Retrogasserian glycerol injection or percutaneous stimulation in the treatment of typical and atypical trigeminal pain

Of 164 patients with trigeminal neuralgia treated by percutaneous retrogasserian glycerol injections, we have studied the long-term outcome (one to four years) of 72 patients. 51 patients suffered from idiopathic trigeminal neuralgia, and of these 92% were freed from pain by the operation. 21 patients suffered from symptomatic trigeminal neuralgia due to multiple sclerosis or of traumatic or infectious origin. Of these, only 38% became free of pain. A further 8 patients with facial deafferentation pain who underwent treatment by retrogasserian neurostimulation with a permanently implanted electrode were included in this study. 4 of these patients were rendered free of pain by this procedure.     

三叉神经痛的伽玛刀与显微外科治疗

目的 探讨原发性三叉神经痛(ITN)和继发性三叉神经痛(STN)的治疗方法及效果.方法 2001年1月至2006年5月在我科接受治疗的145例三叉神经痛患者,其中ITN 98例,STN 47例.伽玛刀治疗81例,其中ITN 68例,STN 13例(继发于脑膜瘤1例,三叉神经瘤12例).开颅手术治疗64例,其中ITN 30例(行微血管减压11例,三叉神经感觉根切断19例);STN 34例(继发于胆脂瘤20例,三叉神经瘤14例).结果 ITN伽玛刀治疗的有效率为94.1%(64/68),完全无痛为52.9%(36/68);STN的有效率为46.2%(6/13),完全无痛为23.1%(3/13).肿瘤控制率为923%(12/13),ITN的微血管减压无痛率为100%(11/11),三叉神经感觉根切断无痛率为100%(19/19).STN肿瘤切除后无痛率为100%(34/34).开颅手术者并发颅内感染2例.5年随访,伽玛刀治疗的ITN的复发率为7.8%(5/64),STN的复发率为66.7%(4/6);微血管减压的复发率为9.1%(1/11),三叉神经感觉根切断的复发率为10.5%(2/19).结论 ITN的伽玛刀治疗有效率高,并发症少,安全性好;微血管减压和三叉神经感觉根切断的有效率更高,但并发症发生率较高.对于STN,我们建议行开颅手术切除肿瘤为首选方法.     

Sixteen-year experience in the treatment of trigeminal neuralgia by percutaneous retrogasserian thermorhizotomy

The authors present a series of 143 consecutive patients with trigeminal neuralgia who were treated with percutaneous retrogasserian thermorhizotomy between 1984 and 2000. Long time results (follow-up of 16 years) revealed full pain relief in 80% of patients, mainly in those with postoperative sensory deficit, 16% suffered pain recurrence and required additional treatment.     

半月节后根甘油阻滞术治疗三叉神经痛失败的原因分析

目的对半月节后根甘油阻滞术治疗三叉神经痛未达到疼痛完全缓解的原因进行分析.方法对1997年至2002年收治的516例三叉神经痛经半月节后根甘油阻滞术治疗的患者进行回顾性分析,其中140例第一次治疗后未能达到疼痛完全缓解.结果91例经再次半月节后根甘油阻滞术治疗后完全缓解,39例第三次阻滞后完全缓解,无效10例.失败的主要原因包括卵圆孔穿刺失误,迷走神经反应,无扳机点和普鲁卡因测试不能达到完全不痛.结论强调经皮穿刺卵圆孔的技术掌握和适应症的选择,治疗过程中应做到普鲁卡因测试后完全不痛,我们认为半月节后根甘油阻滞治疗三叉神经痛安全有效、微创,可作为三叉神经痛治疗的首选方法之一.     

