GIAM AP
D I A D I E MCOT SONG BANG LASER QUA DA KINH NGHIEM SAU Ml/Ol NAM
Tran Cong Duyet''^, Ha Viet Hien'-^, Vo Hong Hanh'-^, Vu Cong L?p^
I. Md OAU
Thodt vi dTa dfm cdt sdng Id mdt bfnh ly tuomg doi thudng gap, chilm da sd cac trudng hgp bfnh nhan nhdp vifn do dau lien quan din cdt sdng. Benh thudng xudt hifn d ngudi ldn, tuy nhien ddi khi ca d tre em. Mdt so thing ke d nudc ngoai cho thdy d khoang 1/3 dan sd tren tudi trudng thanh cd thoat vi dTa dfm, 1% cd cdc trifu chiing lam sang d miic can dieu tri tich cure.
DTa dfm thoat vi cd thi chen ep len bao mang ciing va/hoac cac re thdn kinh, gay cac trifu chiing dau, te, teo hay lift ca d cac vimg phan bd cua ri thdn kinh, ro nhdt la tii chi. Cac trifu chiing nay lam giam rd rft kha nang lao dpng vd chdt lugng cudc song ciia bfnh nhan.
Khi cac phuomg phdp diiu tri bdo tdn nhu nghi ngai, udng thudc, chdm ciiu, vat ly tri lifu, ndn bdp v.v khdng cdn cd tac dvmg thi bfnh nhan cd thi dugc chi dinh can thifp
ngoai khoa. Md hd la phuomg phap kinh diin, din nay vin dugc dp dvmg nhieu. Tuy nhien, phuomg phap md hd ciing chiia nhieu riii ro va pha hiiy mpt phdn cau tnie cdt sing. Vi vdy, mdt sd phuang phdp can thifp it xam Iki hom dugc dp dvmg nhu ml ndi soi, an mdn bang men, thdu tJiift bang sdng radio v.v.
Giam dp dTa dfm cdt sdng bdng laser qua da (gpi tdt la PLDD, tir thuat ngflr tiing Anh Percutaneous Laser Disc Decompression) la mdt phuang phdp can thiep tdi thieu dugc Choy vd Ascher dl xudt vd thvrc hifn ddu tien vao nam 1986 tai Ao. Nhdm tdc gia bai ndy bdt ddu thvrc hien ky thudt nay tir thdng 6 ndm 1999. Bdi vilt nay tdng kit va nit kinh nghifm tren sd benh nhan dugc diiu tri trong vdng 10 nam dau tien.
Nghien ciiu dimg phuomg phap thong ke hdi ciiu khdng cd nhdm chiing.
II. BENH NHAN
Ky thudt PLDD dugc nhdm tdc gid bdt dau thurc hifn tai Tnmg tam Vdt ly Y Sinh hoc (nay Id Phan vifn Vdt ly Y Sinh hpe - Bd Qude Phdng) vd hifn nay chuyen sang Vifn Ngoai khoa Laser. Trong vdng 10 ndm, tir 01/6/1999 din 31/5/2009, 3173 bfnh nhan dd dugc difu tri. Ddc diim phan bd bfnh nhan nhu Bang 1.
Bang 1. Ddc diem phan bd bfnh nhan
Tong so Nam
Nu"
Tuoi trung binh Tre nhat
Gia nhat ' Vi4n Ngogi Idioa Laser
^ Phdn vien Vgt ly YSinh hgc
3173 1592 1581 45,5 14 91
62
NQI KHOA - SO 4/2009
Tieu chudnchpn benh nhan dvia vdo kham lam sang vd chdn doan hinh anh. Cvi thi:
Hinh dnh MRI hodc CT cho thdy cd thodt vi dTa dfm nhung bao xa chua rdch hdn (thodt vi trong bao).
Cdc trifu chitng ldm sang phii hgp vdi dia dfm thodt vi.
Cd it nhdt 2 thdng diiu tri bdo tdn khdng hifu qua, trur trudng hgp thodt vi do chdn thuong md hinh anh vd trifu chiing thoat vi cho tifn lugng kem nlu diiu tri bao tin.
- Bfnh nhan cd nguyen vpng dugc diiu.
tri bdng ky thudt PLDD.
