diem tai TO; (p<0,001);
Oil so Lasigue: dat 82,17 ± 5,99° so vdl 57,92 ± 17,11° taiT°(p<0,001); 100% benh nhan dddc diiu trj la dau vCi;a hoic ning, sau dieu tri ty If niy dii cdn 20%. T'^ If t i l phat: 9,09%, thdi gian a phat dung binh la 6,67 ± 3,21 thing (3- 9 Slang). Phac do an toan: ty If tic dung khong nong muon dddl 7%. KSt lufn: Cd ba phu'dng piiap dieu til la dung thudc (100%), tiem ngoii
ming cdng (90%), phuc hoi chdc ning (60%), cd 56,7% bfnh nhin dddc ket hpp ca ba phu'dng phap. Lieu trinh dieu trj ran 11,27 ± 3,19 ngiy;
cd 93,5% so bfnh nhan dat hifu qui. Ty If til phit: 9,09%. Phic do an toin.
SUMMARY
Sciatica caused by lumbar disc herniation Is a common disease and can be treated with different modalities. Objectives: (1). To comment on treatments for sciatica Induced by lumbar disc herniation In the Rheumatology department. Bach mai hospital from 2010 to 2011. (2). To evaluate the safety and effectiveness of the treatments applied.
Subjects: 60 patients with sicatica caused by lumbar disc herniation treated in the Rheumatology department. Bach mai hospital from 06 January 2010 to 01 April 2011 were diagnosed based on clinical features and lumbar MRI. Methods: Cross-sectional study. Results:
(1) There were 3 methods used. Including medications (NSAIDs, analgesics and muscle relaxant) (100%), epidural Injection (90%), rehabilitation (60%). 56,7% patients were treated with combination of the 3 methods.
Average number of days of treatment was 11,27
± 3,19. (2). Treatments were effective In 93%
patients. VAS evaluated after treatments was 2.08 ± 1,05 compared to 5,83 ± 1,08 at the beginning of the treatoients (p<0,001); Straight- leg raising test was 82,17 ± 5,99° compared to 57,92 ± 17,11° before treadnents (p<0,001);
'TniengBalhgcYHanfl
fhin bien khoa hgc: PGS.TS. Nguyin Vlnh Ngpc
B A I H O I H O I THAP KHOP HOC V l f r NAM LAN THOVII - HOI NGHI KHOA HOC THUONG Nl6NL<NTHgX
100% patients had moderate t o severe pain while this number was only 2 0 % after treatments. The recurrence was 9 . 0 9 % and average period of recurrence was 6,67 ± 3,21 months (ranged from 3- 9 months). Reglms were safe with a adverse effect rate less than 7%. KSt l u f n : There were 3 treatment methods employed. Including medications (100%), epidural Injection ( 9 0 % ) , and rehabilitation (60%). 56,7% patients were heated witti combination of the three methods. Average time needed lor bBatments vras 11,27 ± 3,19 days;
EHecUveness was seen In 93,5% patients. Recun^nce rate was 9,09%. 1lie treadnents were safe.
I. OAT VAN Di'
Dau thin kinh hdng to- cdn gpi li thin kinh tpa 14 mft chiing bfnh rit thudng gip, chiim 11,42% sA bfnh nhin dilu trj nfi tru t?i khoa Co - Xuong - Khdp bfnh vifn B?ch Mai (1991 - 2000). Nguyen nhin chinh gay bfnh 14 thodt vj dia dfm (TVDD) eft sAng thit lung (CSTL). Nghien ciiu djch te t?i mft so vung d miln Bic Vift nam cho thdy cd 0,7% din sA dau thin kinh hdng to do TVDD CSTL. Cd nhilu phuong phip dilu trj dau thin kinh hdng to v4 thudng cin phii kit hpp cic phuong phip niy vdi nhau tt^n cdng mft ngudi bfnh. Chira cd nghien cdu nio dinh gii hifu qui, tic dyng khdng mong muAn cua cic phuong phip dilu trj dau thin kinh hdng to dupc ip dyng trdn thyc t l lim sing. Nhim khio sit tinh hinh dilu ti\ thtfc tl dau thin kinh hdng to t^ khoa Co Xuong Khdp Bfnh vifn Bach Mai nim 2010-2011, nghien cilu dupc thyc hifn vdi myc tieu:
1. Nhgn xit cdc phucmg phdp diiu trj dau thin kinh hdng to do thodt vi dia dfm Igi khoa Ca Xucmg Khdp Bfnh vifn Bgch Mai ndm tir 2010 din 2011.