治疗原发性三叉神经痛三种不同方法的临床疗效分析

目的比较治疗原发性三叉神经痛三种不同方法的临床疗效。方法自2000年5月至2004年6月收治的原发性三叉神经痛患者232例,其中80例行微血管减压术,77例行伽玛刀放射治疗,75例行三叉神经半月节后根甘油阻滞术。术后随访5年以上,对比分析治疗后的即刻缓解率、5年有效率及复发率。结果微血管减压组、伽玛刀治疗组和甘油阻滞组治疗后即刻缓解率分别为81.25%(65/80)、15.58%(12/77)和77.33%(58/75),甘油阻滞组与微血管减压组术后即刻缓解率均显著高于伽玛刀治疗组(P<0.05);5年有效率分别为91.25%(73/80)、63.64%(49/77)和16.00%(12/75),微血管减压组明显高于伽玛刀治疗组及甘油阻滞组(P<0.05),而伽马刀治疗组又高于甘油阻滞组(P<0.05);复发率分别为8.75%(7/80)、20.77%(16/77)和32.00%(24/75),甘油阻滞组复发率最高,其次为伽玛刀组,微血管减压组最低,三组之间差异显著(P<0.05)。结论微血管减压术是治疗原发性三叉神经痛的最佳方法;伽马刀和甘油阻滞术适合于老年患者或有手术禁忌症者,但采用伽玛刀治疗多数患者不能达到疼痛立即缓解,而甘油阻滞术早期效果好,但复发率高。     

伽玛刀治疗原发性三叉神经痛远期疗效分析(附33例报道)

目的分析伽玛刀放射外科治疗原发性三叉神经痛的远期疗效和并发症的发生情况。方法应用Leksell伽玛刀治疗了33例原发性三叉神经痛患者，进行长期的随访（全部都在5年以上，最长超过8年，平均75．7个月），详细记录其疼痛的缓解情况．以及发生的并发症、服用药物、复发等。结果首次治疗后有效率90．9％，5年以上的远期随访有效率78．8％；复发率13．3％，复发的患者再次行伽玛刀治疗仍能取得良好的效果；远期随访并发症发生率15．1％，但均较轻微并能被患者接受。结论伽玛刀治疗原发性三叉神经痛远期随访疗效肯定，并发症较轻且发生率低，可以作为多数患者的首选治疗方法。     

微血管减压术治疗典型及非典型三叉神经痛的疗效对比研究

目的探讨微血管减压术治疗典型及非典型三叉神经痛的不同疗效及其可能机制。方法寸比分析2003～2004年间经微血管减压术治疗的45例典型三又神经痛患者及17例非典型三叉神经痛患者的临床特征、术中所见年口手术疗效。结果45例典型三叉神经痛患者中，平均痛程3．1年，平均发病年龄60．3岁。其中20例（44．4％）患者中疼痛累及三又神经的单一分支，其余25例（55．6％）疼痛均累及2或3个分支。术中见39例（86．7％）为动脉压迫，6例（13．3％）为动脉和静脉混合压迫。术后疼痛完全缓解44例（97．8％），明显减轻1例（2．2）。而在17例非典型三叉神经痛患者中，平均病程8．7年，平均发病年龄55.5岁，疼痛均累及三叉神经的2或3个分支。术中见10例（58．8％）为动脉压迫，7例（41．2％）为动脉年口静脉混合压迫。术后疼痛完全缓解5倒（29.4％），明显减轻10例（58．8％），无效2例（11．8％）。结论微血管减压术治疗典型三叉神经痛的疗效明显优于非典型患者，这可能与典型三叉神经痛患者的病程较短、发病年龄较晚、疼痛多呈单支分布、且以动脉压迫为主以及术中能够实现充分减压有关。     

Trigeminal neuralgia and multiple sclerosis

In a series of patients with trigeminal neuralgia (TN) who were treated with radiofrequency electrocoagulation of the gasserian ganglion and retrogasserian rootlets, either alone or with glycerol, 16 patients with TN and multiple sclerosis (TNMS) are compared with 219 patients with TN without MS. Patients with TNMS were younger and more likely to have bilateral facial pain than those with TN alone. Probability of ipsilateral recurrence was calculated on the basis of Kaplan and Meier product-limit estimates and showed no significant differences in the two groups.     

