單側胸部交感神經切除在一位患複雜性區域疼痛症候群病人的應用

Application of Unilateral Sympathectomy in a Patient with Complex Regional Pain Syndrome Type II

背景：複雜性區域疼痛症候群是一個少見的疾病，它的致病機轉及治療方法目前都處於不確定的狀況。在一些對於非侵入性療法如物理治療，藥物治療，復健無效的病人上才會考慮外科交感神經切除。但是這種療法目前仍有爭議，而且對於長期疼痛的緩解，每個病人都不盡相同。方法：一位61歲的男性因為33年前左手礦碎傷而自第一到第五掌骨以下截肢後就產生左手掌嚴重的刺痛及左手手臂冰冷感。多種治療方法如藥物治療，局部切除神經瘤，熱療，星狀神經結阻斷皆無效或是無法提供長期的疼痛緩解。在診斷為複雜性區域性疼痛症候群第二型合併交感維持性疼痛後即施行內視鏡下胸腔交感神經切除。結果：手術之後疼痛及冰冷感得到立即的緩解。但是不幸的，在手術後一個月，病人的症狀有部分復發的跡象。我們認為如果考慮用手術交感神經切除療法，雙側或是更廣泛的交感神經切除是比較好的選擇。手術交感神經切除對於治療複雜性區域性疼痛症候群第二型還是有它的價值存在。

Complex Regional Pain Syndrome (CRPS) is a rare disease with uncertain pathophysiology and therapies. Surgical sympathectomy is considered especially for patients who are refractory to relatively non-invasive treatments, such as physical therapy, medical control or sympathetic ganglion blocks. However, the effectiveness of this procedure is controversial and the long term relief of pain varies. A 61-year-old male suffered from intractable severe shooting pain over the central area of his left palm and a cold sensation over his whole left arm after amputation of the l' to 5th fingers of his left hand below the metacarpals following a crushing injury 33 years previously. Medical treatment, excision of local neuroma, thermotherapy and a series of stellate ganglion blocks were ineffective or did not provide long term pain relief. Endoscopic thoracic sympathectomy was carried out based on the diagnosis of CRPS type II with sympathetically maintained pain. Excellent relief of pain and cold sensation was observed immediately after the procedure. Unfortunately, the CRPS symptoms partially relapsed 1 month after surgery. We suggest that if thoracic sympathectomy is considered, bilateral and more thorough thoracic sympathectomy, including transection of the corresponding rami communicantes and the Kuntz nerve, should be performed. Surgical sympathectomy still has a role in the treatment of CRPS.