JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N°iy20U
Ky thuat choc cSt dia dem qua da dilu tri giam dau trong thoat vi dia dem cot s6ng that lirng
The Technique of Automated Percutaneous Lumbar Discectomy to Treat the Reduction of Pain in Herniated Lumbar Disc
Ngo Ti£n Tudn, LS Dinh An, D6 Van Lao-ng Benh vien Trung uong Qudn doi
T o m tat
Ky thuat choc cat dTa dem qua da sd dgng kim Tru-Cut* 14G dUpc tien hanh tren 183 b^nh nhan thoat VI dTa dem ra sau mufc do vUa va nang theo phan loai Arseni C (1973). NhCfng Benh nhan nay cd lam sang va hinh anh MRI phu hpp vdi chan doan va tinh trang khdng cai thien khi dUpc dieu trj ndi khoa. Benh nhan dUpc ap dung ky thuat dieu tri sd dung kim Tru-Cut* 14G choc cat dTa dem qua da d Benh vien Trung Uong Quan dpi 108 trong khoang thdi gian t d 2008 den 2013. Ket qua lam sang:tS'le giam dau ngay lap tUc sau.sU dung ky thuat tren d 79,23%; va 100% so benh nhan gidm dau dcacmUc do khac nhau sau 24h can thiep. Sd dung bang phan loai dau VAS, phan Idn benh nhan cd mUc d d dau vda va nhe (chiem ty le 61,75% va 29,51%) sau khi can thiep. TUOng tU, khi sd d u n g thang diem Oswestry, benh nhan cd han che han che van ddng do dau that lUng d dp IV va 111 (chiem t^ le 45,35%
and 28,96%) cd sU cai thien len dp II va I (chiem ty le 64,48% and 31,15%). Dau hieu Laseque (+) trUdc can thiep chiem ty le khoang 100%, sau dd giam xudng khodng 13,2%. Ket qua su giam ap dTa dem bdi sCf dung ky thuat dUpc the hien bang viec cd the loai bd mpt phan nhan nhay d trung tam dTa dem thoat vj.
TLfi<h6a: Thoat vi dTa dem cdt sdng thdt lung.
Summary
The technique of Automated Percutaneous Lumbar Discectomy by using Tru-Cut* 14G needle was conducted on 183 patients with posterior Herniated Lumbar Disc at the moderate and severe levels according to the Arseni C (1973) classification. The patients had the clinical symptoms and MRI results, which were in line with the diagnosis, and the situation had not gotten better after the treatment with internal medicine. The patients were applied with the treatment percutaneous using Tru-Cut* 14G needle, at the 108 Hospital, during the period between 2008 and 2013. The clinical results indicated the reduction of pains immediately after having applied this method in 79.23% of the patients; and 100% of the patients had the reduction of pains at different levels 24 hours after the intervention. Using the VAS pain classification, the majority of patients had moderate or light pains (61.75% and 29.51% respectively) after the interventions. Similarly, using Oswestry classification, the patients who suffered movement
•restrictions due to the back pain at IV and 111 levels (45.35% and 28.96% respectively) improved t o II and I levels (64.48% and 31.15% respectively). The Lasegue (+) sign, which was on 100 % of the patients before the interventions, was reduced to be on 13.2% of patients.
The results in the reduction of pressure by using this technique have also been shown by the fact that it is possible to remove part of the nucleus pulpous at the centre of the Herniated Lumbar Disc.
Keywords: Herniated Lumbar Disc
Phiiii biOii khoa hoc: GS.TS NGUYEN VAN THONG 10
TAP CHI Y DUOC LAM SANG 108
I.Oatvande
Trong v d n g han 50 nam qua da cd nhieu phUdng phap dieu t n t h o a t vj dTa dem cot sdng that lung (TV£>DCSTL) bang ky t h u a t can thiep dia dem tdi thieu qua da lam gidm ap [3], [5]. Cac p h u o n g phap dieu tri giam dp dTa d e m qua da deu hudng tdi viec gidi quyet tinh t r a n g tang ap lUc ndi dTa, tao ca hdi giup benh c d t h e t u h o i phuc [4], [6].
DUa tren ca sd nguyen ly d o chung tdi trien khai ky thuat choc cdt dTa dem qua da (CCDDQD) cua Onik G (1985) [6], [7] bang kim Tru-Cut 14G* t r o n g dieu t n benh ly TVDDCSTL va danh gia hieu qua ve lam sang.
