I. Preface
With the continuous improvement of people’s living standard, chronic pain as a common disease and multi-morbidity has been troubling hundreds of millions of patients. According to preliminary estimates, there are more than 300 million chronic pain patients in China, and the number will increase at the rate of 10-20 million every year.
In developed countries, chronic pain has been studied and treated as a key disease since decades ago, which has created many effective treatment methods and tools.
Among them, the modern minimally invasive treatment techniques represented by intervertebral discotomy, collagenase discolysis, selective neurodesis, radiofrequency, ozone, laser, plasma, foraminoscopy, spinal cord stimulation technology, intrathecal morphine pump, vertebroplasty, etc., have become the main technical means of chronic pain treatment and have achieved very good clinical results, which have been widely recognized by clinicians and patients.
A brief history of the development of pain medicine
In 1975, the InternationalAssociationfortheStudyofPain (IASP) was established.
In 1989, the Chinese AssociationfortheStudyofPain (CASP) was established under the auspices of Professor Han Jisheng, a famous neurophysiologist from Beijing Medical University and member of the Chinese Academy of Sciences.
At present, the Chinese Society for the Study of Pain has established eight academic groups: basic research, cephalofacial pain, anesthesia and analgesia, minimally invasive and interventional, low back pain, soft tissue pain, cancer pain and central pain, which have made remarkable achievements in basic research and clinical techniques of pain and formed an academic system of pain medicine with Chinese characteristics.
III. Construction of pain department
1.Departmental construction
Pain is a multidisciplinary interpenetrating comprehensive discipline, and the formation of a pain specialty based on the existing relevant departments in the hospital is an effective way to get a quick start. From the situation all over the country, there are successful cases of pain specialists formed on the basis of anesthesiology, interventional medicine, neurosurgery, orthopedics and rehabilitation.
2.Talent training
Pain treatment using modern minimally invasive technology is a modern technology developed in recent years. Having talents who master modern minimally invasive techniques is one of the keys to the success of department construction.
3.Systematic configuration of minimally invasive treatment equipment
Practice has proved that the use of minimally invasive technology in the field of pain can reduce medical risks, significantly reduce secondary pain of patients after invasive treatment, reduce doctor-patient conflicts, save medical resources and reduce the burden of medical care. The key to the use of minimally invasive techniques is the reasonable, scientific and practical configuration of minimally invasive equipment and skill mastery.
IV. Minimally invasive means of pain treatment
1.The cold weapon of pain department: percutaneous medullary nucleus pulposus decompression
1>Introduction
Percutaneous myelomeningocele decompression is the use of modern minimally invasive technology to remove the herniated tissue from the nucleus pulposus of the intervertebral disc, in order to rapidly reduce the pressure in the disc and the surrounding nerves, to achieve the purpose of rapid and efficient treatment of discogenic pain.
This technique has taken the world by storm in recent years because of its ease of operation, low risk, good treatment results, low follow-up rate, and zero equipment investment (with basic imaging equipment).
2>Surgical features
1) Minimally invasive (incision diameter of 1.5mm).
2）It can reduce the pressure of the disc or remove the herniated nucleus pulposus with reliable, intuitive and easy to accept by patients.
4）Low pain and short operation time, 1-3 minutes of spinotomy time.
5）Small mechanical decompression damage, less complications.
6）Fast postoperative recovery.
7) No obvious scars after surgery.
3>Structural composition and principle of the rotary cutter
The structural composition of the rotary cutter includes.
(1) Rotary cutter handle, containing: power switch; power indicator; medullary tissue collection compartment; special rotary cutter bit; motor, control circuit, rechargeable battery (built-in);
2) Puncture needle kit (standard). including: puncture needle core; puncture needle tube; depth adjustment marker.
3) Special scraping blade.
Surgical principle.
The special rotary cutting drill bit rotates at high speed to generate negative pressure and rotary cutting, using the principle of Archimedes’ pressure to cause gravitational force and perform percutaneous intervertebral disc puncture rotary cutting decompression on patients with intervertebral disc lesions through the puncture needle.
4>Related issues
Nowadays, most of the clinically applied rotational cutters are operated under blind vision. With the progress of medical technology, rotational cutting under visualization will be the trend of this technology development, and there are already hospitals combining rotational cutting and visualization technology together, which greatly improves the safety of operation.
