Improvement of diagnosis and treatment of glossopharyngeal neuralgia

Differential diagnosis of neuralgias affecting the cranial nerves and of facial pain is often difficult. Glossopharyngeal neuralgia is much less common than trigeminal neuralgia and is not well known. Idiopathic neuralgia of the glossopharyngeal nerve sometimes occurs in association with neurovascular compression syndrome of the vagus and trigeminal nerves. High-resolution MRI of the brain stem with three-dimensional visualization allows a secure diagnosis of neurovascular compression and is useful in the planning of appropriate microsurgical decompression (Jannetta's operation).     

Verbesserung der Diagnostik und Therapie der Glossopharyngeusneuralgie

Differential diagnosis of neuralgias affecting the cranial nerves and of facial pain is often difficult. Glossopharyngeal neuralgia is much less common than trigeminal neuralgia and is not well known. Idiopathic neuralgia of the glossopharyngeal nerve sometimes occurs in association with neurovascular compression syndrome of the vagus and trigeminal nerves. High-resolution MRI of the brain stem with three-dimensional visualization allows a secure diagnosis of neurovascular compression and is useful in the planning of appropriate microsurgical decompression (Jannetta’s operation).     

原发性三叉神经痛的显微外科治疗

目的 :探讨原发性三叉神经痛的显微外科治疗及其疗效。方法 :根据术中探查有无明确的血管压迫三叉神经 ,分别采用显微血管减压术或感觉根部分切断术。 132例病人中 95例行血管减压术 ;37例行感觉根切断术。结果 :无手术死亡病例。随访 6个月 15年 ,治愈或好转 130例 ,有效率为     

微血管减压术治疗颅神经疾病疗效分析

目的 探讨微血管减压术治疗三叉神经痛、面肌痉挛、舌咽神经痛的疗效. 方法 微血管减压手术治疗颅神经疾病156例(三叉神经痛119例,面肌痉挛34例,舌咽神经痛3例). 结果 总有效151例,有效率96.8%,其中三又神经痛、面肌痉挛和舌咽神经痛患者手术有效率分别为94.2%、97.1%和66.7%. 结论 微血管减压术治疗颅神经疾病疗效确切.     

微血管减压术治疗三叉神经痛及舌咽神经痛1150例报告

目的:探讨用微血管减压术治疗三叉神经痛、舌咽神经痛等神经血管压迫综合症治疗方法的改进措施和提高治疗效果的临床经验。方法:系统回顾1984年6月至1999年12月我们采用微血管减压术治疗神经血管压迫综合症病例1150例,其中三叉神经痛1120例,舌咽神经痛30例。结果:有效1112例,有效率为96.7％,本组无死亡。并发症发生率由5年前5.6％下降到近5年的1.6％。结论:提高微血管减压术的治愈率和减少并发症,有多方面因素值得考虑。     

Neurosurgical therapy of facial neuralgias

INTRODUCTION: Neuralgias of the face, especially trigeminal neuralgia and glossopharyngeal neuralgia are indications for surgical interventions after failed medical therapy. In contrast to other forms of headache or atypical facial pain, where surgical measures are considered to be contraindicated, percutaneous procedures or microvascular decompression are able to produce immediate and longstanding pain relief. Careful preoperative evaluation is essential to confirm the clinical diagnosis and to rule out other causes as multiple sclerosis or tumors afflicting the cranial nerves. The following study will summarize the common surgical techniques and their role considering a mechanism-based therapy as well as document long-term results of these measures. METHODS: Between 1977 and 1997 316 thermo-controlled radiofrequency trigeminal rhizotomies (TK) and 379 microvascular decompressions (MVD) were performed in our hospital to treat trigeminal neuralgia; additional 6 MVDs for glossopharyngeal neuralgia and one MVD of the intermediate facial nerve were carried out. Questionnaires were sent out to all patients still living in 1981, 1982, 1992 and 1998. For all other patients, interviews with relatives or the general practitioners were conducted. A retrospective analysis of postoperative pain relief was performed using Kaplan-Meier curves at the latest follow-up. Additionally 80 patients underwent careful quantitative sensory testing with Von-Frey-hairs. RESULTS: 225 patients who underwent microvascular decompression and 206 with radiofrequency trigeminal rhizotomies were further analyzed. There was a 50% risk for pain recurrence two years after radiofrequency rhizotomy. On the other hand 64% of patients who underwent microvascular decompression remained painfree 20 years postoperatively. Patients with microvascular decompression without sensory deficit were painfree significantly longer than patients with postoperative hypesthesia. DISCUSSION: Etiology and pathogenesis of facial neuralgias are far from understood despite several hypotheses. Based on current models there is no explanation for the immediate pain relief especially after microvascular decompression. Some authors even discuss surgical trauma as the only cause for postoperative pain relief.     

