中文摘要
痛风致腕管综合征的诊治与疗效分析
目的:
探讨痛风所致腕管综合征的发病特点及诊治。
资料与方法:
研究2013年7月至2019年12月间吉林大学第一医院和二部手足外科收治的痛风石致腕管和（或）肘管综合征病例，共19例，其中腕管综合征19例，左侧8例，右侧11例，其中1例患者为左腕管综合征并右肘管综合征。所有患者均为男性，年龄38岁至68岁，平均55.1±9.2岁。腕管综合征病程1个月至60个月，平均11.3±14.3个月，肘管综合征病程15天。所有患者均有多年痛风病史，3年至20年，平均10.6±5.5年，身体可见大小不等痛风石结节隆起。术前血尿酸浓度均偏高，6例患者术前行局部彩超检查，均提示痛风石病灶。查体18侧表现桡侧3个半手指麻木和感觉减退，1侧为中环指。大鱼际外观无萎缩12侧，萎缩7侧。
6侧合并手指屈伸障碍，14侧手腕部掌侧饱满隆起，3例患者入院时处于急性关节炎期，腕部红、肿、热、痛。
1例肘管综合征有环指尺侧半及小指麻木，肘部可见皮肤隆起，无爪形手畸形。腕管综合征患者腕部正中神经Tinel征均（+），肘管综合征患者尺神经Tinel征（+）。肌电图检查证实了正中神经或尺神经损伤。根据顾玉东腕肘管综合征临床分型，腕管综合征患者中度11例，重度8例，肘管综合征患者1例为中度。腕管综合征患者均采用OCTR术式，肘管综合征尺神经行前置手术，并针对痛风行综合治疗。
结果:
腕管综合征患者19例，肘管综合征1例，全部通过门诊、电话随访，未见复发，随访6个月～81个月，平均28个月。患者中度11例，重度8例。术后依据上肢周围神经功能标准[1]
评定：优8例（中度6例，重度2例）；良8例（中度5例，重度3例）；可2例（中度0例，重度2例）；差1例（中度0例，重度1例），总优良率84.2%。肘管综合征患者为中度，术后参照上肢功能尺神经评定标准为优。我院2017年统计非痛风所致的腕管综合征患者术后优良率为78.0%。应用 SPSS 23.0 软件,依据病因是否为痛风将两组数据优良率进行费希尔精确检验，P 值大于 0.05，无统计学研究意义。
结论:
1、痛风所致的腕管综合征患者中，男性更常见，且多有痛风病史。
2、腕管和肘管均为受限的狭窄空间，单钠尿酸盐沉积易引起神经损伤，但直接沉积于神经外膜内而造成神经损伤者少见。
3、痛风所致的腕管综合征或肘管综合征均应早期手术治疗，腕管综合征首选 OCTR 术式，肘管综合征首选尺神经松解前置术，此类患者术后预后较好。
关键词: 痛风，腕管综合征 。
Abstract
Diagnosis, treatment and efficacy analysis of carpal tunnel syndrome caused by gout
Objective:
To investigate the characteristics, diagnosis and treatment of carpal tunnel syndrome caused by gout.
Materials and Methods:
A retrospective analysis of 19 cases of gout-induced carpal tunnel and/or cubital tunnel syndrome in hand and foot surgery of the First Hospital and Branch of Jilin University from July 2013 to December 2019, including 19 carpal tunnel syndrome There were 8 cases on the left side, 11 cases on the right side, and 1 case on the right cubital tunnel syndrome, of which 1 case was left carpal tunnel syndrome and right cubital tunnel syndrome. All patients were male, aged 38 to 68 years, with an average of 55.1±9.2 years. The duration of carpal tunnel syndrome is 1 month to 60 months, with an average of 11.3±14.3 months, and the duration of cubital tunnel syndrome is 15 days. All patients had a history of gout for many years, ranging from 3 years to 20 years, with an average of 10.6±5.5 years. There were gout nodules of different sizes in other parts of the body. The blood uric acid concentration was high before operation, and 6 patients had undergone local color Doppler ultrasound examination before operation, and all showed gout stone lesions. The 18 sides of the carpal tunnel syndrome showed numbness and sensation of three and a half fingers on the radial side, and the middle ring finger on one side. There were 12 sides with normal fish and 7 sides with atrophy.