2. Ddnh gii hifu qud vd tinh an todn cua cic phucmg phdp diiu tri dugc dp dgng.
II. o6'l TUONG VA PHIA3NG P H A P N G H I I N C O U 1. D A I tirpng nghiin cihi
OAm 60 bfnh nhin dilu trj nfi tni t?i khoa Co Xuomg Khdp Bfnh vifn Bjwh Mai trong khodng thdi gian td ngiy 06/01/2010 din ngiy 01/04/2011, dip ung cic tidu chuin lya chpn vi lo^i bfnh nhin nghiin cdu dupc trinh biy d phin dudi diy.
Tilu chuin chgn bfnh nhin nghiin ciru
- Dupc chin doin xic djnh dau than kinh hdng to dya vio cic dlu hifu:
+ Dau dpc theo ditdng di cua diy thin kinh hdng to; dlu hifu Lasdgue (+)
+ Kim theo mft hofc nhieu dlu hifu sau: dau hifu chudng bam; cd tu thi giim dau; dlu hifu chdn dp rl (dau ting khi ho, hit hoi, 1^...; rAi l o ^ eim giic (te bi, dj eim...), giim phin x^ gin gAi hofc gin gdt, teo co dui...
- Chin doin nguyen nhin; chyp cfng hudng tit CSTL c6 hinh inh TVDD gay chdn dp re than kinh ngang miic.
Tilu chuin logi bfnh nhin khii nghiin ciru
Dau thin Idnh hdng to do cic nguyen nhin khic: vidm opt sAng dinh khdrp, u, hpp Angsong...
2. Pbinrag phip nghiSo cihi Thiit ki ngkiin cAu: Md ti cit ngang Cic chl Hiu nghiin ciru
- Dfc dilm bfnh nhan nghidn ciiu: TuAi, gidi, nghi nghifp, choi the thao
- Dfc dilm lam sing: tiln sur phlu thuft CSTL; thdi gian mic bfnh (tmh bing thing);
hoin cinh khdi phit bfnh (sau chan thuong, lao dfng qua sdc, vfn dfng sai tu thi, khdng rd); vj tri dau: bdn phii, b€n trii, c i hai bin;
Y HQC VI$T NAM T H A N G 9 - S 6 2/2012
rl tin thuong: re L5, SI, c4 rl L5 vi SI; tinh ohat dau; kilu ca hpc hofc kilu viem; tu the giim dau: cd hofc khdng; dlu hifu chdn ip re: cd hoic khdng; nghifm phip Lasigue (tinh bing df), diu hifu bim chudng: cd hofc khdng.
- Bdc diim cfn ldm sdng
+ X quang CSTL: Tinh tr^mg thoii hda eft sing: hpp lo li& hpp: cd hofc khdng; hpp khe liSn dAt: cd hofc khdng; trupt dAt sAng:
c6 hofc khdng.
+ Cfng hudng tit CSTL: Vj di v4 sA ting thoit vj: phin lo^i thoit vj theo Wood (pMnh, lAi dia dfm, TVDD thyc thy, TVDD ditiii).
- Cdcphucmgphdp dilu tri
+ ThuAc toin than: Lo?i thuAc, lilu lupng, thdi gian dCmg thudc.
+ Tiim ngoii ming Cling: SA lin tiem, ngay tiem.
+ Phuc hAi chdc nang: Chilu hAng ngoai, keo giin CSTL, difn phan...
- +Phiuthuat
- Ddnh gid hieu qud cdi thifn miic df dau ciia cic phucmg phip dieu tri: cii thifn Hiang dilm VAS; nghiem phip Lascgue
3. XA ly so lifu: Phin mIm SPSS 16.0 IILKlTQUA
1. Bfc dilm chung cda doi taifng nghien cdii
- Ting sA: 60 bfnh nhan
Gidi: Nam: 26 ( 43,3%); Ntt: 34 (56,7%), t^ If nam/nO= 1/1,3
- TuAi trung binh: 46,40 ±11,39 (td 21 din 69 tuAi); Ty If bfnh nhin d Ida tuAi td 40-59 cao nhat (63,3%).
- Ti If Iao dfng ning: 61,7%, ttong dd 40% li ndng din.
- Thdi gian mic bfnh trung binh: 1,58 ± 1,82 thing, (3 tuin-12 thing).
- Dfc dilm Iam sing: Ty If trieu chiing khdi phit sau vfn ddng qui siic, sai tu thi, chan thuong: 58,3%. Ty If bfnh nhin dau ben phii: 45,0%; ben trii: 38,3%; hai bSn:
16,7% (p>0,05). Ty If dau kilu re L5:
43,3%; re SI: 33%; L5/SI: 1,7%. Trung binh dilm dau VAS: 5,83 ± 1,08 diem. Tit ci (100%) bfnh nhan dau kilu co hpc, trong dd 43,3% kdm theo tu thi chAng dau, 15% cd rAi loan eim giic, 10,0% cd rdi loan phin xa, 3,3% cd teo CO, khdng cd bfnh nhin nio cd rdi loan co trdn.
