NGUYEN LY VA KET QUA CUA GIAM AP DIA DEM COT SONG DANG LASER QUA DA
T R A N CONG DUY^T, HA Vlgr HliN, V 6 HONG HANH, Vi$n Ngoai khoa Laser
VO CONG LAP - Phin vi$n Vit ly Y Sinh hgc
MdoAu
ThoSt vj dTa dfem IS tdn thuang thud'ng gSp trong benh ly thoSi hda cpt sdng.
Dieu tri gdm eSc ky thuat khong xam l i n , xam lan tdi thieu vS phiu thuat
Giam Sp dTa dem cpt sdng bang laser qua da (PLDD - Percutaneous Laser Disc Decompression) nim trong ky thuat xam lan tdi thieu.
NGUYEN LY 1 - CSu true dTa dem
0" ngudi trudng thSnh, chieu dSy dTa dem cot sdng ed IS mdng nhat, vSo khoang 3 mm, edn d lung IS 5mm vS that lung IS 9 mm. Ngay tai tung viing trong mpt dTa dem cung khdng gidng nhau. NhQ'ng dia dem d tang thap cd dp dSy Idn hon d ting tren nd. c i u triic eiia dTa dem gdm 3 phan : bao xcr, nhan nhiy vS mSm sun.
Bao xa cd cau true IS nhQ'ng spi sun dan eh6o nhau theo hinh xoan de, xep thSnh cSc Idp ddng tSm tao nen dp vQ-ng chae vS cd tfnh dSn hdi. Dd dSy bao xo khong deu nhau d eSc vj tri, phfa trud'c dSy hon phia sau, lai dupe day ching dpc trud'c chic va rpng ehe phu; phia sau vS phfa sau ben mdng ban, lai khong dupe che phu hoSn toSn bdi dSy.chang dpc sau. Dieu nSy eung ly giai eho ly do .tai sao thoSt vj dTa dem thudng xay ra d trung tam hay phia sau lech trSi hoac lech phai.
Nhan nhiy dupe cau tao bdi mpt ludi lien ket gdm eSc spi mem ep chat vSo nhau, trong chira mpt chat CO ban nhiy Idng, IS eSc glicoprotein ngSm nhieu nude (khoang 80-85%, song lupng nude nSy giam d i n theo quS trinh lao hda). (3 ngud'i tre, nhan nhiy vS bao xcr cd ranh gid'i rd. Trong quS trinh ISo hda, td chire dTa dem trung tam mat dan tinh chat keo thuan nhat, do dd ranh gid'i md' d i n . Dieu nSy cung dS nhan thiy tren MRI. Nhan nhiy nam trong bao xo d vi tn 1/3 glQ'a vS 1/3 sau cua dTa dem, ehiem khoang 40% be mSt eat ngang. Khi cpt sdng van dpng thi nhSn nhay ddn lech ve phia ddi dien vdi chieu vSn ddng.
MSm sun bao phu phan trung tam mSt ben vS mSt duo'i cua than dot sdng, phia trud'c vS hai ben dupe vSnh xuong ngoai vi vay quanh.
2 - Nguyen ly PLDD
Tu' cau triic tren cho thay: Co the coi dTa dem nhu mpt he thuy lye kin, gdm bao xa tuang ddi etiac, dai vS nhan nhay IS mpt ehit keo eo dp nhd't cao nim d ben trong. Do tinh vQ-ng chic cua bao xa nen h$ sd irng suit khdi eiia dTa dem rit cao. Mdt su thay ddi nhd ve the tich cung d i n tdi sy thay ddi rat Idn ve mat Sp suit.
ThoSt vj dTa d$m x l y ra khi bao xa ran rSch mdt phin, hoSc m i t kha nang dSn hdi, tao dieu kien cho nhSn nhiy djeh chuyen khdi vj tri sinh ly ciia nd
Nguyen ly cua ky thuat PLDD IS dung nSng lupng laser ISm bde bay mdt lup'ng nhd nhSn nhay, tao ra mpt sy giam ap suit ndi dTa giai phdng sy ch6n 6p len eSc c i u triic t h i n kinh, Nguyen ly nSy dupe Daniel DJ Choy (Hoa Ky) de xud'ng vS chirng minh d i u tien vSo nam 1984. Benh nhSn d i u tien dupe dieu tri bing ky thuSt nSy vSo nam 1986 bdi Choy vS Ascher {Dwc) tai benh vien Dai hpe y Graz (Ao).
