I. Background.
Raynaud’s syndrome is a group of paroxysmal peripheral arterial spasm diseases caused by vascular nerve dysfunction, although it is easy to diagnose because of the paroxysmal “pale – cyanotic – flushed – normal” cyclic change of skin color of the extremities with pain Although it is easy to diagnose because of the typical symptoms and signs, conventional drug treatment is not effective.
In view of the poor results of conventional medical treatment, surgical treatment is now preferred. Commonly used surgical methods include thoracoscopic upper thoracic sympathetic nerve block, chemical thoracic sympathectomy, stellate ganglion block and extra-arterial sympathectomy. Surgical treatment can significantly improve the symptoms of terminal ischemia, promote ulcer healing, relieve pain, reduce the incidence of gangrene and amputation of fingers (toes), and improve the quality of life of patients.
Chemical thoracic sympathectomy is easily accepted by patients because of its small trauma, fast recovery and long-lasting efficacy. However, the location of the thoracic sympathetic nerve chain is deep, and the unarmed operation is very likely to cause pneumothorax and even risk of spinal cord injury. Although the technique of thoracic sympathetic chain block under X-ray guidance of C-arm machine has been introduced in China, it is still difficult to be widely used in clinical treatment due to the ambiguity and imprecision of X-ray positioning, which is risky.
We have a municipal project “CT-guided percutaneous thoracic sympathetic block for the treatment of hand sweating” under research, and since the cause of Raynaud’s disease is similar to that of hand sweating, we have extended my project to the treatment of Raynaud’s disease.
II. Methods.
The family was given a detailed explanation of the operational features, expected effects and possible complications of the “CT-guided percutaneous puncture chemical thoracic sympathetic chain dissection” technique and signed an informed consent form, and after a negative iodine allergy skin test, an intravenous cannula was left in place to open the intravenous infusion channel.
The patient was placed prone on the CT table, and a localization grid was placed on the skin of the back corresponding to the thoracic 3 and 4 vertebrae, and the T34 intervertebral space was accurately located using CT localization images. The target point is the upper edge of the 4th rib joint (corresponding to the lower outer edge of the T3 vertebral body above the small head of the 4th rib), the best skin entry point on both sides is selected, the distance between the entry point and the target point (entry depth), the entry angle, and the distance of the entry point from the midline are recorded with a CT tool ruler, and the angle and relative distance between the CT bed and the frame shown at this level are recorded.
Open the positioning red line, and mark the puncture entry points on both sides on the positioning red line with a marker according to the previously measured distance from the midline. After local anesthesia of the selected puncture point, the needle was punctured with a No. 7 radiofrequency needle under CT guidance according to the proposed angle and depth, which could be adjusted by CT scan again or several times during the needle feeding process until the needle tip arrived at the target point close to the upper edge of the 4th rib joint.
The CT localization image is used again to confirm that the puncture needle is located at the outer edge of the T3 vertebral body above the T34 intervertebral space. The patient’s hands were dried of sweat, and palm temperature was measured and recorded. Back to draw no blood, fluid, gas, each point injected 1% lidocaine 3ml (containing contrast agent 30% iodophoresis injection 0.3ml), CT scan shows the distribution of the injected drug: if the posterior outer edge of both sides of the T3 vertebral body and the spinal groove outside the small head of the 4th rib are covered, the upper edge of the drug does not exceed the wall of the 2nd rib vertebral joint level outside the pleura.
And after 15 min, the patient had no numbness and activity disorder in the lower limbs, no Horner’s syndrome bilaterally, and the palms of both hands were changed from wet and cold to dry and warm (more than 2°C higher than before the drug was administered). The left and right sides were injected with 2.5 ml of anhydrous alcohol each (each 1 ml contained 0.9 ml of anhydrous alcohol and 0.1 ml of 30% iodophoresis injection), and after retiring the needle, CT was performed again to confirm that the alcohol wrapped around the small head of the 3rd and 4th ribs and the lateral side of the T3 and 4 vertebrae outside the wall pleura, and the upper edge of the drug did not cross the upper edge of the T2 vertebrae (as in Figure 3 and Figure 4). CT was performed to observe the lung window for the occurrence of hemothorax and pneumothorax. The pulse oximetry, blood pressure and heart rate of the patients were monitored during the treatment. The efficacy was followed up after the operation.
III. Results
Since June 2010, we have completed the treatment of 6 cases of Raynaud’s disease and achieved the expected results without complications. Postoperative follow-up for 2~6 months, no Raynaud’s present phenomenon will occur even if the patient’s hands are put into ice water for 30 minutes again.