Ky t h u a t da duoc trien khai an t o a n d 183 benh nhan (BN) tai Khoa Ndi Than kinh Benh vien Trung uong Quan ddi 108 tCf nam 2008 den 2013.
Nghien cdu nham muc dich danh gia hieu qua cua ky t h u a t choc cat dTa dem qua da sd d u n g kim Tru-Cut' 1 4 G d b e n h nhan t h o a t vj dTa dem cot song t h a t l U n g .
2. PhUdng phap
2.1. Nguyen ly dieu tn cua ky thuat Nguyen ly cCia ky t h u a t choc c^t dTa dem qua da tuan thO nguyen ly chung cua dieu tri gidm dp dTa dem qua da. Npi d u n g cua nguyen ly la sU d u n g cac tac nhan khac nhau (hda hpc, laser, cd hpc, nhiet do, radiofrequency...) de loai bd nhan nhay tai vj tri trung tam dTa nham lam giam tinh trang tang ap luc ndi dTa, tao dieu kien cho phan nhan nhay thoat vj thu hoi t r d lai, g i i i p benh cd the t u hdi phuc [4]. Ky thuat chpc cat dia dem qua da, sU d u n g kim Tru-Cut 14G' de loai bd nhan nhay v u n g t r u n g tam dTa dem va hieu qud gidm ap dUdc the hien bdi phan nhan nhay da loai bd.
2.2. Chi djnh, chdng chi djnh
183 BN dupe tien hanh ky t h u a t CCDDQD, deu phdi tuan t h u chi d j n h va chdng chi djnh chung cua cua Nachemson A (1989) t r o n g dieu trj giam ap dia d^m qua da [6], [7] va chi djnh, chdng chi d i n h rieng cOa ky thuat.
Chi d j n h rieng cho dieu trj chpc cdt dia dem qua da b5ng kim Tru-Cut 14G* la: BN khdng cd chi djnh phau thudt; dieu tri ndi khoa tren 4 tuan khdng ket
qud; hinh dnh cdng hUdng t d (MRI) cd TVOD ra sau n h u n g chua cd t o n thUdng dUt rach day chang dpc sau va khdng cd chdng chi d j n h chung dieu tri gidm dp dia dem qua da.
Chong chi d i n h rieng khi cd: chieu cao khoang gian d o t sdng tai vj t r i chpc cat hep tren 5 0 % so vdi binh t h u d n g ; hep dng sdng mUc d p ndng d o thoai hoa; tai vi t n chpc cat cd cau xUOng hoac gal xUdng can t r d d u d n g vao dia d e m .
2.3. Bien chdng co the gap
Ky t h u a t CCDDQD cd t h e gap nhdng bien chUng chung cua dieu tri giam dp dia dem qua da n h u cac tac gia t r o n g va ngoai nUdc da cdng bd:
chay mau do t o n t h u o n g cac mach mau Idn d phia trUdc cdt sdng; nhiem t r u n g tai chd; viem dTa dem;
ton t h u o n g than kinh, lietva tang rdi loan van d d n g va cd t h e gay tang dau [5], [6].
2.4. Dung cu, trang thiet bj 2.4.1. Dung cu choc cdt dta dem qua da SCr d u n g loai kim sinh thiet co-xuong Tru-Cut, cd ndng 14G (Gause) cua hang Allegiance Healthcare Corporation (USA). Kim dUdc sd d u n g t r o n g ky thuat Xquang can thiep cdt sdng de sinh thiet cac mau benh pham thudc t o chdc cd-xUOng [2].
2.4.2. Thiet bi ho trg l<y thuat
Ky thuat dieu trj gidm ap dTa dem qua da can trp giup cua may Xquang cd ho t r p hinh anh (Fluoroscopy), tao dieu kien thuan loi cho cac can thiep vao cot sdng [2], [4]. Trong ky thuat CCDDQD, chung tdi sd d u n g may Xquang cd hd t r o hinh anh integris Allura cua hang Philips. Do vay, theo ddi dupe hinh anh dpng d cd hai binh dien d d n g t h d i thay dupe hinh anh t o n g the cua CSTL, hinh dnh chi tiet khoang gian d o t va hoat d d n g eat cua d u n g cu d cac gdc d d khac nhau (thang, nghieng, chech) t r o n g cung m d t thdi diem.