CSc thi nghiem in vitro vS in vivo da ehu'ng minh sy dung dan cua nguyen ly tren.
a - Su giam Sp suit trong dTa d#m
Trong thi nghiem in vitro vd'i c6t sdng ngud'i l i y ra tu" tir thi tuai, Choy vS Altman diing phu tai tao Sp suit noi dTa 2419±589 mmHg. Sau khi bde bay nhSn nhiy bing laser Nd:YAG vd'i nSng luang 1000 J thi Sp suit giam xudng edn 1075±484 mmHg, ung vdi mu'c giam 56%.
Nerubay ISm thi nghi§m in vivo vdi 10 con ch6, nhan thay Sp suit dTa dem sau PLDD deu giam, bien dp giam d L2/3 tu-10% -55%, d L4/5 t u 40%-69%. T^
Cud-ng thyc nghiem tren dpng vSt, cung ehu'ng minh dupe sau khi laser bde bay td chire nhan nhiy, Sp suit noi dTa giam 50%).
Kambin do dae Sp suit dTa dem 10 cas, phSt hi$n sau PLDD, Sp suit trong dTa tu 24.07 kPa giam xudng edn 12.58 kPa.
b - Nhiet do xung quanh dTa dem trong quS trinh PLDD
Theo NhSm Long Hy, trong thu thuSt PLDD, su thay ddi nhiet dp vS anh hudng den td chirc xung quanh ludn IS tieu dilm quan tSm vd m|t ISm sSng.
Nhieu bSc sy ISm sang cd thSi dd nghi ngd' PLDD, chu yeu IS lo tdn thuang nhiet ddi vdi cSc td chu'c xung quanh nhSn nhiy. Vi thd, nhidu tSc gia t i l n hSnh nghien ciru ve van de nSy.
Choy d§ tien hSnh thuc nghi$m xem x6t tdn thuang nhiet tren cdt sdng lung bd vdi laser Nd:YAG 1064nm. TSc gia da do nhiet dd d l5 lien hap vS thSnh trud'c dng sdng. Tir hud'ng sau b§n xuyen kim vS ludn spi quang d i n , d i u kim vua vupl qua bao xa. PhSt tia laser vd'i nSng luang 20J mdi xung thi nhiet dp tai eae diem do chua tSng quS 2°C, vira vSn d trong pham vi an toan.
Tri Vinh Long (Trung Qudc) diing laser bSn d i n bde bay td chire nhan nhay dTa dem tr§n tieu ban ngudi. Trong quS trinh bde bay, dSy chlng dpc tnj'6'c, day ching dpc sau, vS id sau dot sdng cd su thay ddi nhiet dd ddng deu d trong vdng 2°C (bang 1).
Y HOC THUC HANH (729) - SO 8/2010 19
Bang 1. Thay ddi nhiet dp d cSe vj tri khSc nhau, vd'i tdng nSng lutfng khSe nhau trong quS trinh PLDD.
Bang 2. Phan bd benh nhan theo sd dTa dpm dupe can thiep
Nh6m
400J 600J 800J 100
Thay d6i nhiet dp o vung khSc nhau xung quanh dTa dem (°C)
Trude dTa dem 1.02 ±0.22 1.28 ±0.24 1.46 ±0.36 1.87 ±0.57
Sau dTa dem 0.82 ±0.14 1.16±0.17 1.38 ±0.34 1.66 ±0.55
ThSnh trong lo liSn hop 0.92 ± 0.27 1.19±0.20 1.31 ±0.28 1.63 ±0.51 De khao sat anh hu'ang eiia nhiet dp trong thu thugt PLDD vdi cac tham sd khac nhau, Vu'ong NghTa Thanh da irng dung laser bSn din de nghien ciru nhiet dp d dot sdng khi bde bay bang laser. Dat nhiet ke dgng kim vao giu'a day chang dpc sau vS mSng eirng cpt sdng, tac gia da do dupe nhiet dp tuy sdng, 16 gian dot sdng, nhi^t dp d rS than kinh. Trong quS trinh laser ISm bde bay nhan nhiy, nhiet dp d hai nai gin nhu' bang nhau. Khi phat tia laser, nhiet dp xung quanh tang len nhanh chdng vS trong thdi gian gian each nhipt dp hg din; nhung tdc dp hg nhiet chgm ban tdc dp tang nhiet. Khi thoi gian gian each phat tia laser IS Is, nhiet dp td chUe xung quanh tuy hg xudng, nhung chu'a den mire binh thu'dng; sau khi laser phat ra du'pe 4-5 lan (khi xung phat ra 9s), day chang dpc sau, mSng ciing, 16 gian ddt sdng co sy tich luy nhiet dp tang cao ddn tren 40°C. Tuy thupc vao laser phat ra, nhiet dp td chirc xung quanh khdng ngirng tich ty tang cao, khi xung phat ra dupe 11 s, nhiet dp tgi ch5 do CO the dgt den 41 °C. Khi thai gian gian eSch phSt ra tia IS 5s, nhiet dp tir tir hg xudng den muc binh thudng.