The paper has been submitted to the Chinese Journal of Rheumatology for review because it is an original technique.
I. Problems and next steps
1, Raynaud’s disease is often secondary to a variety of autoimmune diseases, in the treatment of Raynaud’s disease at the same time, must ask sister disciplines (rheumatology) to collaborate in the treatment of the original disease.
2, although the media (Jiaxing TV, South Lake Evening News, Jiaxing Daily) on our use of minimally invasive technology to cure Raynaud’s disease reported, there are still many patients still do not understand this information, still suffering from the torture of Raynaud’s disease. We also need to do more publicity through the network and other related media.
3, strive for the early publication of the paper, can make this technology in the domestic peer to promote the application, for more patients to relieve the pain.
Annex 2: The paper (has been submitted to the Chinese Journal of Rheumatology and subjected to.
CT-guided percutaneous percutaneous thoracic sympathetic block for Raynaud’s syndrome
Raynaud’s syndrome is a group of paroxysmal peripheral arterial spasm disorders caused by vascular nerve dysfunction, although it is easily treated by paroxysmal “pale – cyanotic – flushed – normal” periodic changes in skin color with pain. Although it is easy to diagnose because of the typical symptoms and signs, conventional drug treatment is not effective. In this paper, “CT-guided percutaneous thoracic sympathetic block therapy” was used to achieve good results, which are reported below.
Clinical data
1. Subjects: After approval by the hospital ethics committee and obtaining informed consent from patients, six patients with Raynaud’s syndrome who came to the First Hospital of Jiaxing City, Zhejiang Province, between October 2009 and June 2010 to receive CT-guided percutaneous thoracic sympathetic block therapy were used as observation subjects: male/female (1/5), age 41-65 years, average 53.2 years, medical history 7-26 years, average 13.8 years. The patients all had the cyclic change of “pale – cyanosis – flushing – normal” after the hands were exposed to cold, and the pain in the fingers was intense during this change, with frequent attacks in winter and spring. The episodes were frequent in winter and spring, and sometimes they were triggered by emotional stress, excitement or entering a cold air-conditioned room in summer. Two of the patients had the same condition in both feet as in both hands.
All patients had been treated with oral medications (nifedipine, reserpine, prostaglandin, vitamin E and warm tonic Chinese medicine such as compound salvia) by conventional internal medicine in several hospitals, but the symptoms did not improve significantly. After inpatient examination, except for one patient who had positive anti-nuclear antibody (ANA), anti-double-stranded DNA antibody (A-ss-DNA), and anti-synovial antibody (ACA), and was diagnosed as “CREST syndrome” with dysphagia and finger stiffness, all other patients had no autoimmune disease and belonged to primary Raynaud’s disease. The rest of the patients had no autoimmune disease and belonged to primary Raynaud’s disease. The typical Raynaud’s phenomenon can be induced by immersing both hands in ice water for 30 min.
2. Methods: After the preoperative investigations of routine blood, clotting time, prothrombin time, electrocardiogram, and frontal and lateral chest films were normal, the patient and family members were given a detailed explanation of the operational characteristics, expected effects and possible complications of the “CT-guided percutaneous thoracic sympathetic chain block” technique and signed an informed consent form. After the negative iodine allergy skin test, a cannula was left in place for intravenous infusion. The patient was asked to lie prone on the CT table, and the electrocardiogram (ECG), noninvasive blood pressure (NIBP), finger pulse oxygen saturation (SPO2), and palm temperature (T) of both hands were recorded with a multifunctional vital signs monitor.
The CT localization image was used to accurately locate the T34 intervertebral space, and the upper and lower vertebral bodies were scanned with a layer thickness of 3 mm centered on it to select and mark the best skin entry points on both sides, and the selected puncture point was punctured with a No. 7 radiofrequency needle under CT guidance according to the measured angle and depth after local anesthesia, and the needle entry process could be adjusted by CT scanning again or several times until the needle tip arrived at the lateral anterior T3 vertebral body immediately above the upper edge of the 4th rib joint. Extra pleural space, retraction without blood, fluid and gas, each point injected with 3% lidocaine 3ml (containing contrast agent 30% iodophoresis injection 0.3ml), reconstruction after CT scan showed that the injected solution covered the posterior outer edge of both sides of the T3 vertebral body and the spinal groove outside the small head of the 4th rib, and the upper edge of the solution just reached the wall extra pleural at the level of the 3rd rib joint.
