RU2309775C1 - Method for treating pelvic pain of neurogenic etiology in women - Google Patents

Abstract

FIELD: medicine, gynecology, surgery.

SUBSTANCE: the suggested method deals with the blockade of presacral plexus under laparoscopic control due to the following technique: at the level of the middle of the cape of the 5^th lumbar and the 1^st sacral vertebrae one should fulfill the puncture of peritoneum and introduce medicinal solution into presacral space, it contains 94 ml 0.25%-novocain solution, 60 mg naphthidrofuril, 2 ml mexidol and 2 ml vitamin B12. Through the needle it is necessary to apply a catheter into area of lumbar-sacral symphysis, its opposite end should be withdrawn onto anterior abdominal wall to be fixed there. Along the catheter one should introduce medicinal solution for about 3-5 d. The innovation provides stable curative effect at decreased frequency of complications.

EFFECT: higher efficiency of therapy.

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Description

The present invention relates to medicine, namely to gynecology and surgery, and can be used in the treatment of pelvic pain in women at any age.

Known methods for treating pelvic pain.

There is a method of caudal anesthesia by puncturing with a needle of the sacral canal and introducing anesthetic into it (see J. E. Morgan-ml., M.S. Mikhail. Regional anesthesia and pain treatment // Clinical anesthesiology (equipment and monitoring, regional anesthesia, treatment pain) .M., from Binom. - 1998. - P.272-319). However, during this procedure, there is a risk of injury to the puncture needle of the spinal cord with the development of a toxic drug reaction and the possibility of infection with the development of the inflammatory process of the spinal cord.

Known surgical method, which consists in partial denervation of the uterus by presacral neuroectomy with resection of the upper and / or lower hypogastric plexus during laparotomy. The method is aimed at interrupting the flow of afferent impulses from the internal genital organs to the central parts of the nervous system (see G. A. Savitsky et al. Surgical treatment of pelvic pain syndrome in a gynecological clinic. S - Pb. - 2003. - 138 p.).

However, performing a neuroectomy is associated with a high risk of damage to life-supporting anatomical structures: common iliac arteries and veins, presacral venous plexus, ureters, sigmoid and rectal tissues.

The closest is the method of parasacral anesthesia, during which, through a thick needle by puncturing the coccyx, to the right and to the left of it (see A.V. Vishnevsky. Methods of anesthesia for operations on the abdominal cavity (Brown parasacral anesthesia) // Poly. Collected Works. - M., Publishing House of the Academy of Medical Sciences of the USSR. - 1951. - T.4. - P.153) carry out an infiltrative, to a depth of 10-15 cm, anesthetic into the parasacral space.

With the introduction of the anesthetic, the doctor is guided by the tactile sensations of the hands located on the puncture needle, moving into the depths of the tissues from bottom to top, along the sacral cavity, which carries a high risk of trauma to the presacral large venous plexuses, arterial vessels and damage to high-lying bone structures and nerves. The introduction of anesthetic is used once, which reduces the effectiveness of the method.

The technical result of the proposed method for the treatment of pelvic pain is to increase the effectiveness of treatment due to the prolonged administration of the drug solution and to provide a stable clinical positive effect, prolonged remission of the disease, as well as reducing complications.

New in achieving the set technical result is that under the control of a laparoscope at the level of the lumbosacral joint with an endoscopic needle, a medicinal solution is introduced subperitoneally into the presacral space.

It is also new that through the needle into the region of the lumbosacral joint, a thin catheter is inserted subperitoneally to a depth of 4-5 cm, the opposite end of which is brought to the anterior abdominal wall and fixed.

New is the fact that a catheter is injected presacrically with a drug solution within 3-5 days.

The introduction of a medicinal solution under the control of a laparoscope allows you to reduce complications and to avoid damage to bone and vascular structures.

The introduction of a medicinal solution into the presacral space ensures the cessation of pathological impulse from the pelvic organs and tissues through the lumbosacral nerve plexuses into the central nervous system and provides relief of the pain syndrome and a lasting therapeutic effect, the intensity of which is estimated based on subjective and objective data with their gradation by visual the analogue scale (YOUR) and the McGill Pain Questionnare (MPQ).

The daily administration of the drug solution by catheter allows for a continuous prolonged novocaine block of the lumbosacral region, which leads to a quick clinical result of treatment and long-term remission of the disease.

The introduction of a soft synthetic silicone catheter under visual (laparoscopic) control to a depth of 4-5 cm does not lead to trauma to the surrounding anatomical structures.

Administration of a presacral drug solution within 3-5 days is sufficient to relieve pelvic pain.

A comparable analysis with the prototype shows that the proposed method differs from the known one in that under the control of a laparoscope at the level of the middle of the cape, fifth fifth lumbar and first sacral vertebrae, a thin endoscopic needle punctures the peritoneum and introduces a medicinal solution into the presacral space, then through the needle into the lumbar region a thin catheter is administered subperitoneally to the sacral joint to a depth of 4-5 cm, through which a presacral drug solution is subsequently administered, with the opposite end They are placed on the front abdominal wall and fixed, and the drug solution is administered for 3-5 days, which meets the criterion of "novelty."

A new set of features provides an increase in the effectiveness of the treatment of pelvic pain in women with neurogenic (lumbosacral neuralgia, pelvic ganglioneuritis, etc.) cause of the disease, the duration of remission of the disease, reduction of complications during treatment, which meets the criterion of "industrial applicability".

