高頻熱燒灼神經調控止痛術對永久植入的心臟節律器功能無影響：3個成功病例報告

Pulse radiofrequency neuromodulation analgesic therapy has no effect on the function of permanent pacemaker: a case report of 3 successful cases

慢性下背痛是一個常見的問題，同時裝設電子植入設備的病患也越來越多。近年來，高頻熱燒灼神經調控止痛術被認為是一個相當有潛力的治療方法，但因為不確定它會不會對那些裝置的功能有影響，大家對其安全性一直有顧慮。在這篇文章我們提供了三個成功將高頻熱燒灼神經調控止痛術使用在裝有心臟節律器病患身上的案例。病患1是一位88歲男性，因為心律不整已裝設心臟節律器多年。他因為雙側L4及L5神經痛而接受總共三次高頻熱燒灼術（45V,42℃），每次都沒有發生節律器干擾或其他併發症。病患2是一位84歲女性，她因病竇症候群在2011年9月裝了心臟節律器。由於背部術後疼痛症候群及雙側L2坐骨神經痛，她接受了總共三次的高頻熱燒灼術（60V／45V, 42℃），每次都沒有發生節律器干擾或其他併發症。病患3是一位77歲女性，她因病竇症候群在2014年12月裝了心臟節律器。她接受了一次高頻熱燒灼術（50V, 42℃），沒有發生節律器干擾或其他併發症。高頻熱燒灼術被認為會干擾心臟節律器，但是一直沒有明確的證據。我們研究了高頻熱燒灼術的物理特性還有機制，發現它是藉由一個電流產生熱，造成組織的熱傷害來達到止痛效果，並且也會藉由干擾神經傳導物質或是發炎物質的分泌來影響痛覺傳導，而這個電流會從電極經由組織，最後從接地貼片離開人體。所以我們認為因為電流並沒有通過心臟或是心臟節律器的感應器並離他們有足夠的距離，再加上高頻熱燒術所需的能量並不高，所以使用在裝有心臟節律器的病患身上應該是沒有問題的。我們的三個成功案例也支持我們的想法。我們也討論關於高頻熱燒灼術使用在裝設其他電子植入設備的病患的可行性，但這個部分還需要更多的數據跟證據支持。

Chronic low back pain (CLBP) is a common problem all over the world and there are more and more patients with electronic device implantation. In recent decades, pulse radiofrequency (PRF) neuromodulation is considered a potentially effective therapy for CLBP, but there is still concern about safety when using it on patients with electronic device implantation. Here we provide with three successful cases of using PRF neuromodulation on patients with permanent pacemaker (PPM) implantation. Patient 1 is an 88-year-old male who has PPM (mode unknown) for arrhythmia for many years. He underwent PRF (45V, 240 times, 42℃) for bilateral L4 and L5 radiculopathy three times; each time was done safely without sequela. Patient 2 is an 84-year-old female who has PPM (mode DDD) implanted in 2011/09 for sick sinus syndrome. She underwent PRF (60V or 45V, 240 times, 42℃) three times for fail back surgery syndrome and sciatica of bilateral L2; each time was done safely without sequela. Patient 3 is a 77-year-old female who has PPM (mode unknown) implanted in 2014/12 for sick sinus syndrome. She underwent PRF (50V, 120 sec, 42℃) once without sequela. PRF had been considered to be contra-indicated for patients with PPM but without strong evidence. According to the physical features and neuromodulation mechanism of PRF, a current passes from an electrode to tissue and finally leaves from ground plate. It generates heat on the tip of the electrode, which causes thermal damage to target tissue and modulates the signals of neurotransmitters or inflammatory factors. In our opinion, the reason why it is safe to use PRF on patients with PPM may due to the fact that the electrode is so far from the heart and PPM that the electric circuit does not pass through the heart and PPM. It is also possible that the energy required for PRF is not high enough to influence the PPM. Our three successful cases present that PRF neuromodulation can be used safely on CLBP patients with PPM. We also discuss the possible impacts of PRF on other implantable electronic devices. Further data are needed to prove the safety of PRF for patients with permanent electronic device implantation.