術後周邊神經病變之病例報告

Postoperative Peripheral Neuropathy A Case Report

術後周邊神經病變是常見的手術期間的合併症之一，主要的原因為神經缺血，而姿勢不良與血流不足則是神經缺血之根本原因。吾人提出右腎血管肌脂肪瘤案例於使用腹腔鏡行部分腎切除手術後，在橈神經與正中神經支配範圍內有感覺麻木的現象，所幸約一個月後即完全康復之病例報告。一位33歲女性有多年高血壓與糖尿病的病史。因右腎血管肌脂肪瘤而安排住院以腹腔鏡行部分腎切除手術。過去並無手，手痛或頸痛等病史。全身麻醉後，因預期會有大量出血，而放置動脈導管與中央靜脈導管過程順利。病人於左側躺期間，其雙側之手與手臂均有良好的護墊保護。術前血色素12.2g / dL，血球容積33.9%；手術時間達8小時而失血量為2,500毫升，病人輸液1,000毫升6%的hydroxyethyl starch溶液與輸血6U濃縮紅血球。術中在使用dopamine的情況下，血壓還算穩定。手術期間動脈血液氣體分析並無明顯代謝性酸中毒。手術完成後，病患轉加護病房照顧。隔日，病人轉一般病房；然而病人發現其右手大拇指與食指之背側與掌側有感覺缺損。神經傳導檢查顯示輕度雙側腕隧道症侯群。術後第三天感覺缺損的現象已完全恢復，但右手大拇指與食指掌側有明顯的壓痛點產生。吾人以針灸針穿刺壓痛點，其症狀明顯改善。三天後病人出院，其壓痛點以每週一次於門診追蹤治療。於門診治療四次後，其症狀完全消失。本例中，吾人認為其神經傷害的原因是可能是多因素的，如高血壓與糖尿病術前已存在之周邊神經病變與全身麻醉。至於手術與麻醉中的誘發因子還包括動脈導管的放置，低血壓、強心劑的使用（dopamine）、手術麻醉時間過長與姿勢不良等。

Peripheral nerve injury is a common postoperative morbidity and sometimesmultiple factors may be involved in its pathogenesis. Here we report a patient withpostoperative neuropathy in the region innervated by radial and median nerves.She underwent laparoscopic partial nephrectomy for right renal angiomyolipomaunder general anesthesia with arterial blood pressure monitoring. Intraoperativelyher blood pressure went down to 70/40 mmHg because of acute blood loss and weinfused dopamine for half an hour during the hypotensive episode. The patientcomplained of numbness over the dorsal and palmar sides of her right thumb andindex finger on the first postoperative day. Nerve conduction velocity test revealedmild carpal tunnel syndrome in bilateral median nerves. On the third postoperativeday, the numbness disappeared completely but pain over the palmar side of theright thumb and index finger emerged and several tender points were noted. Wedeactivated these tender points with dry needles and the pain was dramaticallyalleviated. The patient was discharged without other complications three days laterand she gained full recovery within a month. We discuss the pathogenesis ofpostoperative peripheral neuropathy in the text.