| [Background and Objection]:Cancer pain has always been a globally recognized tough problem,an archenemy to the public health in the 21st century. According to a WHO report in 2000,about 3000000 to 4000000 cancer patients were suffering from cancer pain at varying degrees,as a result of a delay of treatment.Among the cancer patients who are under treatment,50%have varying degrees of painful feelings,70%(advanced cancer patients)complain that cancer pain is the chief symptom,30%have got the sharp pain that can not be beared.It is shown in an investigation conducted within china that the number of cancer patients with varying degrees of pain takes up 51%to 61.6%.It is crucially important to employ effective analgesia in order to improve the life quality of cancer patients. WHO and Chinese government have listed cancer pain as one of the most important points that need urgent solution.In 1986,WHO set up three fights of scheme for cancer pain treatment.China lay down in 1993 the principle "three stages for cancer pain-relieving".Stage one is drugs represented by asprin;stage two drugs represented by codeine;stage three drugs represented by morphine.This scheme enables 85%cancer patients to be effectively pain-relieved and 75%of the advanced cancer patients can even be removed of the painful feelings.However,8%of the patients can not get pain-relieved after various kinds of drug treatments,they have to undergo surgeries.Among different kinds of surgeries,encephalon stereotactic technique which can brief cancer pain under control by damaging nuclei inside the brain,is accepted by both patients and doctors for its small trauma,definite effect and the capping of total body.Neurosurgeons all over the world have worked at this technique wholeheartedly.Prof.Spiegel is one of them,he chose thalami.Mark had nucleus parafascicularis thalami as his choice,while Bosch in 1991 chose VPL, Wangyehan in 1997 selected CN +cg.The author of this paper in 2003 selected CM. In 2004,Romamelli P,midbrain rostral mesencephalotomy.Yen in 2005,damaged bilateral cingulatus to relieve cancer pain.All the above mentioned were reported in the media and they all get definite dffect.The most exciting thing is that for the last 10 years gamma knife technique has been applied hardly having trauma,to treat cancer pain by damaging nuclei.Under such background,this topic will probe into the following three objectives.Objective One:As mentioned above,among various intracerebral nucleus used in treating cancer pain,which nucleus can relieve pain better after being damaged. According to what the author looked up,there has been no report on the comparison of them in the medical literature at home and abroad.By doing experiments with large rats,and comparing the above pain-relieving effects used clinically,this topic provides objective,scientific basis for clinical application of pain-relieving.Objective Two:On the basis of related-animal experiment,with the report on CM pain-relief,applying minimally invasive surgery encephalon stereotactic technique give treatment to cancer pain of each kind of cancer patient.Choose a certain number of cancer pain patients for treatment using ways of damaging nuclei, and then summarize the effect of pain-relieving,complication,and other experience.Objective Three:In resent years,there have been lots of reports abroad on gamma knife to damage nuclei inside the brain so as to treat cancer pain,while within our country such work has not started yet.This topic on the basis of above work,this topic is to choose similar CM to damage using gamma knife,and them compare their pain-relieve effect,complications with the radiofrequency coagulation,at the same time,sum up and report the experience of this kind of work.[Method]:Aiming at the first objective,comparison of the pain-relief effects afler the damage of nuclei,this topic selected 30 rats,which were divided into sham group,and CM,PF,VPL,CM+cg group.After using 2ul 10%phenol dissolved in glycerin stercotactic inject into certain nuclei to damage it,and then check on it withit the following two methods.Method one:the yelling of the rats whose tail were stimulated,electricity were applied to stimulated the intensity so as to examine the pain threshold before and after damaged.Method two:measuring the time for animal lacking and biting lured by Formalin,lick and flexing time to observe the pain-relief effect after certain nucleus was damaged.In order to explore the pain-relief effect and complications of Nucleus CM,this research topic chose 90 cancer patients,(54 male patients,36 female ones),the age ranged from 35-88,median age is 62.It