2.5. Qui trinh ky thuat choc cat dia dim qua da 2.5.1. Chuan bi benh nhdn
Benh nhan 6\sgc chuan bj ve tinh than, gidi thich ndi d u n g ky thuat, d u n g thuoc an than trudc
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N°1/2014'
15 - 20 phut. Lam cac xet n g h i e m n h u chuan bj trUdc m o , t h d n g qua ky thuat. Ky t h u d t dUdc tien hanh t r o n g dieu kien v d t r u n g .
2.5.2.Cdc bade tien hanh: 4 bU&c
Bifdc 1: xac djnh vj tri dia dem thodt vi can can thiep, diem moc chpc kim tren da va hUdng di cua kim vao dia dem (Bruno Grignon 2007). Gay te tai chd va te vung bdng Novocain 0,25% hoac Lidoeain 1 % .
BU6c 2: chpc kim qua da tai diem mdc tdi vj tri t r u n g tam dia.
BUdc 3: cY)up dTa d e m
Budc 4: t h u c hien cat bd t o chUe nhan nhay d t r u n g tam dTa dem
2.6. Cac chi tieu theo doi
' Hieu qua giam dau ngay sau chpc cat va sau 24 gid - Khdi luong tuong ddi the tich nhan nhay lay dUOc - MUc do dau lupng hda theo thang diem VAS - MUc dp han che van d d n g CSTL d o dau lupng hda theo diem Oswestry.
- Dau hieu Lasegue (+)
3. Ket q u a d i e u t r j cua p h U d n g p h a p choc cat d i a d e m q u a da d 183 b e n h n h a n (2008 - 2013)
3.1. So luang BN dieu trj choc cat dia dim qua da bang kim Tru-Cut 14G'
Bang 3 . 1 . So lUdng BN d i e u t r j tii 2 0 0 8 - 2 0 1 3 Nam
SoBN Tong so
2008 57
2009 21
2010 26
2011 27
2012 35
2013 07 183
3.2. Hieu qua giam dau cua Icy thuat 3.2.1. Hieu qui giam dau
Bang 3.2. Hieu qua g i a m d a u cr ngay sau choc cat va sau 2 4 gicf
Hieu qua giam dau Khong
Co
Ngay sau l<y thuat Sau 24 g i d
SoBN (n=183)
0 145 133
T j ' l e % 0 79,23
100
Tated 183 B N ( t y l e 100%) deu gidm dau sau 24 gid 3.2.2. Nhan xet phdn the tich nhdn nhdy cdt bddu^
Sis d u n g kim Tru-Cut 14G* cat b d dan t o chdc nhan nhay d t r u n g tam dTa cho sd lUpng manh c§t va t h e tich cac benh p h a m lay dupe khde nhau. So l u p n g cac m d n h cat d 1 b e n h nhdn giao d p n g ti^ 24 den 60 m a n h . The t i c h tUdng ddi cOa m o i mdnh cdt t h u d n g la 2x2x6 m m . The tich tUong doi phan nhan nhay lay dUdc d 1 BN giao d p n g t U 1 -2 c m '
Td chUe nhan nhay dia d e m cd dac diem hinh the d m d t t r o n g hai dang: mau sdc t r o n g , Idng nhdt bam d i n h d u n g cu (67,76%) hoac due nga vang, dac q u a n h it bam d i n h d u n g cu (32,24%).