Six patients with carpal tunnel syndrome were complicated with flexion and extension of the fingers, and the palms of the 14 wrists were full and bulged. Three patients werein acute arthritis when they were admitted to the hospital. The wrists were red, swollen, hot and painful. One case of cubital tunnel syndrome had numbness of the ulnar half ofthe ring finger and little finger, skin bulge was seen on the elbow, and there was no claw-shaped hand deformity. Tinel sign (+) of the median nerve of the wrist in patientswith carpal tunnel syndrome and ulnar nerve (+) in the patients of cubital tunnel syndrome. EMG examination confirmed the median nerve or ulnar nerve injury.
According to Gu Yudong’s clinical classification and treatment of carpal tunnel and cubital tunnel syndrome, there were 11 cases with moderate carpal tunnel syndrome, 8 cases with severe carpal tunnel syndrome and 1 case with moderate cubital tunnel syndrome. Patients with carpal tunnel syndrome were treated with OCTR, cubital tunnel syndrome with ulnar nerve preoperative surgery, and comprehensive treatment for gout.
Results:
There were 19 cases of carpal tunnel syndrome and 1 case of cubital tunnel syndrome. All patients were followed up by outpatient, telephone or We Chat. No patients relapsed. The follow-up time was 6 months to 81 months, with an average of 28 months. Carpal tunnel syndrome was moderate in 11 cases and severe in 8 cases. According to the trial standard of upper limb peripheral nerve function evaluation of the Chinese Medical Association Hand Surgery Society [1] (Table 18): 8 cases were excellent (moderate 6 cases, severe 2 cases); 8 cases were good (moderate 5 cases, severe 3 cases) ; 2 cases (moderate 0 cases, severe 2 cases); poor 1 case (moderate 0 cases, severe 1 case), the total excellent and good rate was 84.2%. Patients with cubital tunnel syndrome were moderately graded preoperatively, and evaluated postoperatively according to the upper limb function ulnar nerve evaluation standard (Table 15) of the Hand Surgery Society of the Chinese Medical Association. In 2017, the postoperative excellent and good rate of patients with carpal tunnel syndrome who were not the cause of gout was 78.0%. Using SPSS 24.0 software, chi-square test was performed based on whether the cause was gout. The P value was 0.78, which was greater than 0.05, which was not statistically significant.
Conclusion:
1. Among the patients with carpal tunnel syndrome caused by gout, men are more common and have a history of gout.
