Categories
Change Password!
Reset Password!
Along with the significant improvement in the quality of
life, the incidence of diabetes is also increasing.
Radiofrequency thermocoagulation connected with anhydrous
ethanol (AE) chemical blockade of the Multi-segmental Lumbar Sympathetic
Ganglia was safe and effective. However, larger trials for better understanding
of the detailed underlying analgesic mechanisms are still required.
Along with the significant improvement in the quality of
life, the incidence of diabetes is also increasing. The global prevalence of
diabetes is expected to reach 552 million by 2030, suggests recent data on
epidemiology. The rise in the incidence of diabetes leads to an increase in the
rate of its complications. Diabetic neuropathy is one of the most common
complications of diabetes. Diabetic neuropathy constitutes about 50% while
painful diabetic peripheral neuropathy (PDPN) accounts for 13-26% of the total
burden of diabetes. Cost-effective treatment methods for PDPN are required as
its management is difficult and significantly impairs the QoL of patients. The
various targets for management approaches of PDPN are 2-6 pairs of lumbar
sympathetic ganglia (LSG). L2 and L3 LSG inhibition is related to the blockade
of sympathetic fibres of the lower extremities and dilation of blood vessels.
In this process of repression, L2 ganglia play an integral role and the
location of LSG also differs. The L2 sympathetic ganglia are located in the
upper one-third of the L3 vertebrae and lower one-third of the L2 vertebrae.
Due to this varied location, a multi-segment treatment targeting the specific
areas is required. Surgical and chemical sympathectomies are the types of
traditional LSG blockades. Surgical sympathectomy results in tissue damage and
trauma. Chemical sympathectomy, primarily due to drug diffusion, may harm the
surrounding vital tissues and organs.
Radiofrequency therapy constitutes two methods:
Radiofrequency thermocoagulation lumbar sympathectomy
targets the nerve tissue by increasing the temperature and has been shown to be
another effective treatment approach. Due to increased temperature, the
unmyelinated nerve fiber C-axis axons get dissolved and become necrotic. It generates
significant pain relief by increasing peripheral blood flow, maintaining a
state of vasodilatation in lower extremities and by improving symptoms like
numbness which are caused by nerve injury of lower limbs. However, the validity
of punctured target selection is difficult, and the range of ablation is
limited. Comprehensive treatment approach is required for PDPN management.
Rationale behind research:
The previous studies have indicated the use of single
chemical or single radiofrequency treatment approaches for destroying LSG, but
there is a lack of studies that examine the combination of chemicals and
radiofrequency for PDPN. The present research was conducted to fulfill this
great area of unmet need.
Objective:
The
present research investigated the effectiveness of a combination of anhydrous
ethanol (AE) chemical blockade of LSG and radiofrequency thermocoagulation for
PDPN treatment.
Study outcomes:
Time Points: 1M, 3M, 6M, and 1Y
Outcomes:
Baseline: There were no significant differences observed at
baseline
Study outcomes:
The results of the study found that in the AE group, pain symptoms repeatedly appeared after 3M, steadily becoming worse with the passing time. These results were consistent with the studies reported by Jackson and Gaeta, and it might be related to the regeneration of nerves using the AE. There was a significant reduction in the prevalence of complications under visual guidance. However, the lateral femoral cutaneous nerve or genitofemoral nerve may get permanently damaged due to the variability of damage agent and neural pathway resulting in acute renal failure in serious cases. In this study, there were four cases of genitofemoral nerve damage. After conservative therapy, all four cases were resolved. The maintenance of pain relief for a short period and a higher incidence of complications restrict the use of CLS.
Accurate target position for puncture, clear images, confirming the location of needlepoint position and scanning are few benefits linked with the CT-guided radiofrequency thermocoagulation of LSG. It also helps to prevent the occurrence of complications and can also be performed frequently. Although, there are high requirements for accuracy of nerve target the number and location of lumbar sympathetic ganglia mainly vary with the absent division of sympathetic stem and communicating branches. It can cause incomplete nerve ablation, where the location, action duration and temperature affect the degree of ablation. So, there is no stability in the effect of simple radiofrequency ablation of LSG.
In this study, the radiofrequency group experienced lower analgesic
effect in the early stage as compared to the combination and AE group. Analgesic
effect for up to 1 year and its 1-year total effective rate was significantly
better in the combination group (group C) than the other two groups. As compared
to group A and B, the group C showed high remission rate of numbness symptoms
in the late stage. No significant change in skin temperature was noted. Previous
studies have indicated that disturbance of lumbar sympathetic nerve cells can control
the regeneration of cutaneous vascular cells due to increased expression of
angiopoietin-1 and inhibition of the proliferation of parietal cells and. It
can also reduce the inflammatory reaction in the sympathetic nerve denervation
area, decrease the adrenergic release in the dorsal root ganglion, inhibit
sympathetic activity by stimulating α2-adrenergic receptors and upregulating
α2-adrenoceptors,31 inhibit spinal microglia activation and reduce the expression
of inflammatory cytokines (IL-1β, IL-6, and TNF-α). That is why the complex mechanisms
of sympathetic nerve blockade inducing pain relief requires further studies for
better understanding. At last, it can be concluded that radiofrequency
thermocoagulation blockade of LSG with multi-segmental AE provide effective
pain relief with subsequent reduction in the complications.
NA
The present study recommends the use of the combination of
AE chemical blockade of the lumbar sympathetic ganglia and radiofrequency
thermocoagulation. The combination appears to be more active than the single therapies.
The combination under this study was found to be efficacious and safe. It
provides symptomatic relief and high degree of satisfaction in patients
suffering from PDPN. However, further studies are needed to confirm its use.
Ding et al. Journal of Pain Research 2018:11 1375–1382
Evaluation of combined radiofrequency and chemical blockade of multi-segmental lumbar sympathetic ganglia in painful diabetic peripheral neuropathy
Ding Y et al.
Comments (0)