- 學位論文
單側腰椎神經根痛病人其大腦皮質興奮性的變化
Excitability Changes in Patients with Unilateral Lumbar Radicular Pain
摘要
研究背景：腰椎退化性疾病因為神經壓迫、局部發炎以及缺血等原因，導致病人產生神經根痛，有部份病人經過各種治療無效，其中不乏曾接受包括藥物、物理治療、中醫針灸、甚至最後到手術等治療。在感覺神經因各種原因受傷後，有可能產生感覺神經路徑的敏感化(hypersensitivity), 屬於神經塑性(neuroplasticity)的一種變化。假設在腰椎神經根痛病人產生這種改變，那只針對腰椎神經壓迫做物理治療或者再一次手術減壓，很可能也無法解除病人的疼痛。文獻指出在經顱磁刺激(transcranial magnetic stimulation, TMS)的檢查可以發現某些神經痛(neuropathic pain)病人的大腦皮質抑制功能比健康人下降(cortical disinhibition)；在單側上肢神經痛與正常側的比較研究中，也有同樣的發現。然而並未有研究針對腰椎神經根痛病人去探討他們在經顱磁刺激檢查上的變化，本實驗為一前驅性實驗，希望利用經顱磁刺激檢查神經塑性的功能以及其使用上的便利性，去證實腰椎神經根痛病人大腦神經塑性的變化，透過這些變化找出這個族羣的病人特質，可以讓我們更了解其疼痛的機轉，對治療方向有更好的理論基礎。 研究目的：本研究目的是透過經顱磁刺激，找出臨床上有腰椎神經痛的病人可能在中樞神經系統產生的神經塑性的改變，來更深入了解這些病人其疼痛的病理機轉。 研究設計：本研究為橫斷式研究。 研究對象：本研究對像為20歲以上成年人，臨床上被診斷有單側腰椎神經根痛，且在影像學有神經壓迫之記錄。 研究方法：每位受試者將接受基本資料的紀錄及問卷調查，然後接受一次患側下肢及正常側下肢的經顱磁刺激檢驗，測量脛前肌(tibialis anterior muscle)的動作閾值(motor threshold)，動作誘發電位(motor evoked potential)、皮質靜止期(cortical silent period)、皮質內促進(intracortical facilitation)與皮質內抑制(intracortical inhibition)。 統計分析：本實驗以無母數方法分析患側及正常側兩組經顱磁刺激的數據是否存在差異，p值設定在0.05， 使用軟體SPSS 21.0版本進行統計分析。 結果：共有11位腰椎神經根痛病患參與這個研究，平均年齡在50.96±14.9歲，numeric rating scale及ID pain-T的結果分別為3.64±1.96及2.82±1.09。平均發病時間為11±10.69個月。皮質靜止期的結果並未看到兩側肢體有差異，在皮質內興奮的結果顯示健側肢體比患側有更多皮質內抑制（5 ms, p = 0.041）及皮質內促進（10 ms, p=0.021; 15 ms, p=0.041）現象。 結論：本研究結果發現在腰椎神經根痛病人的健側下肢有皮質內抑制解除（intracortical disinhibition）現象，暗示這種在下肢的神經痛表現在大腦的抑制解除型式可能不同於其它部位或不同病因的神經痛。
並列摘要
Background: Degenerative disease of the lumbar spine is a common problem in adults. It can cause nerve damage due to nerve compression, local inflammation, and ischemia, which might lead to chronic low back pain and leg pain. Some patients have failed various treatments, such as medication, physical therapy, acupuncture, and even surgery. The possible reason for the failure of treatments might be the pain origin changes from local mechanical nerve compression to neuropathic pain, which is a maladaptive neuroplasticity in central nervous system that resulted from prolonged irritation after peripheral nerve injury. It is possibly the reason why some patients’ lumbar radicular pain cannot be relieved by multiple strategies that focus on local treatment. Purpose: By comparing the affected side to the unaffected side, this pilot study try to analyze the cortical excitability in patients with unilateral lumbar radiculopathy via paired-pulse transcranial magnetic stimulation (ppTMS) to explore the possible evidence of maladaptive neuroplasticity changes and to better understand the pathological mechanism of pain in these patients. Design: This study is a cross-sectional study. Participants: The patients enrolled must meet all of the following conditions to participate in this study. 1) Age of 20 years old or older; 2) diagnosed with lumbar radiculopathy; 3) MRI demonstrates compatible nerve compression (or ever demonstrated in MRI if the patients have been through surgery); 4) ID-Pain T Questionnaire ≧ 2 points. The conditions that may associate with other neuropathies will be excluded. And these patients are not contraindicated to TMS examination. Methods: The participants will be assessed for unilateral lumbar radiculopathy with the clinical presentation of neuropathic pain. Pain doctors or neurosurgeons interpret the correlated image findings. The qualified patients will undergo TMS examination for both affected and unaffected legs. The TMS outcomes include resting motor threshold (RMT), resting motor evoked potential (rMEP), corticospinal silent period (CSP), short intracortical inhibition (SICI), and intracortical facilitation (ICF). Statistical analysis: The TMS data of the affected legs will be compared with the unaffected legs using SPSS 21.0 with a significant level of 0.05. Results：Eleven patients were recruited for the study. The mean age was 50.96±14.9 years old. They had a mean numeric rating scale (NRS) of 3.64±1.96 and ID-T scores of 2.82±1.09. The mean pain duration was 11±10.69 months (2-38 months). The CSP duration did not differ between two sides (p=0.374). The results of intracortical excitability demonstrated reduced SICI (ISI of 5 ms, p = 0.041) and increased ICF (10 ms, p=0.021; 15 ms, p=0.041) on the unaffected leg. Conclusions: Our results demonstrated disinhibition in the hemisphere corresponding to the healthy side of patients; imply that the pattern of intracortical disinhibition might be different in patients with lumbar radiculopathies as comparing to neuropathic pain originated from different locations of body and pathologies.
參考文獻
延伸閱讀
- 孟令夫、祝旭東、陳美香（1999）。單側大腦中風病患站姿傾倒趨勢之信度研究與特質分析。中華民國復健醫學會雜誌，27(3)，91-102。https://www.airitilibrary.com/Article/Detail?DocID=10253009-199909-27-3-91-102-a
- 董俊良、林芳瑾、唐鈺晶、黃茂雄、陳嘉炘、林昭宏（2016）。比較上肢痛覺溫度刺激和神經肌肉電刺激對於中風病患大腦皮質興奮性的即時效應：經顱磁刺激先導型研究。物理治療，41(2)，116-117。https://doi.org/10.6215/FJPT.2016.O04
- 董俊良、林芳瑾、唐鈺晶、黃茂雄、陳嘉炘、林昭宏（2017）。比較上肢痛覺溫度刺激和神經肌肉電刺激對於中風病患大腦皮質興奮性的即時效應：經顱磁刺激先導型研究。物理治療，42(1)，1-11。https://doi.org/10.6215/FJPT.PTS1467982607
- Kilijan, W., & Guzy, G. (2007). Pain Intensity and Disability in Patients with Low Back Pain. Acta Universitatis Palackianae Olomucensis.Gymnica, 37(2), 61-61. https://www.airitilibrary.com/Article/Detail?DocID=12121185-200706-201107070059-201107070059-61-61
- Lin, I. S., Lai, D. M., Lau, P. Y., & Hsu, W. L. (2017). Postural Stability in Patient with Chronic Low Back Pain after Lumbar Surgery: A Long Term Follow-Up Study. 物理治療, 42(2), 179-180. https://doi.org/10.6215/FJPT.2017.73.P35