2. The carpal tunnel and the elbow canal are restricted spaces. Monosodium urate deposition is easy to cause nerve damage, but it is rare to deposit directly in the adventitia and cause nerve damage.
3. Carpal tunnel syndrome or cubital tunnel syndrome caused by gout should be treated with early surgery. Carpal tunnel syndrome is the first choice for OCTR, and cubital tunnel syndrome is the first choice for ulnar nerve lysis. The prognosis is good for these patients.
Key words: Gout, carpal tunnel syndrome。
第1章 绪论
嘌呤代谢紊乱和(或)尿酸排泄障碍所致的痛风，是一种代谢性疾病。尿酸钠晶体可以在关节、肾脏和皮下等部位沉积，引起急慢性炎症和组织损伤。不同国家患病率有差异，总体患病率 1%～5%[2]，女性一般绝经后患病。腕管与肘管综合征患病率越来越高，逐渐成为常见病、多发病，这与社会老龄化来临及代谢性、遗传性疾病的增加有关[3]。周围神经损伤患病率的第一位是腕管综合征，肘管综合征第二，但痛风所致腕管综合征或肘管综合征不常见。由于腕、肘管的解剖特点，当痛风石发生于此处，易引起神经损伤。临床对于痛风所致腕管与肘管综合征研究较少，认识尚有不足，可能导致该病诊断延迟或治疗不够全面，最终导致患者恢复差，遗留功能障碍，致使生活质量下降。正因如此，我们回顾分析了我院痛风致腕管和（或）肘管综合征病例的资料和随访结果，探讨其发病特点、诊断及治疗方法，从而提高对该病的认识，合理治疗。
第2章 综述
2.1、痛风的流行病学特点。
20世纪70年代，痛风在中国大陆的报告低于30例[4]。而到2000年，调查显示我国痛风患病率为0.9%，根据最新结果，总人口中13.3%为高尿酸血症患者，而痛风患病率在1%～3%[5]。高尿酸血症与痛风在不同人群与地区发病率不同，其种族差异较明显。痛风有年轻化趋势，对全人类的健康构成威胁。
2.2、痛风的病因、发病机制和影响因素。
原发性痛风是由两方面原因共同影响的结果，包括遗传因素和环境因素。我们目前还不是完全了解其准确病因和发病机制，但尿酸排泄障碍是大多数患者的病因，具有一定的家族易感性。以前的研究已经证明了痛风的发生与血尿酸水平有关联。内源性的嘌呤代谢是体内80%以上的尿酸来源，原发性血尿酸生成增多的主要原因之一是先天性酶的缺陷；尿酸排泄障碍所致的高尿酸血症主要是由于肾小管分泌的减少、重吸收增多和肾小球滤过减少[6]。尿酸盐阴离子交换器(URAT)基因突变以及尿酸盐转运子(HUAT)表达异常，也会引起尿酸滤过减少和重吸收的增多[7]。
痛风形成的关键性生理指针是高尿酸血症[8]。性别、年龄、饮食、药物、家族与遗传以及种族和地域是痛风形成的关键性影响因素。男性30岁以后明显增加，女性一般发生在绝经后。研究表明，饮食中长期富含嘌呤可能是高尿酸的重要原因之一。酒精及其它高嘌呤食物的摄入量与痛风风险增加有关。出现高尿酸血症的重大因素之一是利尿剂[9]。痛风是多基因遗传病，根据既往获取的数据，有人提出血尿酸盐浓度可能与基因的调控有关[2]。
2.3、腕管、肘管的解剖学研究。
2.3.1、腕管的解剖构成。
腕管从远侧腕横纹至其远端约3cm处，位于腕前区[10]，是一个空间受限的骨-纤维隧道，腕骨组成两侧壁和底，屈肌支持带构成顶。腕管内有正中神经、屈拇长肌腱和2-5指的浅深屈肌腱通过。正中神经位置相对表浅，位于腕横韧带与指浅屈肌肌腱之间。桡侧滑膜囊和尺侧滑膜囊分别包裹屈拇长肌腱与其余肌腱。
2.3.2、肘管的解剖构成。
肘管是一个骨性-纤维管道，其空间受限，在尺骨鹰嘴两骨突之间与肱骨内上髁下方存在尺神经沟，纤维性筋膜鞘覆盖其上，二者之间就是肘管。肘管顶部为弓形韧带，从内上髁到鹰嘴；底部为内侧副韧带；后界为三头肌中间头；内上髁为前界；侧面为尺骨鹰嘴；内容物为尺神经。
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2.4、腕管与肘管综合征的病因
2.4.1、腕管综合征
2.4.2、肘管综合征
2.5、诊断.
2.5.1、临床表现
2.5.2、影像学检查
2.5.3、电生理检查
2.5.4、临床分型
2.6、治
2.6.1、非手术治疗
2.6.2、腕管综合征的手术治疗
2.6.3、肘管综合征的手术治疗
第3章 资料与方法
3.1、一般资料.
3.1.1、病例来源
3.1.2、基本情况
3.2、术前分型
3.3、手术治疗及术前与术后处理.
3.3.1、术前处理
3.3.2、腕管综合征的手术治疗
3.3.3、肘管综合征的手术治疗.
3.3.4、术后处理
3.4、统计学方法.
第4章 结果.
4.1、痛风石致腕管与肘管综合征发病特点.
4.1.1、性别特点
4.1.2、腕管与肘管综合征发病人数
4.1.3、年龄分布特点.
4.1.4、病程分布特点
4.2、术后结果统计.
4.3、术后疗效统计学分析.
第5章 典型病例
5.1、典型病例一
5.2、典型病例
第6章 讨论
6.1、痛风致腕管或肘管综合征发病人群特点
6.2、为什么痛风石会引起腕管或肘管综合征
6.3、痛风致腕管与肘管综合征的诊断建议
6.4、手术时机的选择.
6.5、治疗.
6.5.1、痛风致腕管综合征的术式选择
6.5.2、痛风致肘管综合征的术式选择
6.6、痛风致腕管综合征预后
6.7 、不足与展望
第7章 结论
1、痛风所致的腕管综合征患者中，男性更常见，且多有痛风病史。
2、腕管和肘管均为受限的狭窄空间，单钠尿酸盐沉积易引起神经损伤，但直接沉积于神经外膜内而造成神经损伤者少见。
3、痛风所致的腕管综合征或肘管综合征均应早期手术治疗，腕管综合征首选 OCTR 术式，肘管综合征首选尺神经松解前置术。此类患者术后预后较好。
参考文献.
