利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛

目的 评价利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛患者的疗效。方法 15例顽固性三叉神经痛患者,给予0.9%氯化钠注射液100 ml+2%利多卡因注射液0.1 g+25%硫酸镁注射液1.25 g静脉滴注1 h,每周一次,根据患者疼痛缓解情况,决定治疗次数,一般为1~3次。采用疼痛数字评价量表（NRS）评估治疗前、治疗后1周、2周、4周、2月、4月、末次随访疼痛情况。结果 15例患者平均随访时间为19.7（8~35）月。治疗前NRS评分为（8.9±0.7）分,治疗后1周（6.1±1.9）分,2周（2.6±1.3）分,4周（2.1±1.7）分,2月（2.2±1.6）分,4月（2.1±1.7）分,末次随访（2.1±1.8）分。治疗后疼痛明显减轻,差异有统计学意义（P<0.05）。治疗后1周、2周、4周、2月、4月、末次随访的总有效率分别为7%、100%、100%、100%、100%、93%。治疗后分别与治疗前比较,除治疗后1周外,差异均有统计学意义（P<0.05）。15例患者在静滴过程中,无心率减慢、血压下降等不适。结论 利多卡因联合硫酸镁静脉滴注治疗顽固性三叉神经痛安全、有效。     

经皮通道下脊神经根显微减压术治疗神经根型颈椎病的临床研究

目的探讨经皮通道下颈椎后路脊神经根显微减压术治疗神经根型颈椎病(CSR)的疗效。方法连续收集联勤保障部队第九〇〇医院神经外科自2019年9月至2022年10月收治的38例CSR患者, 所有患者均经严格保守治疗无效后改行显微镜和经皮通道系统联合应用下颈椎后路脊神经根减压术治疗。38例患者随访(15.71±7.50)个月, 范围为3～36个月。记录术前1 d、出院前、末次随访时疼痛视觉模拟评分(VAS)及颈椎病日本骨科协会(JOA)评分, 以及该3个时间点的颈椎X线、CT、MRI复查结果。测量并比较术前及术后末次随访时CT重建影像上C2～7矢状位垂直距离(SVA)值。根据公式改善率(%)=[(末次JOA-术前JOA)/(17-术前JOA)]×100%确定患者临床疗效, 其中改善率100%定义为治愈, 改善率>60%定义为显效, 改善率为25%～60%定义为有效, 改善率<25%定义为无效。结果 38例患者术前VAS评分、JOA评分分别为(5.91±0.90)分、(11.37±1.50)分, 末次随访时分别为(0.37±0.31)分、(15.76±1.44)分, 差异均有统计学意...     

脊髓背根入髓区毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素分析(附105例报告)

目的探讨脊髓背根入髓区(DREZ)毁损术治疗臂丛神经损伤后神经病理性疼痛的疗效及其影响因素。方法回顾性分析2005年8月至2018年1月首都医科大学宣武医院功能神经外科收治的105例臂丛神经损伤后神经病理性疼痛患者的临床资料。根据患者疼痛及感觉缺失区对应的皮节,采用颈髓DREZ毁损术治疗。术后对所有患者行电话或门诊随访,随访内容为疼痛数字评分(NRS),以疼痛改善率[(术前NRS-术后NRS)/术前NRS×100%]评估患者疗效;其中改善率>75%为优秀,50%~75%为良好,≤50%为差。进一步采用单因素和多因素logistic回归分析法判断影响患者疗效的临床因素。结果105例患者的手术均成功。术后并发生症包括:手术同侧下肢麻木33例(31.4%)、下肢深感觉障碍20例(19.0%)、下肢无力9例(8.6%),手术对侧肢体麻木5例(4.8%),硬脊膜漏1例(1.0%);无一例出现切口愈合不良和感染。105例患者的随访时间为(47.3±25.5)个月(10~144个月)。至末次随访,105例患者疼痛的中位改善率(上、下四分位数)为100%(60%,100%);其中,74例(70.5%)为优秀,9例(8.6%)为良好,22例(20.9%)为差。单因素分析结果显示,性别、年龄、损伤原因、疼痛出现的时间、疼痛形式、性质及术后并发症对患者的疗效均无影响(均P>0.05),而病程和脊髓萎缩程度对疗效有影响(均P<0.05)。进一步多因素logistic回归分析结果显示,轻度脊髓萎缩是影响患者疗效的独立保护因素(OR=95.952,95%CI:4.171~2207.414,P=0.004)。结论DREZ毁损术治疗臂丛神经损伤后神经病理性疼痛疗效较好且多较持久;同时有轻度脊髓萎缩的患者手术疗效较好。     