3.3. Kit qua lam sang
3.3.1. Mdc do dau lUng Iwgng hoa theo thang diem VAS
B a n g 3.3. M u T c d o d a u l U n g d t r U d c v a sau d i e u t r j ( n = 1 8 3 ) D a u l U n g d o T V O B i B N
choc cat dia dem
Diem dau VAS (10 diem)
Nhe {<4 diem) vera (4-6 d i l m ) Nang (6-8 diem) Rat nang (>8 diem) Diem VAS trung binh d 1 BN
TrUdc dieu trj SoBN
8 35 82 58
Ty le % 04.37 19,13 44.81 31,69 7,14
Sau dieu tn SoBN
54 113 16 0
J</\e%
29,51 61,75 08,74 0 3,96
P
<0,01
<0,C5
<0,05
<0,01
<0,05
C i e m VAS t r u n g b i n h d 1 BN trade dieu tri la 3.3.2. Miic dd Itqti ctie vdn dgng CSTL do dau 7,14 t a o n g ijrng vdi mijfc dau nang. Sau dieu tri chi li/ang tioa tiieo diem Oswestry
con 3,96 t a o n g Qng vdi mure dau t r u n g b i n h va nhe
B i n g 3.4. Mure d o lian clie van dong CSTL do dau d t r u d c va sau dieu trj (n=1S3) Diem Oswestry va mCfc han che van
dong CSTL do dau {T9 le %)
< 1 0 d l e m (Mile 1:0-20%) 11-20 diem (Mile II: 21-40%) 21 -30 diem (Mile 111:41 -60%) 31-40 diem (Mile IV: 61-80%)
>50 d i l m (Mure V: 81-100%) Diem Oswestry T B d l BN
Trade dieu tri S6BN
0 38 53 83 09
TJIe%
0 20,77 28,96 45,35 04,92 22,06
Sau dieu tri S6BN
57 118 3 0 0
T ^ l e % 31,15 64,48 04,37 0 0 15,27
P
<0,01
<0,05
<0,01
<0,001
<0,05
<0,05
Trudc dieu trj, han che van d d n g CSTL do dau chu yeu gap d mdc IV va mdc III. Sau dieu tri gap nhieu nhat lupng BN d mdc II va I
3.3.3. Ddu hiiu Lasegue (+)
Bdng 3.5. Bien d o i cua d a u h i e u Lasegue ( + } d t r U d c v a sau d i e u t r j (n=183)
,
>60° (Khong ro)
560" (Ro) 46°-60°
3 I M S "
<30°
Trudc dieu tr|
SoBN 0 94 56 33
T y l e % 0 51,37 30,60 18,03
100
Sau dieu tri SoBN
159 19 05 0
T y l S % 86,88
13,12 P
<0,001
<0,01
TrUdc dieu trj 1 0 0 % B N e d d a u hieu Lasegue (+) r d v a sau dieu trj chi cdn c d d 13,12% BN 3.3.4. Bien doi cdc chi tieu Idm sdng theo thdi gian
Bang 3.6. Bien d o ! cac chi t i e u lam sang t h e o thc^l g i a n (n=183)
Chi tieu lam sang {n=183) Diem VAS trung binh cr I BN Diem Owestry trung bin/l d 1 8N
Ddu hl$u Lasegue duang tinh ro (%)
Trade dieu tri 7,14 22,06 100
Sau dieu tri 3,96 15,27 13,12
S a u l thang 1,60 9,43 4,92
Sau 6 thang 0,98
5,4 2,73
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N°1/2014
Theo rdi cac chi tieu lam sang d BN trUdc, ngay sau dieu trj va ket qud xa (1 va 6 thang) thay deu gidm theo t h d i gian
3.4. Dp an toan cda ky thuat
Trong 5 nam (2008-2013) sCf d u n g ky t h u d t chpc cat dia d e m qua da bang kim Tru-Cut 14G* dieu tri TVDDCSTL d 183 BN, chung t d i chua gap bien chUng nao cua cac ky t h u a t dieu trj giam dp dTa d e m qua da 4. Ban luan
Ket qud cua chung tdi m d t lan nUa chdng m i n h Uu diem chung eua ky t h u a t dieu t n gidm dp dia dem qua da. Day la loai ky t h u a t d o n gian, khde phuc dupe nhdng han che cua d u d n g m d vao dia d e m cd t h e gay ra nhieu t o n t h u o n g t o chUc phan m e m , gidm chi phi do gidm ngay ndm dieu t n cung nhU mang lai nhieu Ipi ich khac cho ngudi benh ... [1], [4], [6]. Tuy nhien de dat dUpe hieu qud dieu trj phdi tuan t h u chat che chi djnh, chdng chi d j n h chung cua dieu tri giam dp dTa dem qua da cung nhU chi d i n h va chdng chi d j n h rieng cua ky t h u a t nhU da duoc t r i n h bay.
Theo cac tdc gid, dieu trj giam dp dTa dem qua da cd hieu qua dat tdi 75 - 80% [6], [7]. Ket qua ky t h u a t chpc cat dia dem qua da bang kim Tru- Cutl4G* dieu tri TVDDCSTL eua chung tdi cho thay giam dau ngay sau ky t h u a t dat tdi 79,23% va 100%
BN ed giam dau d cac mdc dp khde nhau sau 24 gid.
Dau lUPng hda theo thang diem VAS trudc dieu tri deu d mUc nang va rat nang (44,81% va 31,69%
t u o n g dng vdi 82 va 58 BN) sau dieu tri chi cdn d mUe vda va nhe (61,75% va 29,51% t u o n g Ung vdi 113va54BN).
T u o n g t u , BN cd han che van d d n g CSTL do dau luong hda theo diem Oswestry trudc dieu trj chu yeu d mdc IVva 111 (45,35% va 28,96 %), sau dieu trj chi eon d mdc II va I (64,48% va 31,15%).