核磁共振成像诊断三叉神经痛的价值分析与研究

目的：研究探讨MRI检查在三叉神经痛诊断中的价值。方法：100例拟行微血管减压术的原发性三叉神经痛患者,于术前行MRI检查,分别采集三维快速稳态自由梯度（three dimensional- fast imaging employing steady state acquisition,3D-FIESTA）、三维时间飞跃（three dimensional-time of flight,3D-TOF）序列图像,判断神经血管接触压迫情况。以手术诊断结果为参照,计算和比较3D-FIESTA、3D-TOF术前诊断三叉神经痛患者神经血管接触压迫的灵敏度、特异度、准确率,分析2种序列成像诊断结果与手术诊断结果之间的一致性,并计算和比较3D-FIESTA、3D-TOF对不同责任血管的显示率。结果：100例三叉神经痛患者中,有75例经手术诊断证实存在神经血管接触压迫患侧三叉神经脑池段及邻近脑干组织的情况。以手术诊断结果为参照,3D-FIESTA、3D-TOF诊断三叉神经痛患者神经血管接触压迫的灵敏度（97.33%比94.67%）、特异度（92.00%比96.00%）、准确率（96.00%比95.00%）比较,差异均无统计学意义（P>0.05）。一致性分析显示,3D-FIESTA、3D-TOF对三叉神经痛患者神经血管接触压迫的诊断结果与手术诊断结果之间的一致性均保持在良好水平（Kappa值均>0.7）。3D-FIESTA、3D-TOF对1级、2级、3级、4级、5级神经血管压迫程度的诊断符合率比较,差异均无统计学意义（P>0.05）。3D-FIESTA、3D-TOF对小脑上动脉、小脑前下动脉、椎动脉、基底动脉等责任血管的显示率均为100.00%,二者对2支以上动脉、动脉+静脉的显示率未达到100.00%,3D-FIESTA分别为94.74%、75.00%,3D-TOF分别为89.47%、50.00% ,但二者比较差异无统计学意义（P>0.05）。结论：术前行MRI检查可对原发性三叉神经痛患者的神经血管接触压迫情况予以清晰显示,尤其是采用3D-FIESTA、3D-TOF这2种序列成像 ,不仅可作为三叉神经痛的主要诊断手段,还可作为三叉神经痛手术定位的辅助手段。     

Anatomie et neuro-imagerie de la névralgie trigéminale

The trigeminal nerve is the largest and most complex of the 12 cranial nerves. It supplies sensations to the face, mucous membranes, and other structures of the head. It is the motor nerve for the muscles of mastication and contains proprioceptive fibers. It exits the brain by a large sensory root and a smaller motor root coming out of the pons at its junction with the middle cerebral peduncle. It passes laterally to join the Gasserian (semilunar) ganglion in the Meckel cave. Trigeminal neuralgia (TN) is a debilitating facial pain disorder, frequently caused by vascular compression of the trigeminal nerve. The most frequent cause of TN is a mechanical irritation of the nerve caused by neurovascular contact, the neurovascular compression syndrome (NVCS). It is widely believed that compression in the socalled root entry or exit zone of the nerve causes NVCS. Most investigators define the root entry or exit zone as the region extending from the nerve’s point of entry into or exit from the brainstem to the point of transition from the central myelin (oligodendroglia) to the peripheral myelin (Schwann cells). The superior cerebellar artery is responsible for most cases of NVCS. Imaging combined with clinical information is critical to correctly identify patients who are candidates for microvascular decompression. We review trigeminal nerve anatomy and propose to recognize important magnetic resonance imaging findings in patients with trigeminal neuralgia.     