Trong thyc nghiem, nhiet dp tiiy sdng vS r§ thin kinh trude sau thap han 40 dp C. Nhu vgy, neu duy tri thdi gian phat tia gian eSch 5s thi ea qua trinh bde bay nhan nhay IS an toan.
Thi nghiem in vivo ciia Choy vol 13 con eho mongrel can ngng 22 den 30 kg du'pe tien hSnh bang laser Nd:YAG. Moi con dupe tiln hanh PLDD d mpt dTa dpm vdi cae xung laser 20W, Is vS thd'i gian gian cSch 5s, tdng nang lu'png 1.000J. Tit ca cac con cho deu binh thudng, trU mpt eon di khgp khilng. Hai tuan sau PLDD, tat ca cho dupe gilt va md tir thi. Khong thay trudng hpp nSo bj tdn thu'ang ngogi dTa, mgc dii dTa d^m eua cho mdng hon cua ngu'ai rat nhieu.
Ban than chiing tdi cung da thyc hien thi nghipm in vitro nhieu lan vol cpt sdng heo tu'oi. Phau tich cho thiy nlu kim du'pe chpc chinh xSc thi vdi cac thong sd laser gidng nhu- PLDD thyc d bpnh nhan thi tdn thirong nhiet chi khu trii trong nhan nhay.
CSc thi nghiem tren, cung vdi kit qua lam sSng cua nhieu tSc gia tren t h i gidi cho thiy PLDD IS mpt ky thugt CO dp an toSn rit eao.
KfeT QUA L A M S A N G 1 - Bfnh nhan
Trong gin 11 nam, tu 01-6-1999 din 31-3-2010, chiing toi da thyc hien ky thugt PLDD eho 4152 bpnh nhan, trong do co 2109 nam vS 2043 nu. Tudi trung binh benh nhan la 45,5, tre nhat 14, giS nhat 91 tudi.
Tdng sd dTa dem dupe can thiep IS 7777, trung binh 1,87 dTa cho mpt benh nhan. B^nh nhan du'pe can thiep nhilu nhit la 6 dTa.
86 dia dem dwac can thiep 1
2 3 4 5 6
So benh nhan 1407 2016 610
89 28 2
Ty le (%) 33,89 48,55 14,69 2,14 0,67 0,05 Bang 3. PhSn bd benh nhSn theo vj tri dTa dem d u p e can thiep
Vj tri dia dem C2-C3 C3-C4 C4-C5 C5-C6 C6-C7 C7-D1
C^c dia dem cpt song ngyc kh^c
D12-L1 L1-L2 L2-L3 L3-L4 L4-L5 L5S1
So benh nhan 4 466 855 932 328 3 12 3 25 65 565 2762 1757
Ty le {%) 0,09 11,22 20,59 22,44 7,90 0,09 0,29 0,07 0,60 1,57 13,60 66,52 42,32 Tieu chuin chpn bpnh nhan, ky thugt tien hanh PLDD, phu'ang phSp danh giS kit qua da dupe chiing toi thong bSo trong nhilu cong trinli nghien cuu tru-oc day.
2- Kit qua
Bang 4. Kit qua thdng ke tren 2745 benh nhan PhSn loai
Xu^t sSc Tot Trung binh
K6m
So benh nhan 906 1305
487 47
Ty le (%) 33,01 47,54 17,74 1,71 Tdng ty Ip bpnh nhan dgt kit qua xuit sac vS tdt, tire IS nhQ'ng ngudi v l ea ban khdi bpnh IS 80,55%. Trong sd 47 benh nhSn kit qua kem co 21 ngudi di md hd.