三叉神经痛微血管减压术手术技巧及并发症分析(附238例病例报告)

目的探讨微血管减压术治疗三叉神经痛的手术技巧及术后并发症。方法回顾性分析2005年10月到2013年10月行三叉神经痛微血管减压术治疗的238例患者的临床资料。结果术后疼痛消失224例(94.1%),疼痛明显减轻10例(4.2%)。术后并发口周疱疹87例(36.6%),面部麻木、浅感觉减退者40例(16.8%),脑脊液漏5例(2.1%),听力下降者1例(0.42%)。随访3个月到6年,随访期间复发或无效12例,总体治愈率94.96%。结论微血管减压术治疗三叉神经痛效果确切,有针对性的手术策略和细致的手术操作能显著减少并发症的产生。     

庆大霉素神经阻滞治疗三叉神经痛的疗效观察

目的研究庆大霉素神经阻滞治疗三叉神经痛的临床疗效。方法选择2012-03—2014-03来我院就诊的116例三叉神经痛患者为研究对象,随机分为实验组和对照组,2组分别给予庆大霉素和无水乙醇神经阻滞剂进行治疗。治疗5周,随访3个月,采用主诉疼痛的程度分级法(VRS)和生活质量指数评定量表(QOL)观察比较两种治疗方案对患者疼痛程度和生活质量的疗效,记录治疗和随访期间患者并发症情况。结果治疗后实验组感觉无疼痛患者37例(63.79%),显著高于对照组的18例(31.03%),差异具有统计学意义(P0.05)。治疗后实验组患者总体生活质量为(8.6±1.1)分,显著高于对照组的(6.7±1.2)分,差异具有统计学意义(P0.05)。实验组治疗期并发症发生率显著低于对照组,差异具有统计学意义(P0.05)。随访期2组并发症较治疗期显著降低,实验组较对照组降低更为显著,差异具有统计学意义(P0.05)。结论庆大霉素神经阻滞治疗可显著改善三叉神经痛患者疼痛症状和生活质量,此种方法操作简单,并发症少,疗效显著,值得临床推广。     

原发性三叉神经痛二次伽玛刀治疗疗效分析

目的通过对二次伽玛刀治疗原发性三叉神经痛病例的长期随访,评价治疗的安全性,有效性及并发症发生情况。方法 1998年4月～2009年9月,54例经伽玛刀治疗后无效或复发的原发性三叉神经痛患者接受二次伽玛刀放射外科治疗。初次治疗中心放射剂量平均为80.9Gy(70～90Gy),二次治疗放射剂量平均为74.8Gy(70～80Gy)。结果 23例患者(42.6%)完成了随访,疼痛复发时间平均18个月(6～78个月)。二次治疗后疼痛完全缓解者17例(74.0%);疼痛缓解程度>50%,服用药物减量>50%者3例(13.0%);疼痛缓解程度<50%或无效者3例(13.0%),总有效率87.0%。疼痛缓解出现平均时间为10周(1～16周)。面部麻木,感觉异常的发生率为18例(78%),7例(30.4%)患者出现咬肌无力。结论二次伽玛刀治疗原发性三叉神经痛安全有效,但并发症的发生率明显增高。     