_ Chong chi dinh tuyft ddi:
- Bao xa bi va nhan nhdy thoat ra ngodi, cd manh va tur do.
- Viem xuomg ndng.
Chit h?p dng song nang do gai xuang hodc vdi hda.
Trugt cpt sdng tren dp I tai vi tri dinh can thifp.
Ung thu, lao xuomg.
Gay, vd xuomg.
Chong chi dinh tuomg doi:
-^ Bfnh nhan da dugc phau thudt cdt bdn sdng (laminectomy).
Bfnh nhan dd dugc can thiep tieu nhan bang men chymopapain hodc sdng radio.
Thoat vi ldn, chilm fren 70% thilt dien ngang dng sdng.
Day day chdng vang.
Thoai hda dTa dem nang, cd bpt khi d nhan nhdy.
Viem dinh cdt sdng.
Benh nhan cd bfnh tim mach, chiic nang gan than kem.
Benh nhdn khdng dn dinh vl tam ly.
Trong sd cac bfnh nhan dugc dieu tri, cd 28 bfnh nhdn da dugc m l hd (laminectomy) trudc do nhung khdng thanh cdng, van cdn dau nhieu.
Trudc can thifp, bfnh nhan dugc giai thich vl nguyen ly ky thudt PLDD, tien lugng diiu tri vd ky cam kit tir nguyfn diiu tri. Xet nghiem tiln phdu ca ban. Cdc bfnh nhan cd cac bfnh ly khac thi dugc chi dinh them mpt so xet nghifm cdn thilt nhu X- quang tim phoi, difn tim, difn ca v.v.
Tong sd dTa dfm dugc can thifp Id 5909, trung binh 1,86 dTa cho mdt bfnh nhdn. Bfnh nhan dugc can thifp nhilu nhdt la 6 dTa.
So dia dem du'dc can thiep 1
2 3 4 5 6
So benh nhan 1095 1532 458
66 20 2
Ty le f o/ol 34.50 48,28 14,43 2,08 0,63 0,06
Bang 3. Phdn bd bfnh nhdn theo vi tri dTa dfm dugc can thifp
Vi tri dia dem a-C3 C3-C4 C4-C5
So b§nh nhan 2 350 632
Tylefo/o) 0,06 11.03 19.91
C5-C6 C6-C7 C7-D1
Cac dTa dem cdt sdng nqu'c khac D12-L1
L1-L2 L2-L3 L3-L4 L4-L5 L5S1
704 254 3 11
3 18 49 427 2123 1333
22,18 8,00 0,09 0,35 0,09 0,57 1,54 13,46 66,91 42,01
III. PHUONG PHAP
Nguyen ly cua ky thuat PLDD la dimg nang lugng laser bdc bay mdt lugng nhd nhan nhdy, tao ra mdt sir giam dp sudt ndi dia giai phdng svr chen ep len cac cdu tnie thdn kinh.
Cd the coi dTa dfm nhu mdt he thuy lire kin, gdm bao xa tuomg ddi ciing va dai va nhan nhdy la mdt chdt keo cd dp nhdt cao d ben trong. Do tinh ciing cua bao xa nen he sd ling suat khdi cua dTa dfm rdt cao. Mdt sur thay ddi nhd vl thi tich ciing dan din thay ddi rdt ldn ve dp sudt.
Bk thurc hifn ky thudt PLDD, chiing tdi sir dimg cdc laser Nd:YAG cd bude sdng 1064 nm. Loai laser nay dugc da sd ddng nghifp sii dvmg lam PLDD do dp hdp thu cao cua nhan nhdy d bude sdng cua nd. Cac thilt bi dugc dung la laser CL50 (Nhat Ban) vd CLMD (Hoa Ky).
Ky thudt PLDD dugc thurc hifn dudi gay te tai chd. Mdt so it tac gid thirc hifn dudi gay me, nhung chiing tdi ciing nhu nhilu tdc gia khac cho rdng gay te cd uu the hom.
Ndng lupmg laser dugc truyen bdng ddy quang dan dudng kinh 400 micron ludn qua cdc kim chpc tir ngoai da vao nhan nhdy dTa dfm, dinh vi 3 chilu bdng X-quang C-arm.