Nlu xet rieng nhQ'ng ngirdi chi cd thoat vj dTa dem cpt sdng cd thi eSc ty le kit qua tu'ong Ung la 31,01%;
54,28%; 12,71% vS 2,00%. Ty le kit qua xuat sic co thap ban trung binh, nhung tdng ty le xuat sac va tot Igi cao han.
Ve biln chUng cua ky thugt, trong mu'di mpt nam qua ehung toi ggp hai trudng hpp co abeess cgnh mang cung, dupe xw ly bang rgch, md dudng dan luu va khSng sinh dn thda, khong co di chung. Khong eo tru'ang hpp tii' vong hoge bien chirng d l Igi di chirng vTnh vien nao. Co hai trudng hpp bpnh nhan dau mgnh keo dSi sau PLDD, nhung eSc xet nghiem vS chan doan hinh anh sau do phat hipn bj ung thu' di can vao cpt sdng ma hinh anh MRI chup tru'dc lue thyc hien PLDD khong co diu hipu nghi ngd gi ca. Benh nhan tir vong do benh ly ung thu'.
Thdi gian hdi phue tuy thupc vSo tudi, thdi gian mac benh vS mUc dp benh. Noi chung benh nhan tre vS thoi
20 Y HOC THUC HANH (729) - SO 8/2010
gian mac benh ngan thud'ng co kha nang hdi phyc nhanh hon vS tdt ban. Kit qua xuat sac va tdt cQng giam dan theo sd dTa dem bj thoat vj. Cac thdng ke theo cac tieu chi nSy da dupe chung toi thyc hifn d mpt sd nghien ciru trude.
Ty le xuat sac vS tdt d eSc benh nhan cd tiln su md hd cung thap ban ty Ip ehung. Tuy nhien, vi sd bpnh nhan nay it nen nhgn xet ehi co tinh tham khao.
BAN LUAN
Trung tam Vgt ly Y Sinh hpe (Phan vipn Vgt ly Y Sinh hpe) va hien nay Vipn Ngogi khoa Laser IS nai thyc hipn dau tien ky thuat PLDD d Vipt Nam. Trong 11 nam qua cung cd mpt vai dan vj khac thyc hipn, nhu'ng mdi dUng Igi d mire dp thii' nghiem. Thyc t l 11 nSm da ciing co kit lugn rang PLDD IS mpt ky thugt egn thipp ngogi khoa tdi thieu c6 nhilu uu diem trong dilu tn thoat vj dia dpm cpt sdng, nlu dirpc thyc hipn bai ban. Uu t h i ndi bgt cua PLDD so voi md hd IS:
Thyc hien duoi gay te. Hgu phau nh? nhSng.
Benh nhan ngogi tru, khong phai lu'u vien.
Khong tgo seo, khdng gay xa dinh than kinh.
Khong ISm mat dp vu'ng chic cua cpt sdng.
Thoi gign hgn chi vgn dpng ngan.
Cd the Igp Igi vS khong can trd phau thugt hd, nlu can.
Co thi thyc hipn mpt lue d nhieu ting, nhieu vj tri each xa nhau.
Dp an toSn cao.
Co the thyc hien eho eSc bpnh nhan co tinh trgng tim mgch, gan, thgn, tilu dudng va tinh trgng sUc khoe Chung kem mS viec md hd eo t h i trd nggi hoge khong thyc hien dupe.
Ve dSnh giS kit qua, tat ca cac tSe gia tren t h i gidi diu dya vao mire dp cai thipn tren lam sSng. Vi dya vSo lam sang nen khd djnh lirpng vS cQng ed mpt sd sy khac nhau trong tieu chi dSnh gia. Tuy vgy, ed t h i ndi kit qui eiia chung toi cung tuang duong vai kit qua trung binh eiia t h i gidi.