不同药物联合治疗外周原发性三叉神经痛对比研究

目的分析不同药物联合治疗外周原发性三叉神经痛患者的临床疗效。方法选择2013-06—2014-06收治的82例外周原发性三叉神经痛患者,按照随机数字表法分为实验组40例和对照组42例,实验组给予罗哌卡因联合复方倍他米松治疗,对照组采用卡马西平和维生素B12治疗,比较2组治疗前后NRS评分、临床疗效、不良反应及生活质量评分的变化。结果治疗前2组NRS评分均较高,差异无统计学意义(P0.05),治疗1周、3周和6周后,2组NRS评分均较治疗前显著降低(P0.05),但实验组在治疗1周、3周和6周后的NRS评分降低幅度较对照组更为明显,差异具有统计学意义(P0.05);实验组显效25例,有效14例,无效1例,总有效率97.5%,显著高于对照组的64.3%,差异具有统计学意义(P0.05);实验组头痛眩晕、恶心呕吐、视物模糊及共济失调等不良反应显著少于对照组,差异具有统计学意义(P0.05);实验组患者的生理功能、躯体疼痛、情感职能、生命活力、精神健康及社会功能等生活质量的评分均显著高于对照组,差异具有统计学意义(P0.05)。结论罗哌卡因联合复方倍他米松治疗外周原发性三叉神经痛患者,能够显著降低NRS评分,提高临床疗效与生活质量评分,且具有一定的安全性,是一种令人满意的治疗方案。     

利多卡因治疗脑卒中后顽固性呃逆28例分析

目的观察利多卡因对脑卒中后顽固性呃逆的疗效。方法60例卒中后顽固性呃逆病人分为2组,其中治疗组22例,男18例,女4例,年龄(62±6)岁,采用利多卡因治疗,利多卡因100mg加液体静滴,2次/d,疗程3~5d;对照组32例,男23例,女9例,年龄(63±8)岁,采用胃复安、654-2、氯丙嗪及针灸按摩等常规方法治疗。结果治疗组总有效率92.8%,而对照组总有效率为65.6%,治疗组疗效明显高于对照组(P<0.01)。结论利多卡因静滴治疗卒中后顽固性呃逆是安全有效方法。     

灯盏花素联合银杏达莫注射液治疗缺血性脑梗死的疗效及协同作用分析

目的分析灯盏花素联合银杏达莫注射液治疗缺血性脑梗死的临床疗效与协同作用。方法选取我院2012-12—2014-12收治的100例缺血性脑梗死患者为研究对象,按随机数字表法分为对照组与观察组各50例。对照组给予银杏达莫注射液治疗,观察组则采用灯盏花素联合银杏达莫注射液治疗,2组均治疗4周,采取神经缺损功能评分量表(NFDS)评估患者神经功能恢复情况,采用日常生活活动能力量表(Barthel指数)评价患者日常生活能力恢复状况。结果观察组总有效率为84.00%,对照组为56.00%,2组对比差异有统计学意义(P0.05);治疗1周、2周、4周后观察组NFDS评分分别为(11.31±5.63)分、(8.21±5.21)分、(6.13±5.37)分,与对照组相比差异有统计学意义(P0.05);治疗1周、2周、4周后观察组Barthel指数评分分别为(35.57±10.66)分、(39.11±11.34)分、(43.55±12.71)分,与对照组相比差异有统计学意义(P0.05)。结论在缺血性脑梗死患者临床治疗中,采用灯盏花素联合银杏达莫注射液治疗,临床效果好,患者神经功能及日常生活能力改善明显,值得推广。     

原发性三叉神经痛患者伽玛刀治疗术前、后血浆P物质水平的观察

目的观察三叉神经痛患者伽玛刀治疗前后血浆P物质的变化,探讨其在三叉神经痛病因及伽玛刀治疗机制中的意义。方法对48例接受伽玛刀治疗的原发性三叉神经痛患者随访疗效,并于术前、术后4、8周测定血浆P物质水平。结果①术后4、8周时的治疗有效率分别为40%、56%;②术后4、8周的血浆SP[分别为(86±19)ng/L、(75±16)ng/L]较治疗前[(109±24)ng/L]下降,差异均有统计学意义(分别t=9.756、13.357,均P=0.000);③术后4周、8周时治疗有效组的SP下降率[分别为(25.8±12.9)%(、33.9±12.6)%]高于同期治疗无效组[分别为(16.6±10.3)%(、26.3±8.9)%],差异均有统计学意义(分别t=2.748、2.336,P=0.009、0.024);④术后4周时的疗效与SP下降率正相关(rs=0.421,P=0.003)。结论三叉神经痛患者伽玛刀术后血浆P水平下降,P物质可能参与了三叉神经痛的发病机制、并与伽玛刀的早期疗效有关。     

Clinical outcomes of 114 patients who underwent Gamma-knife radiosurgery for medically refractory idiopathic trigeminal neuralgia