2. Nhan xit cic phirong phip dieu trj - Cd ba phucmg phip dieu tri npi khoa CO bin 14 dung thuAc, tiem ngo4i mang cirng, phyc hdi chdc ning. Ty If bfnh nhin dupc kit hpp ci ba phuang phip dilu trj nfi khoa li 56,7%.
- vi cdc phuang phdp dieu tri ngi khoa + Dilu tri thuAc: 100 sA bfnh nhin. Cd ba nhdm thuAc dupc sd dyng: chAng viem khdng steroid, thuAc giam dau vi giin co ttong dd 90% bfnh nhan dupc phAi hop ci ba nhdm thudc.
+ ThuAc chAng viem khdng steroid:
100% sA bfnh nhin. Da sA bfnh nhin sd dyng nhdm uc chl chpn Ipc COX 2: mobic (80%) hofc Celebrex (15,0%), chi cd 5%
dung Voltaren.
-I- ThuAc giim dau: 93,3% sA bfnh nhan.
Da sd bfnh nhin sd dyng giam dau bic hai:
efTeralgan codein (61,7%), ulttacet (30%).
+ ThuAc giin ca: 96,7% sA bfnh nhan, ttong do myonal 78,3% vi mydocalm 23,3%.
+ Tiim ngoii ming ciing vdi hydrocortisone acetate: 90% sd bfnh nhin
+ Phyc hdi chiic ning: 60°/o so bfnh nhin. Cd 60% kit hpp chilu den hAng ngoai, difn phan v4 keo giin CSTL.
B»l HOl HOl THAP KHOP HOC VlfT NAM LAN THIiVII • Hpl NGH| KHOA HOC THI/ONG NlSN LAN THgX
3. Hifu qui v4 tic dyng khdng mong + Cii thifn chi sA VAS: VAS tnmg btah muln ciia cic phinmg phip dilu trj dat dupc sau dilu ttj 14 2,08 ± 1,05 dilm so 3.1. Hifu qud cua cdc phuvng phdp vdi 5,83 ± 1,08 dilm tai thdi dilm bit dlu diiu lii dilu tti T°; (p<0,001)
- SA ngiy dilu ttj trung binh: 11,27 + •)- Chi sA Lasigue: sau dilu trj d»t 82,17 3,19 ngiy. ± 5,99° so vdi 57,92 ± 17,11° t*iT° (p<0,001)
- Kit qui sau khi ra vifn
- Hifu qud cua tilm ngodi mdng cimg
Biiu di 3.1. Cii thifn miic df dau theo VAS sau tiSm ngoii ming ciing Triinj; iiinli
diem dau
\
3 2 1 0
4,72
• .
Tnrc'rc licm NMC
.1.(1(1
Tii'in NMC mui 1
3. IS
•
Ticni NMC mui 2
2,44
Tiem NMC mui 3
1.91
^"'^ "^
.Sau tifim NMC
Nhan .vf7; Mirc do dau ciia bOnli nlidn duac cai thiC'n nga> tir lan tiem dAu lien vi cdi thi^ ro niiat sau [Jem mui 3 (p<OOI)
Bieu do 3.2. Cai tlii^n mirc do dau InaVc \'a sau dieu Iri v
T y i ? % i o o % 80%
60%
40%
20% ' ^ 0% -^^^
-^ • A ^
A 1 1
MM 1
^^^J
TT^^"^^
i , " / ^
^ I j D Dau nSng
^ • B a Dau viia
^ ^ 1 • Dau nhe
^ H El Khdng dau
I H ^ ^ ^ ^ T h i i i diem dieu tri TrircSc didu tri Sau didu tri
Nhfn xit: Tit c4 (100%) bfnh nhin ttudc dilu ttj 14 dau vCia hofc nfng, sau dilu trj tJ If niy chi cdn 20%; 80% bfnh nhin chi cdn dau d miic dp'nhp.
- Thit bgi diiu tri nfi khoa: 6,7% bfnh nhin duprc chi phiu thuft.