微血管减压术治疗典型及非典型三叉神经痛的疗效比较

目的比较微血管减压术治疗典型及非典型三叉神经痛的疗效,探讨其机制.方法对比分析62例经微血管减压术治疗的三叉神经痛病人的临床特征、术中所见和手术疗效.其中45例为典型者,17例为不典型者.结果典型病人平均病程3.1年,平均年龄60.3岁;20例（44.4%）疼痛累及三叉神经的单一分支,25例为2～3支痛;术中见39例（86.7%）为动脉压迫,6例为动静脉混合压迫;术后44例（97.8%）疼痛缓解,1例无效.非典型病人平均病程8.7年,平均年龄55.5岁;均为多支疼痛病人;术中见10例（58.8%）为动脉压迫,7例为动静脉混合压迫;术后疼痛缓解5例（29.4%）,减轻10例（58.8%）,无效2例.结论微血管减压术治疗典型三叉神经痛的疗效明显优于非典型者,可能与其病程较短,发病年龄较晚,疼痛多呈单支分布,以动脉压迫为主,且术中能够实现充分减压有关.     

立体定向放射外科治疗原发性三叉神经痛:远期并发症和疗效分析

目的探讨立体定向伽玛刀放射外科治疗原发性三叉神经痛的远期并发症和疗效。方法对伽玛刀治疗的33例原发性三叉神经痛病人进行长期随访(5～8年,平均75.7个月),记录其并发症和疼痛缓解情况。结果并发症发生率15.1%;短期随访有效率90.9%,远期有效率75.7%。结论立体定向伽玛刀治疗原发性三叉神经痛远期疗效可靠,并发症较少而且较轻微,可以作为首选的治疗方式。     

原发性三叉神经痛的病因及显微血管减压治疗(附91例临床分析)

目的探讨原发性三叉神经痛病因及显微血管减压治疗的手术技巧。方法回顾性分析显微血管减压术治疗的91例原发性三叉神经痛病例资料。结果三叉神经入脑干区有血管压迫者89例。术后疼痛立即消失或显著减轻者78例,1周内明显减轻者11例。随访3~48个月(平均32个月),疼痛消失86例(94.5%),明显缓解、服得理多能够控制满意者5例,无复发病例。结论三叉神经入脑干区血管压迫是原发性三叉神经痛的常见病因。显微血管减压术是有效的治疗方法。准确判定责任血管并采取适当材料及方法使入脑干区减压是提高有效率,减少复发的主要措施。     

颅神经血管压迫综合征手术治疗的探讨

目的总结采用微血管减压术治疗原发性三叉神经痛、面肌痉挛和舌咽神经痛等颅神经血管压迫综合征的临床治疗经验。方法系统回顾2006年1月至2009年3月采用微血管减压术治疗颅神经血管压迫综合征患者256例,其中三叉神经痛134例,面肌痉挛117例,舌咽神经痛5例。结果三叉神经痛患者手术有效率为94.8%,面肌痉挛患者为96.6%,5例舌咽神经痛患者术后症状均消失。本组术后发生轻度不良反应者15例,占5.9%;发生较重并发症6例,占2.3%,没有死亡病例。术后有效的患者中,168例获得随访,平均随访36个月,复发12例,复发率为7.1%。结论微血管减压术是治疗颅神经血管压迫综合征的有效方法,良好的外科手术技能可有效地降低术后并发症的发生。     

颅神经血管压迫综合征微血管减压术治疗探讨

目的探讨用微血管减压术治疗三叉神经痛、面肌痉挛、舌咽神经痛等颅神经血管压迫综合征的临床经验。方法系统回顾1999年至2005年我们采用微血管减压术治疗神经血管压迫综合征病例420例，其中三叉神经痛282例，面肌痉挛120例．舌咽神经痛18例。结果总有效406例，有效率96．67％，本组无死亡病例。结论微血管减压术是治疗颅神经血管压迫综合征的有效方法。     

A randomized, controlled trial of high-dose dextromethorphan in facial neuralgias