The optimal radiation dose and target of Gamma-knife radiosurgery (GKRS) for medically refractory idiopathic trigeminal neuralgia (TN) are contentious. We investigated the effects and trigeminal nerve deficits of GKRS using two isocenters to treat a great length of the trigeminal nerve. Between January 2005 and March 2010, 129 patients with idiopathic TN underwent GKRS at the West China Hospital of Sichuan University. A maximum central dose of 80-90 Gy was delivered to the trigeminal nerve root with two isocenters via a 4 mm collimator helmet. One hundred and fourteen patients were followed-up periodically by telephone interview to determine the effects, trigeminal nerve deficits and time to the onset of pain relief. The mean follow-up duration was 29.6 months. One hundred and nine patients had complete or partial pain relief and the treatment failed in five patients. Nine patients experienced a recurrence after a mean time of 12.7 months, following an initial interval of pain relief. There were no significant differences between patients with different grades of pain relief with respect to central doses. The mean time to the onset of pain relief was 3.6 weeks. The time to the onset of complete pain relief was significantly shorter than that for partial pain relief. Forty-nine patients reported mild-to-moderate facial numbness and one patient experienced paroxysmal temporalis muscle spasms two weeks after the treatment. GKRS treatment for medically refractory idiopathic TN with two isocenters resulted in an initial pain improvement in 95.6% of patients. The early response to the treatment might suggest a good outcome but, given the high incidence of nerve deficits, GKRS for TN with two isocenters is not recommended as a routine treatment protocol.     

Botulinum toxin A in the treatment of trigeminal neuralgia

Aims: The aims of this study were to investigate the clinical effects and safety of botulinum toxin A (BTX-A) in treating trigeminal neuralgia and its influences on accompanied depression, anxiety, sleep disorders, and quality of life. Methods and Material: Eighty-seven patients with one-branch classical trigeminal neuralgia were injected with BTX-A in the pain area. The visual analogic scale score, sleep interference score, Hamilton Anxiety Scale score, Hamilton Depression Scale score, and side effects were assessed at 1 week prior to and 8 weeks after treatment, respectively. Results: The effective rates after 1, 2, 4, and 8 weeks of treatment were 48.28%, 66.67%, 78.16%, and 80.46%, respectively. The effective rates of anxiety and depression were 90.32% and 96.77%, respectively. When compared to that before treatment, the quality of life was significantly better in terms of role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health (all P < 0.01), while physical function was not significantly improved (P = 0.317). Conclusion: BTX-A treatment can significantly relieve the pain in trigeminal neuralgia patients; improve anxiety, depression, and sleep; and increase the quality of life. BTX-A treatment is a safe and effective method to treat classical trigeminal neuralgia.     

伽玛刀双靶点与单靶点治疗原发性三叉神经痛的对比分析

目的对比分析伽玛刀双靶点与单靶点治疗原发性三叉神经痛的疗效。方法回顾性分析236例单靶点与12例双靶点治疗的经验。均使用Leksell—B型伽玛刀，准直器4mm。双靶点者靶点分别置于三叉神经根脑桥进入区和近三叉神经半月节处，单靶点者仅置于三叉神经根脑桥进入区。两组均为中心剂量70—90Gy，50％等剂量线限定靶点；将20％等剂量线限定在脑桥表面，使脑干表面剂量小于16Gy。结果随访12～114个月，平均66.4月。单靶点组有效223例（94．5％），无效13例（5．5％），复发14例（5．9％），发生并发症9例（3．8％）。双靶点组有效12例（100％），发生并发症4例（33.3％）。经统计学分析，两组治疗有效率差异无统计学意义（P〉0.05）．并发症发生率以双靶点者为高（P〈0.05）。结论双靶点治疗不能明显提高有效率，反而可使并发症发生率明显增加。当三叉神经根紧贴脑桥或受压变形时，为弥补单靶点可能引起的三叉神经受照不足，可使用双靶点治疗。     