MRI迷路水神经成像对三叉神经痛神经血管压迫的诊断价值

  目的  探究MRI迷路水神经成像诊断三叉神经痛和神经血管压迫的效果。  方法  回顾性分析我院168例三叉神经痛患者的临床资料,均行手术治疗证实,且进行MRI迷路水神经成像检查,分析患者神经血管压迫的影像学检查结果,与手术结果对比,并比较患者三叉神经池段形态学参数（三叉神经脑池段最大长度及面积、三叉神经-桥脑夹角、桥小脑角池截面）。  结果  168例三叉神经痛患者中MRI成像检测处左侧受压80例,与临床左侧三叉神经痛分布区的相符率为90.91%,右侧受压74例,与临床右侧三叉神经痛分布区的相符率为92.50%,未见压迫14例;患侧和健侧压迫位置的差异无统计学意义（P>0.05）;主要压迫动脉为中小脑上动脉,占70.83%（119/168）;患侧压迫程度较高（P < 0.05）;两侧三叉神经最大长度的差异无统计学意义（P>0.05）,患侧三叉神经横截面积、三叉神经桥脑夹角、桥小脑角池截面积较低（P < 0.05）。  结论  MRI迷路水神经成像能够有效诊断三叉神经痛,显示神经周围具体情况,判断三叉神经脑池段形态学改变,为临床三叉神经痛神经血管压迫的诊断提供依据。      

三叉神经痛神经血管压迫的影像学评价

精确地评价三叉神经入口处神经血管压迫,对三叉神经痛患者施行微血管减压术的规划是有用的。应用界限成像融合三维磁共振脑池造影术/血管造影术能立体的显示三叉神经入口处神经血管压迫的解剖学关系,评价责任血管的存在,压迫的部位及程度。界限融合三维磁共振脑池造影术/血管造影术对三叉神经痛患者的诊断及成功地实施微血管减压术是有用的。     

采用显微血管减压术治疗三叉神经痛

目的：总结近年采用显微血管减压手术治疗三叉神经痛的方法和结果，以期进一步提高手术治愈率。方法：回顾分析从1994年1月至2003年12月进行后颅窝手术探查的21例原发性三叉神经痛患者。19例行显微血管减压术。有1例术中采用脑室镜协助观察。结果：在头颅磁共振扫描上，有11例可见疼痛一侧的桥脑旁有异常血管影。术中发现三叉神经出脑干处有血管压迫者19例(动脉血管压迫16例，静脉血管压迫3例)。19例中，术后早期疼痛完全缓解17例。结论：显微血管减压术是治疗原发性三叉神经痛的安全和有效的方法。     

Place de la chirurgie dans la névralgie du trijumeau

Trigeminal neuralgia is a potentially disturbing disease and may be resistant to classical medications such as anti-epileptic drugs. The first step is to check out the clear assessment of an essential trigeminal neuralgia so as to rule out specific etiologies of the trigeminal pain. There are mainly three kinds of surgical strategies: microsurgical neurovascular decompression, percutaneous gasserian lesioning and radiosurgery with Gamma knife. Microsurgical neurovascular decompression is an open surgery and the goal is to take away a vessel (mainly an artery) from the trigeminal nerve as it has been assumed that this conflit was the pathophysiological reason for the ??epileptic-like?? pain. This surgery has been around for at least 40 years. The results are very good, with 90% of the patients being satisfied and relieved from pain. Moreover, the results are long lasting with a 70% rate of satisfaction for the longest follow-up published. The morbidity is low even for elderly people in good health condition. There are several percutaneous techniques. The principle is doing a lesion on the retrogasserian part of the nerve, either by radiofrequency (thermic lesion), or by compression with a balloon (compressive lesion). The results are also good, with 90% of the patients being immediately relieved from pain, but there is a higher risk of recurrence and some potential morbidity (trigeminal numbness or trigeminal dysfunction mainly with radiofrequency lesion). The Gamma knife procedure is a radiosurgical procedure using cobalt radiation, in one shot, at a 80 Gy dosage, with a single 4 mm isocenter located at the entry zone. There is a delay in getting relief from pain. The results are good, with 80% of the patients being relieved. Somehow, there is a tendency of pain recurrence at mid-term follow-up and a 50% rate of patients being satisfied at a 5 year follow-up. The respective indications of each technique depend on the patient, the surgeon and their experience and the avaibility of the techniques. Altogether, it has been assumed that microvascular decompression is the first option for patients with neuralgia resistant to anti-convulsivant medications. Patient in poor medical conditions, or with MS lesion or refusing surgery, can be relieved by radiosurgery or percutaneous techniques.     