BACKGROUND: NMDA glutamate receptor antagonists such as ketamine and dextromethorphan reduce pain in certain neuropathic pain conditions. However, there have been no controlled trials of NMDA antagonists in facial neuralgias. METHODS: A randomized, double-blind, crossover trial compared 6 weeks of oral dextromethorphan with active placebo (low-dose lorazepam) in 19 patients, stratified into three groups: 11 with facial pain and possible trigeminal neuropathy, five with anesthesia dolorosa, and three with idiopathic trigeminal neuralgia. Dosage was titrated in each patient to the highest level reached without disrupting normal activities. RESULTS: Patients completing the trial included 10 with possible trigeminal neuropathy, four with anesthesia dolorosa, and two with trigeminal neuralgia. In patients with possible trigeminal neuropathy and anesthesia dolorosa, dextromethorphan decreased pain by a mean of only 2 to 4%, and these estimates were not significant. Both patients with trigeminal neuralgia had more pain during dextromethorphan treatment than during placebo treatment. Of three patients who demonstrated an analgesic response to dextromethorphan during the main trial, only one repeatedly responded in four subsequent confirmatory drug-placebo crossovers. CONCLUSIONS: Dextromethorphan shows little or no analgesic efficacy in pain due to possible trigeminal neuropathy and anesthesia dolorosa. Additional trials are necessary to conclusively evaluate the efficacy of NMDA-receptor antagonists in trigeminal neuralgia.     

微血管减压术治疗三叉神经痛的疗效分析

目的介绍乙状窦后锁孔入路微血管减压术（MVD）治疗三叉神经痛（TN）的手术经验,探讨影响手术疗效的因素。方法回顾分析2697例TN患者的临床资料,重点介绍手术操作及注意事项。结果治愈2541例,显效76例,有效48例,无效31例,死亡1例。2190例接受3～240个月的随访,1965例治愈,91例显效,40例有效,30例无效,64例疼痛复发（其中37例行2次手术治愈）。结论异常血管压迫三叉神经入根区并合并局部蛛网膜增厚粘连是TN的主要病因。行MVD同时松解蛛网膜,做到彻底减压。依据病人的不同情况采取相应的减压措施是提高MVD治疗TN效果的重要手段。     

Preliminary results of 45 patients with trigeminal neuralgia treated with radiosurgery compared to hypofractionated stereotactic radiotherapy,using a dedicated linear accelerator

Radiosurgery (RS) and hypofractionated stereotactic radiotherapy (HSRT) were performed in 23 and 22 patients respectively for the treatment of trigeminal neuralgia. RS and HSRT were performed with a dedicated linear accelerator (LINAC): an invasive frame (for RS) or a relocatable stereotactic frame fitted with a thermoplastic mask and bite blocks (HSRT) were used for positioning patients. The RS treatment delivered 40 Gy in a single fraction, or for HSRT, the equivalent radiobiological fractionated dose – a total of 72 Gy in six fractions. The target (the retrogasserian cisternal portion of the trigeminal nerve) was identified by fusion of CT scans with 1-mm-thick T2-weighted MRI, and the radiant dose was delivered by a 10-mm-diameter cylindrical collimator. The results were evaluated using the Barrow Neurological Institute pain scale during follow-up (mean 3.9 years). The 95% isodose was applied to the entire target volume. After RS (23 patients), Class 1 results were observed in 10 patients; Class II in nine, Class IIIa in two, Class IIIb in one, and Class V results in one patient. Facial numbness occurred in two (8.7%) patients, and the trigeminal neuralgia recurred in two patients (8.7%). Following HSRT (22 patients), Class I results were achieved in eight patients, Class II in eight, Class IIIa in four, and Class IIIb in two patients; recurrence occurred in six (27.5%), and there were no complications. Thus, both RS and HSRT provided effective and safe therapy for the treatment of trigeminal neuralgia. Patients who underwent RS experienced better pain relief and a lower recurrence rate, whereas those who underwent HRST had no side effects, and in particular, no facial numbness.     