局部注射布比卡因联合口服卡马西平治疗三叉神经痛的疗效分析

目的分析局部注射布比卡因联合口服卡马西平治疗三叉神经痛的临床疗效,以期为原发性三叉神经痛的诊疗提供借鉴。方法选取2012-04—2014-06入住我院原发性三叉神经痛患者64例为研究对象,随机分为2组,观察组予以局部注射布比卡因联合口服卡马西平治疗,对照组予以口服卡马西平治疗,分别记录治疗前及治疗后1周、2周、3周、4周、2个月、3个月、6个月的疼痛强度评分,并记录治疗期间出现的不良反应。结果对照组有效24例(70.6%),观察组有效28倒(93.3%),2组比较差异有统计学意义(P0.05)。观察组出现嗜睡5例,头晕3例,恶心口干各1例;对照组出现嗜睡6例,头晕4例,恶心口干各2例,2组不良反应比较,差异无统计学意义(P0.05)。2种治疗方式均未发现血尿常规及肝、肾功能等异常改变。结论局部注射布比卡因联合口服卡马西平治疗原发性三叉神经痛有明显的疗效,且优于卡马西平组,不良反应发生率无明显增加,值得进一步推广。     

Efficacy and tolerability in patients with chronic facial pain of two consecutive treatment periods of rTMS applied over the facial motor cortex,using protocols differing in stimulation frequency,duration, and train pattern

ObjectiveWe conducted an open-label cross-over study assessing the global effect of two high-frequency protocols of electric-field navigated repetitive transcranial magnetic stimulation (rTMS) targeted to functional facial motor cortex and comparing their efficacy and tolerability in patients with chronic facial pain. Outcome predictors were also assessed.MethodsWe randomized twenty consecutive patients with chronic facial pain (post-traumatic trigeminal neuropathic pain, n=14; persistent idiopathic facial pain, n=4; secondary trigeminal neuralgia, n=2) to receive two distinct 5-day rTMS interventions (10Hz, 2400 pulses and 20Hz, 3600 pulses) separated by six weeks. The target area was assessed by mapping of lower face representation. The primary endpoint was the change in weekly mean of pain intensity (numeric rating scale, NRS) between the baseline and therapy week (1^st week), and follow-up weeks (2^nd and 3^rd weeks) for each rTMS intervention. Response was defined using a combination scale including the patient's global impression of change and continuance with maintenance treatment.ResultsOverall, pain intensity NRS decreased from 7.4 at baseline to 5.9 ten weeks later, after the second rTMS intervention (p=0.009). The repetition of the treatment had a significant effect (F=4.983, p=0.043) indicating that the NRS scores are lower during the second four weeks period. Eight (40%) patients were responders, 4 (20%) exhibited a modest effect, 4 (20%) displayed no effect, and 4 (20%) experienced worsening of pain. High disability and high pain intensity (>7) predicted a better outcome (p=0.043 and p=0.045). Female gender, shorter duration of pain and low Beck Anxiety Inventory scores showed a trend towards a better outcome (p=0.052, 0.060 and 0.055, respectively).ConclusionsHigh-frequency rTMS targeted to face M1 alleviates treatment resistant chronic facial pain. Repeated treatment improves the analgesic effect. A protocol with higher frequency (above 10Hz), longer session duration (more than 20 minutes) and higher number of pulses (above 2400 pulses/session) did not improve the outcome. The results support early consideration of rTMS.     

Percutaneous Radiofrequency Thermocoagulation in Trigeminal Neuralgia : Analysis of Early and Late Outcomes of 156 Cases and 209 Interventions

ObjectiveTrigeminal neuralgia is one of the most common causes of facial pain. Our aim is to investigate the efficacy and borders of percutaneous radiofrequency thermocoagulation in the treatment of trigeminal neuralgia. MethodsBetween May 2007 and April 2017, 156 patients with trigeminal neuralgia were treated with radiofrequency thermocoagulation. These 156 patients underwent 209 procedures. In our study, we investigated the early and late results of percutaneous radiofrequency thermocoagulation under guiding fluoroscopic imaging in the treatment of trigeminal neuralgia. Barrow Neurological Institute (BNI) pain scale was used for grading the early results. In addition, Kaplan-Meier survival analysis was used to assess long-term outcomes. Of the 156 patients who underwent radiofrequency thermocoagulation for trigeminal neuralgia, 45 had additional disease. Patients with this condition were evaluated with their comorbidities. Early and late results were compared with those without comorbidity. ResultsIn 193 of 209 interventions BNI pain scale I to III results were obtained. Out of the 193 successful operation 136 patients (65.07%) were discharged as BNI I, 14 (6.70%) as BNI II, 43 (20.58%) as BNI III. Sixteen patients (7.65%) remained uncontrolled (BNI IV and V). While the treatment results of trigeminal neuralgia patients with comorbidity seem more successful in the early period, this difference was not observed in follow-up examinations. ConclusionFinally, we concluded that percutaneous radiofrequency thermocoagulation of the Gasserian ganglion is a safe and effective method in the treatment of trigeminal neuralgia. However, over time, the effectiveness of the treatment decreases. Neverthless, the reapprability of this intervention gives it a distinct advantage.     