After 15 min observation, the patient had no numbness and movement disorder in the lower limbs, no Horner’s syndrome bilaterally, both hands became warm, and 2.5 ml of anhydrous alcohol (each 1 ml contained 0.9 ml of anhydrous alcohol and 0.1 ml of 30% iodophoresis injection) was injected into the left and right sides respectively. After withdrawing the needle, the CT scan was repeated to observe the flow of the injected alcohol outside the wall pleura, and to observe the lung window without the occurrence of hemothorax and pneumothorax to end the operation. The patient’s vital signs such as pulse oximetry, blood pressure, heart rate palm temperature, and pulse volume wave amplitude were monitored during the treatment. On the second day, the first week, the first, third and sixth month after surgery, the patient’s hands were immersed in ice water again for 30 min to observe whether the Raynaud’s phenomenon could be induced again.
II. Results
All six patients were hospitalized, and the preoperative routine auxiliary examinations were normal. All of them were successfully punctured to the target point under CT guidance, and no hemothorax or pneumothorax occurred. After the injection of local anesthetic, CT scans mostly showed that the drug flowed outside the wall pleura along the lateral side of T3 and 4 vertebral bodies, partially wrapping the 3rd and 4th rib cavity, with the highest distribution upward to the lower edge of the 2nd rib cavity. After the injection of local anesthetic for 5 min, the patient’s hands were changed from “cold” to “warm”, the palm temperature increased by 3.1℃ on average, the pulse volume wave amplitude increased by more than 55% on average, the oxygen saturation of finger pulse also increased significantly, and there was no significant change in heart rate and blood pressure. There were no significant changes in heart rate and blood pressure. The changes in heart rate (HR), non-invasive blood pressure (NIBP: systolic blood pressure SBP, diastolic blood pressure DBP), finger pulse oxygen saturation (SPO2), pulse volume wave amplitude (A), and palm temperature (T) of both hands were tested before and after drug injection.
No Horner’s syndrome occurred in all patients after anhydrous alcohol injection, and the patients walked back to the ward. After the operation, both upper limbs felt warm, and the fingers of both hands changed from stiff to soft and could clench their fists. On the second day, the first week, the first, third and sixth month, respectively, the patients were allowed to immerse their hands in ice water again for 30 min, and no further Raynaud’s phenomenon could be induced. In one case, the dysphagia of CREST syndrome did not improve significantly, and in one case, the sweating of lower back, lower abdomen and both lower extremities increased after surgery compared with that before surgery, and the sweating disappeared after 3 months.
Discussion
Since the French physician Raynaud first reported 25 cases of episodic finger ischemia caused by finger artery spasm in 1862 and named it Raynaud’s disease, people have been interested in the typical paroxysmal “pale – cyanotic – flushed – normal” skin color of the extremities, which is induced by cold stimulation or emotional excitement. The syndrome is characterized by a paroxysmal “pale – cyanotic – flushed – normal” cycle with pain.
It is now believed that the pathological mechanism is mainly the intense spasm of the small muscular and finger (toe) arteries, which causes tissue ischemia (pale phase), hypoxia and metabolite accumulation (cyanotic phase), followed by vasodilation, tissue congestion and reperfusion (flushed phase), improvement of hypoxia and removal of metabolite accumulation (normalization) [1]. Studies have shown that the perivascular autonomic and sensory nerves, vascular endothelial cells, and vascular smooth muscle are involved in the regulation of vasodilation, with thoracic sympathetic hyperexcitability probably being the main cause of this sign.
In view of the poor results of conventional medical treatment, surgical treatment is currently preferred. Commonly used surgical methods include thoracoscopic suprathoracic sympathetic nerve block, chemical thoracic sympathectomy, stellate ganglion block [5] and extra-arterial sympathectomy of sympathetic nerve endings. Surgical treatment can significantly improve the ischemic symptoms of limb ends, promote ulcer healing, relieve pain, reduce the incidence of gangrene and amputation of fingers (toes), and improve the quality of life of patients.
Chemical thoracic sympathectomy is easily accepted by patients because of its small trauma, fast recovery and long-lasting efficacy. However, the location of the thoracic sympathetic nerve chain is deep, and the unarmed operation is very likely to cause pneumothorax and even risk of spinal cord injury. Although the technique of thoracic sympathetic chain block under X-ray guidance of C-arm machine has been introduced in China, it is still difficult to be widely used in clinical treatment because of the high risk due to the ambiguity and imprecision of X-ray positioning.