Idiopathic trigeminal sensory neuropathy in childhood

Harris first reported transient idiopathic trigeminal sensory neuropathy in 1935, although it later appeared that, in some of his patients, this condition evolved to typical chronic and painful trigeminal neuralgia. The patients who were later described by Hill and Hughes suffered a combined motor-sensory Vth cranial nerve dysfunction, and most cases reported by Spillane and Wells developed sustained permanent trigeminal neuropathy. The largest reported series of pure trigeminal sensory neuropathy includes 10 adults with varying degrees of sensory disturbance confined to all three nerve divisions. These patients experienced no facial pain or motor deficit, and 5 (50%) recovered completely within a few months. It is estimated that typical trigeminal neuralgia occurs in about 1 in 25,000 of the population and is uncommon prior to the third decade, with 1% of the cases occurring before the age of 20 years. To our knowledge, we present the first clinical report of idiopathic trigeminal sensory neuropathy occurring in childhood.     

Trigeminal evoked potentials and sensory deficits in atypical facial pain--a comparison with results in trigeminal neuralgia

Trigeminal evoked potentials (TEPs) and sensory deficits in eighty-three patients admitted for first surgical treatment of facial pain were retrospectively analysed. Thirty-seven patients suffered from trigeminal neuralgia (TN), 10 from symptomatic TN (sTN), and 36 from atypical facial pain (AFP). Eighteen percent of the TN patients reported sensory deficits on the pain side, but 35% had delayed ipsilateral N13 waves. Of the sTN patients, 60% had either sensory deficits or a pathological corneal reflex and 62.5% a pathological N13. Of the AFP patients, 61% complained of sensory deficits, but only 31% had a pathological N13. The percentage of pathological P19 waves was slightly lower (20%, 50%, and 11%, respectively), but showed a similar trend. Normal TEPs were found even in the presence of a sensory deficit (reported only in the AFP group). These findings may add weight to the hypothesis of underlying psychiatric disorders in AFP.     

Experimental trigeminal glycerol injection. Electrophysiologic and morphologic effects

The mechanism by which glycerol abolishes the pain of tic douloureux with minimal trigeminal deafferentation remains unknown. To study the action of glycerol, ten cats underwent unilateral retrogasserian injection of anhydrous glycerol. The contralateral (control) side was injected with saline. Glycerol injection increased the average latencies and reduced the average amplitudes of trigeminal brain-stem evoked potentials. Histopathologic examination disclosed focal demyelination, axonal swelling, endoneurial fibrosis, and neuronal loss. Evoked potentials were severely altered or abolished in cats with axonal damage in the maxillary portion of the postganglionic nerve. Glycerol injection into the trigeminal nerve damages axons and myelin sheaths. We believe that relief of tic douloureux after glycerol injection most likely results from further destruction of the abnormally myelinated fibers implicated in the etiology of trigeminal neuralgia.     

原发性三叉神经痛的伽玛刀双靶点治疗

目的 探索使用双靶点来改进伽玛刀治疗三叉神经痛的技术，提高有效率，减少复发率。方法 55例病人接受了伽玛刀双靶点治疗，9例失随访。87％的病人术前有手术史。一个靶点放在三叉神经根近桥脑处，另一个放在近半月神经节处，中心剂量84～90Gy，周边剂量42～45Gy，桥脑临界剂量20Gy。结果 随访4～72个月(平均30个月)。术后疼痛消失时间为2h～16个月(平均4个月)。按疼痛缓解评分，在随访时点，总有效率为95．7％，面部感觉异常等并发症的发生率为10．8％。经统计学分析，某些因素与疗效相关。结论 采用伽玛刀双靶点治疗三叉神经痛，因增加了辐射容量，比单靶点的成功率高、复发率低，并发症发生率与双靶点相近。特别值得一提的是，当病人术前有沿三叉神经注射史的，双靶点治疗比单靶点治疗的优越性更明显。