Y HQC VI$T NAM T H A N G 9 - S6' 2/2012
3.2. Tic dgng khong mong muon cua cicphumgphip diiu trj
- Dilu tn thuAc (giim dau chAng viem khing steroid): cd 5/60 bfnh nhin (8,4%);
cliu ylu tten dudng tidu hda; 4/60 (6,7%) bfnh nhan tAn thuong d^i diy ttong dd 3/4 bfnh nhan (75%) viim d? diy vi 1/4 ngudi (25%) loit ti tting. Cd 1/60 bfnh nhin (1,7%) cd ting men gan mdc df nhp.
- Tiim ngoii ming ciing: 1/54 bfnh nhan (0,02%) cd phin iing dj ling nhp (ngua sau tiSm), 2 bfnh nhin (0,04%) dau ting sau ti6m. Khdng cd bfnh nhin nio bj sAc phin vf hofc nhiim tting ncri tiim.
IV. B&N LUAN
Trong nghiin ciiu cda chdng tdi, dupc coi li ddng thuAc khi sd dyng bit ky mft trong sA cic loai thuAc thufc nhdm chAng viSm khdng steroid, giin co hofc thuAc giim dau. Tit ci 100% sA bfnh nhin dilu tti thulc, 90% tiem ngoii ming ciing, 60%
dupc dilu tri phyc hAi chdc ning, 6,7% (4 lifnh nhin) dupc phau thuit- Cic bfnh nhin phlu thuft trudc dilu trj deu cd mdc dp dau n^g vi miic dp dau khdng cii thifn hofc cii thifn rit it sau dilu trj. Cd mpt bfnh nhin cd tiln sd phau thuft dia dfm L4-5, xuit hifn dau tid Ifu sau 8 nim. Trong 4 bfnh nhan thi ci 3 bfnh nhan cd miic dp thoit vj tien hinh inh cpng hudng tir li mure df vita (thoit vj thirc thy) v4 1 bfnh nhin thoit vj miic df nfng (thoit vi di tiii).
Phin Idn bfnh nhin (56,7%) dupc dilu In kit hpp ba phuong phip li thuAc (giim dau, gian ca, chAng viim khdng steroid), phyc hdi chiic ning (chilu hAng ngo^, difn phin, keo giin eft sAng thit lung) vi tiem ngoii ming ciing. Ngoii ra cd 31,7% bfnh nliin 31,7%) chi dupc dilu ttj hai phuang phip li dCmg thuAc (giim dau, giin co, chAng
viem khdng steroid) vi ti§m tiim ngoii ming Cling. Trong nghiin cdu cda Phan Thi Hanh (2009) [12], ci 60 bfnh nhan (100%) dupc dieu trj bing thuAc chAng viem khdng steroid kit hpp vft ly trj lifu (chilu hAng ngoai, difn phin, kdo giin eft sAng thit lung vi vfn dpng thich hpp), ttong dd 30% kit hpp tiim ngoii ming Cling.
Nghiin cihl cda chiing tdi cho thiy mdc df dau cda bfnh nhin dupc cii thifn ding ke sau dieu trj. Trung binh dilm dau trudc dilu tti li 5,83 ± 1,08, sau dilu tii 10 ngiy giim xuAng cdn 2,08 ± 1,05, sy cii thifn niy cd ^ nghia thAng ke vdi p<0,001. Trudc dilu t4 cd 36,7% bfnh nhan dau vua, 63,3% dau nfng, Ichdng c6 bfnh nhin nio dau nhp. Sau dieu tri 10 ngay so bfnh nhin dau vtta giim xuAng cdn 18,3%, dau nfng giim cdn 1,7%
vi cd tdi 80,0% bfnh nhin chi con dau d mdc dp nhp.Thed Phan Thj Hanh (2009) [12]
ttong nghiin ciiu dupc de cfp d tten: mdc df dau trung binh giim td 7,3 xudng cdn 6 diem sau I tuin dilu trj. Trudc dilu trj cd 46,7%
cd mdc df dau nfng, sau dilu trj 1 tuin giam cdn 15% vi sau 4 tuin giim xudng cdn 1,7%.
Trong khi do, trudc dilu tri cd 16,7% dau nhp, sau dilu tii 3 tuin con sA niy ting len 40% vi sau 4 tain li 80%, su khic bift cd -j nghia thAng ke vdi dp tin ciy 95%.
Kit qui dupc duy tri sau dilu tii.Trong sA 33 bfnh nhin dupc chdng tdi phdng van cd 3/33 bfnh nhin tai phit dau (9,09%), thdi gian tii phit dau ttung binh Ii 6,67 ± 3,21 thing, sdm nhit 14 3 thing v4 mufn nhit 14 sau 9 thing.