includes 36 cases of lung cancer,21 cases of nasopharyngeal carcinoma,10 cases of intestinal cancer,8cases of cancer of pancreas,8cases of osteocarcinoma,4 cases of carcinoma of kidney,3 cases of hepatocarcinoma.The brain stereotactic technique was used to damage the CM nucleus with radiofrequency coagulation lesions.Under local anesthesia,set up the framework of brain stereotactic equipment, then targeting by using CT scanning,as a result,three-dimensional space coordinate of CM was worked out-x=8mm,z=0mm.In order to obtain précised axial image of the front and back commissural in scanning,the author's experience is to take joint line of the two points.The poing which is 2mm above the temporal canthus and the point 35mm above the middle point of the external acoustic pore,as the baseline for CT scanning from this baseline,some plana can be got by thin-layer scanning,then you may reach your aim.By using radiofrequency apparatus and necessary electrode(diameter 1.8mm, the length of the exposed point 4mm),electrophysiological stimulation and radiofrequency were carried out.After sending the electrode to the target,the electrophysiological stimulation of both low frequency and high frequency was applied to check the nucleus position,making sure that the kinesthetic and esthesia function are not impaired,followed by reversible experiment(45℃,30seconds).After making sure that there is no visible complications,the temperature will gradually rise to 70℃-75℃that will last 90 seconds.According to the ten-grade method by WHO and Hamilton depression Scale(HAMD),to quantify the pain-relief effect before and after the operation.To compare the pain-relief effects and complications after using gamma knife and radiofrequency coagulation lesions to damage the nucleus,this topic selected 15 cases of cancer pain patients(9 males,6 females)age ranging from 21-78,median age 47,including 5 cases of lung cancer,3 cases of nasopharyngeal carcinoma,3 cases of intestinal cancer,2 cases of malignant lymphoma,1 case of cervix carcinoma and 1 case of osteocarcinoma.Similar CM nuclei were damaged with gamma knife technique.Before MR localization,an AC-PC body surface symbol line should be marked on the head,i.e,the joint line of submarin of the wing of nose and the incisure of the ear lobe,try to parallize the basal ring of the head frame with the symbol line.The median sagittal plane of the head frame overlaps with the median sagittal plane of the skull.Do thin layer localizing scanning,with MRI(1.5T)so as to obtain the precise axial image of the joint line of AC-PC,then decide the three-eimensional space coordinate of CM mucleus in this image.The coordinate as the center,block a targeting area which is a 6mm in diameter and is an CM nucleus approximately.By using collimator(4mm),an isocenter point,and enclosed by isodose curves(50%-60%),the maximum dose in the center reaches 160GY.At the same time,damaging is done by CM nucleus gamma radiation to damage bilaterally.By applying the above two quantitative index to the assessment of painful feelings, score it before and after operation,compare their pain-relief effects and complication, meanwhile summarize the experience of the this work.[Result]:This topic successful set up the damaged model of nuclei of the rats. 30 rats are all alive.From histotomy neuronecrosis of damaged nuclei coule be seen, porosis formed,there existed RBC infiltrate,the traumatic edge is visible,reactive edema band could be seen around,while that of the sham could not be seen.Through MR examination,the damaged part had a precise limit,clear edge,and the slight edema band could be seen around.The thermal pain thresholds before and after various damage of the nuclei of the rats were examined with the tale stimulate method.The pain thresholds among various groups before operation were of no statistic significance(p＞0.05).The pain thresholds of each group were significantly improved raised(p＜0.01),while that of sham has no significant change.When comparing the pain thresholds alteration among each group,we could find that the different value of pain thresholds of each group was quite different with that of the sham.