Treatment of recurrent trigeminal neuralgia due to Teflon granuloma

Recurrent trigeminal neuralgia after microvascular decompression (MVD) may be due to insufficient decompression, dislocation of the implant to pad the neurovascular contact, or the development of granuloma. Here, we report on our experience with Teflon granuloma including its treatment and histopathological examination. In a series of 200 patients with trigeminal neuralgia MVD was performed with Teflon felt according to Jannetta’s technique. In three patients with recurrent facial pain Teflon granuloma was found to be the cause for recurrence. In each instance, the granuloma was removed for histopathological examination. Mean age at the first procedure was 62.3 years and at the second procedure 66.3 years. Recurrence of pain occurred between 1 and 8.5 years after the first procedure. MRI scans demonstrated local gadolineum enhancement in the cerebellopontine angle, and CT scans showed local calcification. Intraoperatively dense fibrous tissue was found at the site of the Teflon granuloma. Histopathological examination revealed foreign body granuloma with multinuclear giant cells, collagen-rich hyalinized scar tissue, focal hemosiderin depositions, and microcalcifications. The Teflon granuloma was completely removed, and a new Teflon felt was used for re-decompression. Patients were free of pain after the second procedure at a mean of 40.3 months of follow-up. Teflon granuloma is a rare cause for recurrent facial pain after MVD. Small bleeding into the Teflon felt at surgery might trigger its development. A feasible treatment option is surgical re-exploration, nerve preserving removal of the granuloma, and repeat MVD.     

Diagnosis and differential diagnosis of trigeminal neuralgia.

Trigeminal neuralgia is a chronic facial pain classified as a neuropathic pain. There is widespread agreement regarding the International Association for the Study of Pain definition of classical idiopathic trigeminal neuralgia as "a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve." However, there are variations in presentation that are less easy to diagnose and an erroneous diagnosis of trigeminal neuralgia is occasionally made. In patients with tumors or multiple sclerosis, trigeminal neuralgia is termed secondary. Currently, clinical manifestations are the mainstay for diagnosis because there are no objective tests to validate the diagnosis. The sensitivity and specificity of these clinical manifestations is reviewed. Magnetic resonance imaging (MRI) and three-dimensional fast-in-flow with steady-state precession MRI are performed to determine the presence of tumors or plaques of multiple sclerosis and to assess possible compressions and deformations of the trigeminal nerve. Their specificity and sensitivity regarding compressions found at the time of surgery is reviewed. Other differential diagnoses for chronic unilateral orofacial pain are discussed.     

Studies on the operative outcomes and mechanisms of microvascular decompression in treating typical and atypical trigeminal neuralgia

OBJECTIVE: To evaluate the operative outcomes and mechanisms of microvascular decompression in treating typical and atypical trigeminal neuralgia. METHODS: A group of 45 patients with typical trigeminal neuralgia and 17 patients with atypical trigeminal neuralgia treated by micro-vascular decompression from 2000 to 2002 were reviewed, including their clinical presentations, operative findings, and outcomes. RESULTS: Of 45 patients with typical trigeminal neuralgia, the mean duration was 3.1 years, and the mean age of pain onset was 60.3 years. Single trigeminal division was involved in 20 patients (44.4%), and 2 or 3 divisions were involved in the other 25 patients (55.6%). During the operation, artery compression was found in 39 patients (86.7%), and the combined artery and venous compression was found in 6 patients (13.3%). Postoperatively, complete pain relief was achieved in 44 patients (97.8%), and significant pain relief was achieved in 1 patient (2.2%). As for 17 patients with atypical trigeminal neuralgia, the mean duration and the mean age of pain onset was 8.7 years and 55.5 years, respectively. Two or 3 trigeminal divisions were involved in all of these patients. During operation, artery compression occurred in 10 patients (58.8%), and the combined artery and venous compression was found in 7 patients (41.2%). Postoperatively, complete pain relief was achieved in 5 patients (29.4%), and partial pain relief was achieved in 10 patients (58.8%), and 2 patients showed no response to microvascular decompression. CONCLUSIONS: The operative outcome of microvascular decompression in patients with typical trigeminal neuralgia was better than that of patients with atypical trigeminal neuralgia, which perhaps related to short duration, late onset of pain, limited distribution, artery compression, and complete operative decompression.     

Funktionelle Störungen des kraniomandibulären Systems und der Halswirbelsäule als differentialdiagnostisches Problem der idiopathischen Trigeminusneuralgie

Introduction

Unfortunately, sharp, severe pain in the area of distribution of the fifth cranial nerve is frequently termed trigeminal neuralgia, and no differentiation is made between typical and atypical neuralgia and other types of facial pain disorders. This can lead to inadequate treatment.