Cai kho cua ky thugt PLDD IS phau thugt vien khong quan sat tryc tiep dupe cSc hipu irng tuang tSc laser tren md. Hieu irng nay chi c6 the phSn doSn mOt cSch giSn tilp qua tinh trgng thoSi hda, mit nude cua dTa dem, cSc diu hieu thoSt hai, thoSt djeh, than hda trong quS trinh thyc hien ky thu^t. Vi v|ly, vi#c chpn cSc thong sd bipc xg laser tdi uu ddng vai trd quylt djnh thSnh edng. De chpn dupe thdng sd tdi uu c i n c6 hilu bilt
sau sac ve hipu ung tuang tSc cua buc xg laser vdi mo sinh hpe va kinh nghipm. Co le day cung IS nguyen nhan ISm mpt sd trung tam khSc bd cupc.
Di biit thdm chi tiit, Hdn hi tare tiip vdi BS. Trin CdngDuygt DT: 0988160788.
TAI LIfU THAM K H A O
1. -Choy D.S.J. Percutaneous Igser disc decompression - A practical guide. Springer 2003.
2. Choy D.S.J. Percutaneous Laser Disc Decompression (PLDD): 352 Cases with an 81/2 - Year Follow-up .J. Clin. Lgser Med. & Surg. Vol.13 No. 1 (19 95), 17-21.
3. Ha Viet Hien, Tran Cong Duyet. Some comments on indication for percutaneous laser disc decompression., 10th Congress Asign- Pacific Association for Laser Medicine & Surgery, Shanghai, Trung Qudc 2004. Free paper.
4. Ha Vilt Hiln, VQ Cong Lgp, Trin Cong Duy$t, Le Due Td.Y nghTa ciia vipc chup cpng hudng tir kilm tra sau ky thugt giam Sp dTa dpm cpt sdng bing laser qua da. Tgp chi Y hpe thyc hSnh 2000;8(385):45-47.
5. HS Vilt Hiln, Trin Cong Duyet. Giam Sp dTa dem cpt sdng bing laser qua da cho bpnh nhan da phau thugt hd. Tgp ehi Y hpe thyc hSnh 2001 ;6(398):29-31.
6. Hellinger J. Nonendoscopic Percutgneous 1064- Nd-YAG-Laser Disk Decompression. Mechanism, Technique and Experience. Abstract of XII. International Congress of the Intemational Society of Laser Medicine
& Surgery. Rostock Germany (1997). 40.
7. Hellinger S. and J. Hellinger. Percutaneous Laser Disk Decompression and Nudeotomy in Cases of Postnueleotomy Syndromes. Abstract of XII.
International Congress of the Intemational Society of Laser Medicine & Surgery. Rostock Germany (1997). 38.
8. Hiraishi K., N. Ohmori, R. kosaka, T. Yonezawa, T. Onomura, I. Adachi, T. Matsuoka, G. Honghan, I.
Narabayashi. Serial Changes on MR Imaging of Herniated Lumbar Disc Treated by Percutaneous Laser nudeotomy: Correlation with Early Clinical Results.
JMRM Vol. 16 No. 5 (1999), 176-186.
9. Kanayama T. Limits of Efficacy of Percutaneous Laser Disc Decompression (PLDD) for Lumbar Disc Hemiation. X. Congress of Intemational YAG Laser Symposium.Ho Chi Minh City Vietnam (1998).
DUAC DAU NHAN XETSlTTHAY DOI HUYET DONG vAl TEST TRUYEN DjCH QT DENH NHAN SOC NHliM KHUAN
D A N G P H U I T N GPHAP DO CUNG LlATNG TIM PICCO
TOM T A T
Myc tieu: Bwdc dau nh$n xet sw thay doi huyet dgng vdi test tniyen djeh d benh nhan soe nguyen khuan bang phwang^phap do cung Iwgng tim lien tiic PICCO
Thiet ke: Nghien ciru lam sang mo ta cd so sinh Dja diem: Khoa Cap ewu b$nh vi$n B$ch mai
NGUYIN HQU QUAN, NGUYIN ANH TUXN
N G U Y I N DAT ANH
Khoa Cip CCPU BSnh vi§n Bach mai
B$nh nhan: 5 b$nh nhin soe nhiem khuin Can thl$p: Truyen djeh
Ket qua nghien ciru: Cic thdng so huyet dgng dwgc do d^c dwa theo phwang phap hoa loang nhiet Sau khi test truyen djeh lam tang mgt each co y nghTa CVP (p<
0,05) tir 10 ±5 len 12 ±5 cmH20, GEDVI tir 714 ± 207
Y HOC THl/C HANH (729) - SO 8/2010 21