Dau hieu Lasegue (+) la chi tieu dupe quan tam dac biet trong benh ly TVDDCSTL. Trudc dieu tri Lasegue (-I-) cd d 100% BN vdi mUc dp duong tinh rd, chi tieu nay gidm ngay sau ^ e u trj, chi cdn d 10,38%
tuong Ung vdi 19 BN. Cac chi tieu Idm sang tren cdn
t i e p t u c d u o c cai t h i e n t h e o t h d i gian, sau 1 vd 6 thang.
Tai Viet Nam, dieu trj g i a m ap dTa d e m qua da da dUdc t r i e n khai d T.P H d Chi M i n h (1999), Benh vien Viet - Ode (5/2007) va vien Qudn y 103 (8/2008).
Hieu qud dieu trj da dUpc c h d n g m i n h t h d n g qua cdc bao cao cda cac tdc gid. Trong d i ^ u trj chpc cdt dia d e m qua da bang kim Tru-Cut14G* ngoai nhiing ket qua lam sang t h u dUpc, c h u n g tdi cdn chdng m i n h dUdc hieu qud gidm dp t h d n g qua viec loai bd m p t khdi lUdng nhat d j n h t h e tich nhdn nhay. Hi$n nay tren t h e g i d i , d u n g cu cdt b d n h d n nhay van tiep tuc cai tien t h e o hUdng tU d d n g hda nhU d u n g cu gidm ap DeKompressorStryker* [7].
5. Ket luan
Ky thuat chpc cat dia dem qua da dieu trj TVDDCSTL bdng kim Tru-Cutl4G* dUa tren dung nguyen ly dieu tri gidm dp dd biet va ky thuat dd chdng minh dUdc hieu qud gidm ap d dia dem thoat vi.
Chi d j n h dieu tri chpc cat dTa d e m qua bdng kim Tru-Cut14G' can chat che, phu h p p vdi nhdng chi d j n h , c h d n g ehl d j n h c h u n g va rieng m d i cd t h e dat d u p c hieu qua n h u m o n g m u d n .
Hieu qud dieu trj rd rang nhat cua ky t h u a t la tac d u n g lam gidm dau ngay sau ky t h u a t (79,23%) va sau 24 g i d (100%). LUdng hda mdc dp dau bdng diem VAS cho thay mUc d p dau sau dieu trj chu yeu chi cdn d mUe vda va nhe (61,75% va 29,51% tUdng Ung vdi 113 va 54BN). Cac chi tieu lam sang khac n h u han che van d d n g CSTL d o dau sau dieu trj chi cdn gap d mUc 11 va mdc I (64,48% va 31,15%) so vdi mdc IV va III (45,35o/o va 28,96 %) trUde dieu trj. Dau hieu Lasegue (+) rd t d 100% trudc dieu trj cdn 13,2%
sau dieu trj.
T a l l l e u t h a m khao
1. Nguyen Van Chuong (2003), "Dieu trj thodt vj dia dem cdt sdng that lung bang phUdng phdp chpc hiit dTa dem qua da". Tap chfy hoc thtfc hdnh. 7, tr.
41-43.
2. Davis M. (2004), "Spinal Biopsy Techniques", Interventional Radiology of the Spine Image-Guided
14
Pain Therapy, Humana Press, Totov/a New Jersey, USA, pp. 1 8 1 - 1 9 6 .
3. Haldeman S., Kirkaldy-Willis W.H., Bernard T.N.
(2002), An Atlas of back pain. The Parthenon Publishing Group, New York, U5A,tr. 7-12.
4. Hijikata S., Yamgishi M., et al. (1975),
"Percutaneous discectomy. A new treatment method for lumbar disc herniation", 7 Toden Hasp, 5, pp. 5-13. John M., e t a l . {2004), Image-guided spine inten/entions. Springer-Verlag, New York.
5. Saal J.A., Saal J.S., Herzog R.J. (1990), 'The natural history of lumbar intervertebral disc extrusions treated nonoperatlvely". Spine, 15, pp. 683-686.
6. Singh V., Derby R. (2006), "Percutaneous Lumbar Disc Decompression", Pain Physician, 9, pp. 1533- 3159.
7. Vijay S., Richard D. (2006), "A Focused Review Percutaneous Lumbar Disc Decompression" Pain Physician, 9, pp. 139-146, ISSN 1533-3159.