Clinical material and methods

From 1987 to 1993, 577 patients were referred to our clinic with the diagnosis “idiopathic trigeminal neuralgia”. Re-examination of these patients was based on a comprehensive history, behavioural and psychosocial assessment, general inspection of the head and neck, evaluation of the craniomandibular system and cervical spine, neurovascular, neurosensory and motor evaluation of cranial nerves, intraoral evaluation, head and cervical spine scans (CT and/or MRI), diagnostic anaesthetic injections, laboratory tests and/or response to therapy.

Results

The follow-up examinations and treatment results allowed confirmation of the diagnosis in only 55% of all cases. There were 82 patients (14%) with craniomandibular disorders, 54 patients (9%) with cervical spine syndrome and 18 patients (3%) with cervical and/or dental causality in addition to the trigeminal neuralgia.

Conclusion

The process of differential diagnosis is critical in trigeminal neuralgia, because an incorrent or missed diagnosis is one of the most frequent causes of treatment failure. As idiopathic trigeminal neuralgia, craniomandibular disorders or the cervical spine syndrome can involve similar symptoms and response to the use of medication, close interdisciplinary cooperation in the process of diagnosis is recommended.     

继发性三叉神经痛诊疗策略

目的探讨继发性三叉神经痛的诊断及治疗策略。 方法回顾使分析北京大学人民医院神经外科2017年1月至2022年3月临床收治的继发性三叉神经痛患者，共34例，并参考相关文献。 结果34例继发性三叉神经痛病例均由占位性病变引起，所有患者均接受手术治疗，31例肿瘤完全切除，3例部分切除，其中10例术中发现血管压迫三叉神经，行三叉神经微血管减压术。术后33例患者的疼痛症状消失，1例患者明显减轻。 结论相应CPA区占位性病变是继发性三叉神经痛的首要病因，原发性因素可同时存在，头颅CT及MRI检查必不可少，手术是治疗继发性三叉神经痛的首选治疗手段。术中切除肿瘤后，应注意是否存在血管压迫神经情况，做到三叉神经充分减压。     

微血管减压术治疗三叉神经痛的疗效及其并发症的预防与处理

目的探讨微血管减压术治疗三叉神经痛的疗效及其并发症的预防与处理策略。方法采用微血管减压术治疗93例三叉神经痛患者,对其临床疗效及术后并发症等临床资料进行回顾性分析。结果 93例中89例术后疼痛症状消失,有效率为95.70%。术后并发症的发生情况：皮下积液4例,脑脊液漏1例,听力下降3例,耳鸣3例,面神经功能障碍4例,手术无效4例,死亡1例。结论微血管减压术治疗三叉神经痛是一种十分成熟的技术,规范手术的各种操作和积极应用监测技术能够尽量避免各种并发症的发生,显著提高手术的安全性。     

Hemibody pain relieved by microvascular decompression of the contralateral caudal medulla: Case report

Microvascular decompression (MVD) of cranial nerves has become an established treatment for trigeminal and (vago)glossopharyngeal neuralgia and for hemifacial spasm. The authors present the case of a 64-year-old man who had a 3.5-year history of severe, drug-resistant hemibody pain with sensory and autonomic disturbance. The ipsilateral trigeminal, cochlear, and glossopharyngeal function also was affected. The contralateral posterior inferior cerebellar artery was seen on magnetic resonance imaging to be indenting the caudal medulla anterolaterally, causing displacement. After MVD of the medulla, there was an immediate and complete resolution of the pain and almost complete resolution of the sensory and autonomic disturbances. The pain later recurred mildly and transiently. The residual symptoms had resolved by 2 years.     

The Effect of Traditional Herbal Medicines; Uyakujunkisan on Trigeminal Neuralgia in an Elderly Patient—A Case Report and Literature Review

? Abstract: This report describes the successful treatment of a 72‐year‐old female with refractory trigeminal neuralgia using a traditional herbal medicine, Uyakujunkisan (UJS). The case report is of a 65‐year‐old female who developed right‐sided trigeminal neuralgia that was partially responsive to carbamazepine (CZ). The pain gradually increased in intensity and at 72 years of age she presented for herbal medicine therapy. Cranial MRI demonstrated vascular compression of the right trigeminal nerve at the cerebellopontine angle by the anterior inferior cerebellar artery. Although microvascular decompression was considered, UJS was prescribed after informed consent. After 3 weeks of treatment with UJS, dramatic improvement of symptoms permitted a decrease in CZ dose. ?