Glycerol rhizotomy via a retrosigmoid approach as an alternative treatment for trigeminal neuralgia

Objectives

Trigeminal neuralgia is a sensory nerve disorder characterized by lancinating pain and treated most commonly with carbamazepine, rhizotomy treatment, or open surgical management with microvascular decompression. We describe a novel technique to complement surgical treatment for trigeminal neuralgia via direct injection of the trigeminal nerve with glycerin in the cisternal portion of the nerve.

Patients and methods

We performed a retrospective analysis of patients who received standard microvascular decompression and injection of glycerin to the inferior third of the cisternal portion of the nerve anterior to the root entry zone with lack of a compressive vessel on MRI as the primary indication. Fourteen patients were identified and demographic information, post-operative course and complications were recorded.

Results

There were eleven females and three males with an average age at time of surgery of 54.8 years. 100% of patients reported that their trigeminal pain was significantly improved following surgical intervention. Four out of fourteen patients reported a 50–80% decrease from the pre-surgery baseline pain at one month and three month follow up. One patient developed a CSF leak, and no surgical site infections or motor deficits were observed.

Conclusion

Intra-operative glycerin rhizotomy in conjunction with microvascular decompression can be used to safely treat patients suffering from trigeminal neuralgia.     

Predictive model for pain recurrence after posterior fossa surgery for trigeminal neuralgia

BACKGROUND: Surgical exploration of the posterior fossa is the definitive treatment for trigeminal neuralgia refractory to medication, but predictors of its success in effecting long-term pain relief have not been established. OBJECTIVE: To develop a model that allows stratification of patients' risk of postoperative recurrence of pain based on pretreatment factors. METHODS: We reviewed the records of 420 consecutive patients who underwent posterior fossa exploration by one of us (C.B.W.) for the treatment of idiopathic trigeminal neuralgia. The primary outcome measure was recurrence of trigeminal pain. The predictive value of preoperative and intraoperative factors was evaluated. Multivariate analysis revealed the statistically significant predictors of pain recurrence, permitting creation of a risk model for recurrence of pain. RESULTS: After surgery, trigeminal pain had lessened in 98% of patients and completely resolved in 87%. There were no perioperative deaths. After a mean follow-up of 56.3 months, 93% of patients reported significant pain improvement and 72% continued to have no pain. The estimated likelihood of pain recurrence at 8 years was 34%. Significant predictors of eventual recurrence of pain were age younger than 53 years at the time of surgery, symptoms lasting longer than 11(1/2) years, female sex, and pain on the left side in men. These factors were weighted and incorporated into a risk model that revealed 4-year pain-free survival of 89% +/- 4% for the low-risk group, 80% +/- 4% for the moderate-risk group, and 58% +/- 6% for the high-risk group (data are mean +/- SD). CONCLUSIONS: We developed a predictive model that stratifies the risk for eventual recurrence of pain after posterior fossa exploration for trigeminal neuralgia. This information may be useful in counseling patients regarding treatment.     

Botulinum toxin and intractable trigeminal neuralgia

The effects of botulinum toxin have been demonstrated in pain syndromes such as migraine, tension headache, and postherpetic neuralgia. With this background data in hand, the authors planned a randomized, open-ended study to investigate the efficacy of botulinum injections in cases of refractory trigeminal neuralgia. In 8 patients with trigeminal neuralgia, 100 U botulinum toxin was injected into the region of the zygomatic arch. The results of their statistical analyses demonstrated that the medication can be effective in treating trigeminal neuralgia. The patients did not develop any significant adverse effects. Botulinum toxin can be used in the treatment of refractory trigeminal neuralgia.