(p＞0.001).The comparison between Group VPL and other three groups was remarkable,whereas,the comparison among Group CM,PF,and CM+cg was not noticeable(p＞0.05).That pain reaction took place soon after hypodermic injecting with formalin was phase-one.After the duration of 3-5 minutes,the animals became calm about 10-15 minutes later,then phase-two appeared for the duration of about 20-40minutes.ANOVA analized the five rat groups at their first phase.The licking duration for each group whose thalamic nuclei were damaged had statistic significance compared with that of the sham(p＜0.01).The difference among Group VPL,Group CM and Group CM+cg has got statistic significance(p＜0.01),while the frequency of flexing and flinching was of great significance except Group PF which different the sham(p＜0.01).The rest groups had no statistic significance in comparative difference(p＞0.05).At phase two,the licking time for each group towhose thalamic nuclei damage had statistic significance with the sham difference.(p＜0.01).The comparative difference among Group VPL,CM and GM+cg has striking significance(P is 0.001 and 0.023).the flexing duration for Group PF and VPL has noticeable significance with the sham in comparative different(p is 0.041,and 0.013).Except for Group VPL and Group CM+cg whose flinching time had sharp significance with the sham in comparative difference(p is 0.006 and 0.013)(p is 0.049 for Group CM+cg),the rest groups had no noticeable significance in comparative differeace.(p＞0.05).79 patients stopped using analgesic after radiofrequency operation,l lstill complain of pain sense,they scored still 3 points,though,there appeared 24 cases of recurring pain in the follow-up visits,the rest have remained the state of stopping using analgesic,13 cases stopped using analgesic for more than one year,3 cases have remained in that state for more than 2 years.After the operation,there were is cases of hypersomnolence,10 cases of uroclepsia,8 cases of speech disorder,3 cases of subparalytic oculomotor nerve of one side.However,the above symptoms disappeared after treatment.Two patients died 12 days after the operation,one died of generalized depletion because of complication hematoma inside the brain,another, who had lung cancer,died 8 days after the operation because of complicating lung infection due to poor respiratory function.The whole group had no complicating hemiplegia.With the score of,and by using the wilcoxon coupling method,the pain score before and after the operation was analized statistically,there was sharp difference(p＜0.05),by using coupling t test,the score of Hamilton depression was compared before and after the operation,there also existed clear difference(p＜0.05).15 cases treated by gamma knife stopped using analgesic after operation,the score of pain were 0-3 grade.The patients were observed in the hospital only one day, commonly feeling light headache and vomiting.A following up indicted that cancer pain in 4 cases relapsed but below 5 scores,the rest of the patients were analgesic persistently as long as 9 months.The comparison between gamma knife and adiofrequency before operation with Wilcoxon statistics means no noticeable significance in comparative differeace.(p＞0.05).Tow group patients after operation with Mann-Whitney U means no noticeable significance in comparative differeace.(p＞0.05).It means same in effect of analgesia.[Conclusion]:1.Through the above damaging experiment of the pain thresholds,the pain thresholds of CM,PF,VPL,and CM+cg nuclei inside the brain,which are commonly used clinically to relieve pain,were improved,and it can be proved that each nuclei can relieve pain,and VPL is best.By using formalin to stimulate the rats in order to evaluate the pain-relieving effect before and after the above nuclei were damaged, we can improve that each nuclei can relieve pain after being damaged,among them VPL has the best result.It was also shown that the pain-relieving effect of complex nuclei CM+cg was not as good as that of single CM.There are some guiding effect to the thought that the pain-relief effect of complex targets is better than that of single one.2.Pain-relief effect of CM nuclei,after damaged by thermo cogulation radiofrequency,can reach 90%for cancer pain relief.About 20%of the patients have recurred pain sense after one-year follow-up visits.There exists certain complications after the operation because of the edema of impaired foci of the brain tissue.However,recovery can be got through expectant treatment,and it is safe generally.But the complications such as hematoma can be very fatal.3.Compared with thermal radiofi'equency,using gamma knife to impair CM nuclei so as to control cancer pain is of no visible difference.By using 4mm collimator,CM nuclei were damaged with the irradiation of 150-160Cy.In this way, not only can the nuclei damaging in the targeting area be ensured to happen steadily so as to obtain the pain-relieving effect clinically,but brain edema can also be prevented,and the patients,generally have not severe complications. |
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