Vdi cac dTa dfm cdt sdng thdt lung vd ngurc, dimg kim chpc tuy #18 di tir phia sau ben, theo gdc chech khodng 45 dp. Ddi vdi cac dTa
dem ddt sdng cd va C7-D1, dimg kim #20 chpc tir phia trudc ben. Day quang ddn nhu ra khdi dau kim tir 2 - 5 mm, tranh hifn tugng truyen nhift theo kim.
Ddi vdi dTa dfm cpt sdng cd diing cdng sudt 10-15W, phat theo xung Is, ydi tdng nang lugng 300 - 700J. Ddi vdi dTa dem cdt song thdt lung dimg cdng sudt 12 - 27W, phat theo xung 1 s, tdng nang lugng 400 -1900J.
Sau can thifp, bfnh nhan dugc cho nghi ngai 30 phiit din 1 gid va cd thi ve (iha sau dd. Cac thudc khang sinh phdng ngirffljfciam dau, gian ca dugc cho thdng thudng 5 - 1 0 ngdy. Mpt so benh nhan dugc cho vat ly tri lieu bd sung.
IV. KET QUA
Danh gia kit qua dira vdo svt cdi thifn cua cac trieu chiing lam sang, qua cdc ldn tai kham ciia bfnh nhan, hodc qua trao doi bdng difn thoai, theo cac tieu chi:
Cdm giac dau, te chu quan;
Cam giac dau khi thdy thudc kilm tra;
Tam van dpng cua cdc chi;
Ca Ivrc;
Khd ndng ldm vifc, sinh hoat ciia bfnh nhan.
Thdi gian theo doi ngdn nhdt la 2 thang, dai nhdt la 122 thdng.
Phan loai kit qua theo bin mdrc:
NQI KHOA-SO 4/2009
Xuat sac:
Kha:
Trung binh
Kem
+ het cac cam giac dau, te cd UUdc khi lam PLDD + khdng cd cam giac dau khi thay thudc kiem tra + tam van ddng cua cdt song, cac chi trd lai binh thudng + cd lire binh thu'dng
+ benh nhan trd lai du'dc vdi cdng viec trUdc dd, khdng cd trd ngai trong sinh hoat
+ khdng phai diinq thuoc giam dau + cam giac dau, te chu quan giam ro ret + it cd cam giac dau khi thay thudc kiem tra
+ tam dp van ddng cdt song, cac chi cai thien nhieu
+ cd li/c kha hdn tru'dc khi lam PLDD (ddi vdi nhu'ng benh nhan cd yeu cd)
+ benh nhan cd kha nang lao ddng va sinh hoat tUdng ddi binh thu'dng + it khi phai diing thudc giam dau
+ cac trieu chufng lam sang giam khoang 20-50%
+ phai dimg thudc giam dau mpt sd ddt
+ benh nhan lao ddng chan tay nang phai chuyen nghe + chat lu'dng cudc sdng cd b| anh hu'dng
+ cac trieu chufng lam sang giam du'di 20%
+ cd the phai md hd.
Sl bfnh nhan theo ddi dugc Id 2745 ngudi. Kit qud nhu sau:
Bang 4. Ket qua thing ke tren 2745 bfnh nhan
Phan loai Xuat sac
Tdt Trunq binh
Kem
So bSnh nhan 906 1305
487 47
Tv le (O/o) 33,01 47,54 17.74 1.71
Ting ty If bfnh nhdn d?it kit qud xudt sdc vd tit, tiic Id nhflmg hgudl vl ca ban khdi bfnh Id 80,55%. Trong sl 47 bfnh nhdn kit qud kem cd 21 ngudi di m l hd.
Nlu xet rieng nhumg ngudi chi cd thodt vj dia dfm cgt sdng' cd thi cdc t^ If kit qud tuong img Id 31,01; 54,28; 12,71, 2,00. Ty If kit qud xudt sdc cd thdp hom trung binh, nhung tong ty If xudt sdc vd tot lai cao hom.
v l biln chiing ciia ky thudt, trong mudi nam qua chiing tdi gdp hai trudng hgp cd abcess canh mang ciing, dugc xii ly bdng xe r?ich dan luu vd khdng sinh on thda, khdng cd di chiing. Khdng cd trudng hgp tii vong hodc biln chiing dk lai di chiing vTnh vien ndo. Cd hai trudng hgp bfnh nhdn dau manh keo ddi sau PLDD, nhung cdc xet nghifm vd chdn dodn hinh dnh sau dd phdt hifn bi ung thu di cdn vao cdt sdng md hinh dnh MRI chvip
trudc luc thyc hifn PLDD khdng cd ddu hifu nghi ngd gi cd. Bfnh nhan tu vong do benh ly ung thu.
