骶管囊肿文献导读：一例合并抑郁的女性骶管囊肿患者

原文：Depressive symptomatology in a female patient with Tarlov cyst

作者：Konstantinos Kontoangelo , Marina Economou , Vasiliki Katsi, Charalambos Papageorgiou

1st Department of Psychiatry, Eginition Hospital, Medical School, University of Athens, Athens, Greece（希腊，雅典）

编译：沈霖 杨敏    审校：郑学胜

Case presentation

This is a case of a 56-year-old female patient reporting symptoms of low back pain, buttock pain, shoulder pain, arthralgias, and limited spinal mobility. The intensity of the pain that the patient experienced was described by her as a severe stabbing and shooting pain, splitting and exhausting, and sickening and very fearful, causing her severe discomfort. She had been suffering from back pain since the age of 51. The patient reported that during the last 2 years, she had been prescribed a combination of various medications for pain relief with only transient improvement. The patient was complaining of walking difficulties and presented with sudden right buttock pain, right inguinal fold pain, and low back pain for 2 months, with inability to walk and to sit down. Imaging a spinal MRI was performed and revealed a large cystic formation from three cysts compressing in the lumbar region. At levels 04-05 and 05-I1, small-scale circular projection of the intervertebral discs is observed, with no appreciable narrowing of the intervertebral tracts. Tarlov cysts were observed in the sacrum bone with widening of the segments which show a hardening edge and smooth limits. The bigger right cysts had a diameter of 2.7 cm and the left had a diameter of 1.7 cm. On the Short-Form McGill Pain Questionnaire, she scored I-a = 24, II = worst possible pain, and III =2, while on the Beck Depression Inventory (BDI)6 she had a score of 24. Her score on BDI was mainly shaped from her reported symptoms in the subscale that measures somatic-vegetative performance complaints (consisting from the last eight items of the BDI). She was prescribed duloxetine (30 mg/day), and the dosage of duloxetine was escalated to 60 mg/day after 2 weeks of titration and then 120 mg/day after 4 weeks with satisfactory results. The pain subsided along with depressive symptoms (Figures 1 and 2)

患者是一位56岁的女性病人，主要的症状是下腰痛，臀部疼痛，肩关节痛和脊柱活动受限。患者的疼痛被她描述为严重的刺痛和枪击痛，疼痛欲裂，同时使人精疲力尽，令人作呕且非常可怕，导致她严重不适。她从51岁起就一直背痛。患者表示在过去的2年里，她使用了多种止痛药的联合用药，但只有短暂的改善。患者主诉行走困难，表现为右臀部疼痛，右腹股沟疼痛及腰痛，症状持续2个月，无法行走和坐下。脊柱磁共振提示巨大的囊性占位，并在椎管内有压迫。同时在腰4-5和腰5-骶1节段，可以观察到椎间盘的小范围圆形突出，椎管没有明显的狭窄。骶骨可见骶管囊肿，相应节段椎管变宽，骨质边缘变硬，界限光滑。较大的右侧囊肿直径为2.7cm，左侧的直径为1.7cm。在McGill疼痛问卷中，她得到了I-a=24，II=最严重的疼痛，III=2，而在贝克抑郁量表（BDI）中，她得到了24分。她在BDI上的得分主要是根据她在评估躯体植物神经功能表现的子量表（由BDI的最后8个项目组成）中报告的症状汇总而成的。于是我们给她开了度洛西汀（30毫克/天），在使用2周后，度洛西汀的剂量增加到60毫克/天，4周后增加到120毫克/天，结果令人满意。患者疼痛随着抑郁症状而减轻（图1和图2）

专家点评：郑学胜主任医师指出神经根囊肿根据其位置和大小可能产生相应的症状，最常见的是感觉障碍、运动障碍和自主神经系统功能障碍。这些囊肿位于骶神经时，则会引起疼痛，麻木以及排尿排便的症状。而临床上，我们观察到很多有症状的骶管囊肿患者通常会抱怨自己有轻度抑郁、工作问题、性功能障碍以及肠道或膀胱症状。在这种情况下，患者实际的疼痛强度往往会被自身的心理状态而“夸大”，从而加重患者的不适。而本例患者服用的度洛西汀在几种神经源性疼痛模型中被证明是有效的。度洛西汀是一种5-羟色胺和去甲肾上腺素的双重再摄取抑制剂，在美国被批准用于治疗严重抑郁症、广泛性焦虑症、糖尿病周围神经病引起的疼痛等疾病。在欧洲，度洛西汀也被用于治疗女性压力性尿失禁。骶管囊肿患者往往会因为急性疼痛会导致抑郁情绪，而长期慢性疼痛会导致抑郁。疼痛会引起悲伤、焦虑、抑郁和烦恼感，在慢性疼痛患者中，重度抑郁症的平均患病率在18%到85%之间。疼痛会对抑郁症的预后和治疗产生不利影响，反之亦然。疼痛的严重程度与抑郁程度有显著的相关性。所以这是一个相互加重的恶性循环。而且抑郁一旦出现，有可能持续多年，越来越严重，无法自拔，并可能产生次生危害。所以，骶管囊肿患者及家属一定要特别注意主动克服抑郁的心理状态。同时，临床医师也需要及时干预，必要时使用药物治疗。