The method is as follows.

In the operating room, after sedation, a typical three-trocar laparoscopy is performed. A laparoscope with a diameter of 10 mm is inserted through the navel, and two manipulator tools with a diameter of 5 mm are introduced symmetrically through the left and right side channels of the trocars installed in the iliac regions. Inspect the abdominal cavity (pelvic organs) in order to exclude visible organic pathology. Then, under the control of a laparoscope, the sigmoid colon is displaced laterally to the left at the level of the middle of the cape, the fifth sacral and first sacral vertebrae, the peritoneum is grasped and lifted from the adjacent paravertebral tissues with forceps. After this, an endoscopic needle puncture the peritoneum and fall into the presacral space. 100 ml of a medicinal solution is introduced, consisting of 0.25% novocaine - 94 ml, naftidrofuril 60 mg, mexidol 2 ml, vitamin B ₁₂ 2 ml (1000γ). Next, through the needle, a soft silicone catheter with an inner diameter of 1.0 mm is introduced subperitoneally along the sacrum to a depth of 4-5 cm. The free end of the catheter is brought to the anterior abdominal wall. The needle is removed, the catheter is fixed to the skin of the anterior abdominal wall. This completes laparoscopy.

The duration of the operation is no more than 20 minutes. In the postoperative period, daily for 3-5 days, through the left catheter, a drug solution similar to the initial in volume and composition is injected into the presacral space. The introduction is performed until the relief of the pelvic pain syndrome and obtaining a persistent therapeutic effect that allows you to perform daily physical activity. The intensity of stopping is estimated on the basis of subjective and objective data with their gradation on a visual analogue scale (YOUR) and the McGill Pain Questionnare (MPQ). The effectiveness of the proposed method of treatment is 95-100%.

The method is illustrated by the following clinical examples.

Example 1. Patient N., 37 years old, due to pelvic pain syndrome, for a long time (6 years) received various types of therapy on an outpatient basis, including antibacterial (antibiotics of various groups taking into account the seeded flora) and non-steroidal anti-inflammatory drugs, physiotherapy treatment , massages, acupuncture, mud therapy. The indicated types of treatment were few (only for the period of treatment) or generally ineffective.

Diagnosed with Pelvic pain syndrome of unknown origin. The examination (ultrasound examination of the pelvic organs - transabdominal, transvaginal, transrectal), computed tomography of the pelvis did not reveal organic pathology from the pelvic organs. A neurologist was diagnosed with pelvic neuralgia.

A laparoscopy was performed, at the diagnostic stage of which no organic pathology was found in the abdominal cavity. Under the control of a laparoscope, 100 ml of a medicinal solution was introduced into the presacral space, consisting of 0.25% novocaine - 94 ml, naftidrofuril 60 mg, mexidol 2 ml, vitamin B ₁₂ 2 ml. Then, a thin silicone catheter with a diameter of 1 mm was inserted into the lumbosacral joint, the free end of the catheter was brought to the abdominal wall and fixed. Daily for 3 days, 100 ml of the drug mixture of the same composition was injected into the sacral space through a catheter. After the first blockade, the pelvic pain syndrome was partially stopped, and after the third procedure the patient did not notice pain at all. In the postoperative period, the patient did not require additional painkillers.

Observation of the patient for 1 year after surgery did not reveal a relapse of the disease. Based on the subjective and objective data of the visual analogue scale and the McGill questionnaire, the patient assessed her condition as satisfactory.

Example 2. Patient S., 32 years old, was admitted to the gynecological department with complaints of pain in the lower abdomen, giving back to the lower back. These symptoms are noted within 2 years, after the abdominal operation was performed - supravaginal amputation of the uterus without appendages. During a special gynecological examination, transabdominal and vaginal ultrasound examinations, no obvious organic palogy was found in the pelvis, there were only indirect signs of an adhesion process (limitation of the mobility of the uterine appendages during displacement). Prior to going to the hospital, the patient was outpatiently monitored by obstetrician-gynecologist and neuropathologist, on the recommendations of which she received absorbable therapy, physiotherapy treatment. Diagnosed with pelvic pain syndrome of neurogenic etiology. A laparoscopic examination was carried out during which, in the area of the cervical stump, insignificant planar friable adhesions were found that did not limit its mobility. At the final stage of laparoscopy, the proposed medicinal mixture was presacred, and a catheter was inserted into the presacral space to prolong drug therapy, through which the drug solution was administered for 5 days. When observing the patient for 3 years after the operation, relapse of the pain syndrome based on subjective and objective criteria was not noted.

Claims (1)

A method of treating pelvic pain of neurogenic etiology in women, including a block of the presacral plexus, characterized in that under the control of a laparoscope at the midpoint of the cape of the fifth lumbar and first sacral vertebrae, endoscopic puncture of the peritoneum is performed and a drug solution containing 94 ml of 0.25- is introduced into the presacral space solution of novocaine, 60 mg of naftidrofuril, 2 ml of mexidol and 2 ml of vitamin B12, then a catheter is inserted through the needle into the lumbosacral joint, the opposite end of which They are removed to the anterior abdominal wall and fixed; in the future, a medicinal solution is administered via a catheter for 3-5 days.