Thdi gian hdi phue tuy thudc vao tudi, thdi gian mdc bfnh va miic dp bfnh. Ndi chung bfnh nhan tre va thai gian mdc bfnh ngdn cd thudng cd kha ndng hdi phue nhanh hom va tdt hom. Kit qua xudt sdc vd tdt ciing giam dan theo sd dTa dfm bi thodt vi. Cdc thdng ke theo cac tieu chi nay da dugc chiing tdi thyc hifn d mdt sd nghien cuu trudc.
Ty If xudt sac va tdt d cdc benh nhan cd tien sir ml hd cung thdp hom ty If chung, tuy nhifn vl sd bfnh nhan nay hai it nen nhan xet chi cd tinh tham khao.
V. BAN LUAN
Trung tam Vat ly Y Sinh hpe (Phan vifn Vdt ly Y Sinh hpe) va hifn nay Vien Ngoai khoa Laser la nai thvrc hifn dau tien ky thudt PLDD d Vift Nam. Trong mudi nam qua ciing cd mdt vai dom vi khac thyc hifn, nhumg mdi dimg lai d miic dp thit nghifm.
Thyc te 10 nam da ciing cd ket luan rdng PLDD la mpt ky thuat can thiep ngoai khoa tdi thilu cd nhieu uu diim trong diiu tri thoat vi dTa dfm cdt sdng, nlu dugc thyc hien bdi ban. Uu the ndi bat cua PLDD so vdi md hd la:
Thuc hifn dudi gay te. Hdu phau nhe nhdng.
- Benh nhan ngoai tni, khdng phai luu vifn.
- Khdng tao seo, khdng gay xa dinh thdn kinh.
Khdng lam mdt vflmgcdt sdng.
Thdi gian han chf vdn ddng ngdn.
Cd the lap lai va khdng can trd phau thuat hd, nlu can.
Cd the thyc hifn mpt liic d nhilu tang, nhilu vi tri each xa nhau.
Dp an todn cao.
Cd thi thuc hien cho cdc benh nhan cd tinh trang tim mach, gan, than, tiiu dudng vd tinh trang sue khde chung kem md m l hd cd thi trd ngai hodc khdng thyc hifn dugc.
v l ddnh gid kit qua, tdt cd cdc tdc gia tren the gidi deu dya vao muc dp cdi thifn tren lam sang. Vi dya vao lam sang nen khd dinh lugng va ciing cd mgt so sy khac nhau trong tieu chi danh gia. Tuy vay, cd the ndi ket qud cua chiing tdi ciing tuomg duomg vdi ket qud trung binh cua the gidi.
Cai khd cua ky thuat PLDD Id phau thuat vien khdng quan sat tryc tiep dugc cac hifu ling tuomg tac laser - md. Hifu iing ndy chi cd the phdn doan mdt each gidn tilp qua tinh trang thoai hda, mat nudc cua dTa dem, cdc ddu hifu thoat hai; thodt dich, than hda trong qua trinh thyc hifn ky thuat. Vi vay, vifc chpn cdc thdng sd blip xa laser toi uu ddng vai trd quyet dinh thanh odng. Df chpn dugc thdng sd tdi uu can cd hieu bilt sdu sdc vl hieu ling tuong tac cua biic xa laser vdi md sinh hoc vd kmh nghiem. Cd le day cung la nguyen nhan lam mdt sd trung tam khac bd cudc.
VLLdlcAMON
Bk triin khai thanh cdng ky thuat PLDD, chiing tdi nhan dugc sy ho trg to Idn vd vd tu cua TS. Masashi Marumo (Nhat Ban) vd Hdi Laser Y hpe va Ngoai khoa Chdu A-Thai Binh Duong. Nhan dip ndy xin giii din TS.
Masashi Marumo, GS., Narong NimsakuJ, TS.
Norio Daikuzono led cam on chan thanh nhdt, p TAI UEU THAM KHAO
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NQI KHOA - SO 4/2009
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