2.Radiofrequency nerve adjustment, destruction
1>The principle of radiofrequency nerve adjustment and destruction
The principle is the use of controlled temperature action on the ganglion, nerve trunk, nerve root, intervertebral disc and other parts of the nerve conduction function to regulate or make its protein coagulation, blocking the conduction of nerve impulses. It is a physical nerve blocking therapy.
Currently, there are two types of radiofrequency nerve destruction: standard radiofrequency destruction and pulsed radiofrequency conditioning.
Standard RF is a continuous, low-intensity energy output mode. Radiofrequency energy is delivered to the target tissue and the ions in the target tissue move rapidly, and the friction of this rapid movement generates heat to destroy the target tissue. The RF electrode senses the temperature of the target tissue to control the output of RF energy, which can create a destruction temperature of up to 95℃.
Pulsed RF is an intermittent, high-intensity energy output mode. The resting period facilitates heat dissipation, avoiding the possibility of significant temperature increase and nerve damage.
This method is more selective in blocking C-fibers that transmit nociceptive sensations, reducing sensory or motor nerve damage. Its destruction temperature does not exceed 45°C. The mechanism may be that a temperature of 42-44°C produces “reversible damage”, which can alter the function of nerve cells and regulate nerve conduction without causing permanent structural damage.
2>Indications for radiofrequency neurodestruction
The general principles for the selection of radiofrequency thermocoagulation treatment are as follows:
Long-term chronic pain and interfering with normal life.
Those with poor results from conservative treatment.
Patients without psychiatric or drug-related disorders.
Patients who understand the realistic level of radiofrequency disruption treatment and the risks
Those with successful diagnostic nerve blocks.
Clinical applications are mainly for.
(i) small joint pains of the cervical, thoracic and lumbar spine and posterior spinal nerve branch pain.
② sacroiliac joint pain, ankylosing spondylitis.
③ cervical, thoracic, lumbar and sacral spinal nerve root release.
④trigeminal neuralgia.
⑤ radiofrequency disruption of the pterygoid ganglion.
(vi) radiofrequency destruction of the stellate ganglion.
(vii) radiofrequency destruction of thoracic and lumbar sympathetic ganglia.
⑧ radiofrequency destruction of the abdominal plexus.
⑨ cancer pain treatment.
3.The era of biochemical weapons: superoxygen (O3, ozone)
1>The principle of superoxide (03) treatment of disc herniation
Superoxide (03) can oxidize and decompose the protein and polysaccharide macromolecular polymer in the nucleus pulposus, so that the structure of the nucleus pulposus is destroyed, and the volume of the nucleus pulposus shrinks and solidifies after being oxidized, and the compression of the nerve root by the nucleus pulposus disappears with the extension of time; and there is no damage to the fibrous ring and other tissue structures.
At the same time, due to the anti-inflammatory and analgesic effects of ozone, the patient’s radicular pain can be relieved immediately after injection into the nerve roots. The nucleus pulposus structure gradually atrophies and solidifies with the extension of time.
2>Superoxide (03, ozone) clinical characteristics
High safety, relatively non-invasive, high efficiency, low complication rate, wide range of use, can be used for cervical and lumbar spine nucleus pulposus ablation, knee joint cavity injection, treatment of intractable herpes zoster posterior pain
4.percutaneous puncture laser treatment of herniated disc (PLDD)
1>PLDD technology principle
Under local anesthesia, the 19G-21G trocar needle is first punctured to the center of the intervertebral disc, and then the optical fiber is inserted in the needle, and the laser energy is guided to the nucleus pulposus of the intervertebral disc by the optical fiber, and the laser energy is designed under the control of microcomputer to automatically vaporize and “remove” the nucleus pulposus of the intervertebral disc to reduce the pressure in the disc, so as to At the same time, the warmth generated by the laser makes the tissue vasodilatation and the reduction of painful substances and other effects work together to achieve the treatment.
2>The characteristics of PLDD are
Easy clinical operation, relatively non-invasive, high efficiency, low complication rate, safer local anesthesia, mild pain, short operation time, reduced cost, early recovery, usually 2-3 days to return to work.