Kit qui cua chung tdi cho thiy khi phAi hpp ba phuong phip dilu tti 14 thuAc, dim ngoii ming cung vi phyc hAi chiic ning thi hifu qui giim dau tAt hon chi dilu tii phoi hpp hai phucmg phip diu mi khdng kit hpp phyc hAi chdc ning: khi dilu tii phAi hpp ba
BAI Hfl HOl THAP KHOP H O C V I p NAM LAN T H O VII - HOl NOH| KHOA HQC THOONG NI6N lAW THdX
phuong phip, dilm VAS trung binh giim di 3,84 ± 1,20 dilm trong khi phAi hpp hai phucmg phip chi giim di dupc 3,73 ± 0,99 dilm song sy khic bift khdng cd ^ nghia thing ki (p>0,05).
Cic bfnh nhin trong nghien ciiu niy dupc dilu trj bing ba loiii thuAc chAng viim khdng steroid: Diclofenac (Voltaren);
Meloxicam (Mobic) vi Ceiecoxib (Celebrex) , thupc nhdm dc chl chpn Ipc C0X2. Diy li cic thuoc it giy tic dyng khdng mong muAn trdn dudng tiiu hda: cd 4/60 bfnh nhin (6,7%) viem loit da diy- ruft trong dd 3/4 bfnh nhin (75%). Mpt bfnh nhan cd hinh inh nfi soi 14 xung huyit niim mac da diy v4 nhilu ttpt ndng d hang vi. xuit hifn sau dilu trj 12 - 13 ngiy. Cd mpt trudng hpp sau 20 ngiy dung thuAc cd nhilu A loit dudng kmh 0,5-1 cm t^ ti tting. Ngoii ra, cd 1/60 bfnh nhan (l,6%)c6tingmen gan muc dp nhp (OPT li 122 UI/L). Khdng cd bfnh nhin nio bj suy diin hay xuit hifn con hen phi quin.
DAI vdi phuong phip tiem ngoii ming cung: 1/54 bfnh nhan (0,02%) cd phin ling dj ung nhe bilu hifn bdi ngua sau tiim, 2 bfnh nhin (0,04%) dau ting sau tiem. Khdng cd bfnh nhin nio bj sAc phin vf hofc nhiim tiiang ncri tiem. Khdng gip tic dyng khdng mong muon nfng hoic nguy hiem tdi tinh mang.
V. KET LU$N
1. Cd ba phirong phip dilu trj dau thin kinh hdng to do thodt vj dia dfm dupc ip dyng tai khoa Ca Xucmg Khdp Bfnh vifn B^ch Mai li ddng thuAc bao gAm thuAc chAng viem khdng steroid; thuAc giim dau vi thuAc giin co (100%), tiim ngoii ming cdng
(90%), phyc hAi chiic ning (60%). T^ If bfnh nhdn dupc kit hpp ci ba phuang phip dilu ttj nfi khoa li 56,7%.
2. Hifu qui vi tic dyng khdng mong muln cda cic phvong phip dilu trj
2.1. Hifu qud cia cdc phuang phip diiu tri
- SA ngiy dilu hi ttimg blnh: 11,27 ± 3,19 ngiy.
- Mdc df dau trung binh thi hifn qua dilm sA VAS dupc cii thifn d mdc 2,08 ± 1,05 dilm cd y nghla so vdi trudc dilu trj li 5,83 ± 1,08 dilm t?i T°, thdi dilm bit dlu dilu trj (p<0,001)
- Tuang ty, chi sA Lasigue ting 16 td 57,92 ± 17,11° d thdi dilm ttudc dilu ttj l&i 82,17 ± 5,99° tai thdi dilm sau dilu ttj (p<0,001)
- Tit ci (100%) bfnh nhin ttudc dilu ttj cd muc dp dau vira din nfng, sau dilu trj ty If niy chi cdn 20%; 80% bfnh nhin chi cdn dau d mdc dp nhp.
- Ty If tii. phit 14 9,09%, thdi gian tii phit ttung binh 14 6,67 ± 3,21 thing (3- 9 thing).
- Thit b?i dilu tti nfi khoa: 6,7% bfnh nhin, phii chi djnh phiu thuft
2.2. Tic dgng khSng mong muin cua cic phuang phdp diiu trj
- Ty If tic dyng khdng mong muAn tren dudng tidu hda phit hifn qua nfi soi li 6,7%
vi ting men gan mdc df nhp xuit hifn it 1,6% tnrdng hpp.
- Trong cic tnrdng hpp dupc tiim ngoii m4ng Cling cd 0,02% cd phin ling dj ilng nhf vi cd 0,04% dau ting sau tiim.
- Khdng gfp tdc dyng khong mong muAn nfng hofc nguy hilm tdi tinh ra^g.
