三叉神经痛的外科治疗：经皮治疗或微血管减压治疗结果分析

目的 比较当代治疗三叉神经痛3种外科方法的疗效。方法 采用相同原则，对483例原发性三叉神经痛患用3种不同外科方法治疗的临床效果进行分析。结果 采用微血管减压（MVD）治疗155例，出院时分析获疼痛完全缓解76．1％，部分缓解19．3％，无效4．5％，平均随访52．5个月，疼痛完全缓解58．5％，部分缓解27．3％，部分缓解27．3％，无效14．1％。采用射频热凝（TCG）治疗113例，出院时疼痛完全缓解61．9％，部分缓解25．6％，无效12．5％；平均随访45．4个月，疼痛完全缓解2．2％，部分缓解33．7％。采用经皮球压迫（PMC）治疗215例，出院时疼痛完全缓解67．4％，部分缓解21．4％，无效11．2％；平均随访38．3个月，疼痛完全缓解13．6％，部分缓解29．2％，无效57．1％。结论 MVD最有效，尽管PMC在治疗上也起很大作用，但应作为MVD的一种替换手段。     

伽玛刀治疗三叉神经痛疼痛缓解时间分析

目的分析和总结采用双靶点伽玛刀治疗三叉神经痛术后疼痛缓解时间规律,为伽玛刀的临床治疗提供参考。方法 2005年1月-2011年1月,共147例原发性三叉神经痛患者于四川大学华西医院接受Leksell C型伽玛刀治疗。使用4 mm准直器在三叉神经根制作2个等中心靶点,中心剂量80～90 Gy,控制脑桥照射剂量<20 Gy。术后定期对患者进行随访,对疼痛缓解时间进行统计分析。结果 130例患者获得随访,随访时间11～64个月,平均28.7个月。术后疼痛完全缓解95例(73.1%),部分缓解29例(22.3%),无效6例(4.6%)。疼痛缓解时间4 h～12个月,平均3.6周,其中疼痛完全缓解患者的疼痛缓解时间明显短于部分缓解患者(P<0.05)。53例(40.8%)患者于术后出现术侧轻度面部麻木。结论患者术后疼痛缓解时间可能是预测伽玛刀治疗效果的重要因素,但疼痛缓解时间个体差异大,应进行长期随访观察。     

原发性三叉神经痛伽玛刀放射外科治疗的有效性评估

目的:评价伽玛刀放射外科治疗原发性三叉神经痛的安全性、有效性和心理状态。方法:2004年8月~2010年9月,98例经药物和其他方法治疗无效的原发性三叉神经痛患者接受伽玛刀放射外科治疗。放射剂量中位值是80 Gy(75~85 Gy)。采用患者自我报告疼痛的控制、生活满意度指数A(1ife satisfaction index A,LSI-A)的变化进行疗效评估。结果:治疗后89例(90.8%)患者获得随访,平均随访期35个月(13~60个月)。本组病例中治愈51例(57.3%);显效19例(21.3%);有效11例(12.4%);无效8例(9%),总有效率为91%;伽玛刀治疗后LSI-A总分平均值(36.25±3.87)高于治疗前(25.67±3.5);其中67例以往未接受过手术治疗患者中62例获得随访,58例有效,总有效率为93.5%。11例患者感觉患侧面部麻胀感,1例(二次治疗者)张口轻度受限。结论:伽玛刀放射外科治疗三叉神经痛显著缓解疼痛,提高生存质量。     

伽玛刀单靶点治疗原发性顽固性三叉神经痛:73例随访观察

目的:评价伽玛刀单一靶点治疗顽固性三叉神经痛的疗效、安全性,以期为改善三叉神经痛患者的身心健康及生活质量提供干预方向。方法:回顾性分析1995-07/2003-06本院接受伽玛刀治疗的三叉神经痛患者73例,其中男31例,女42例,年龄35～79岁,平均61岁。病程1.5～29年,平均4.5年。所有的病例均设置单一靶点治疗,靶点部位选择在三叉神经入桥脑处,中心剂量70～90Gy,准直器为4mm。结果:伽玛刀治疗后全部患者在24h出院,出院后随访时间6～68个月不等,平均随访时间36.7个月。术后18例显效(24.7%),46例有效(63%),9例无效(12.3%)。症状缓解时间为2周～6个月,平均为3.5个月。治疗后症状复发6例,给予二次治疗,3例症状缓解,3例症状无变化。治疗后出现头痛呕吐反应3例,全部于1周后消失;面部麻木7例,无咀嚼肌运动障碍及角膜发干或溃疡发生。结论:伽吗刀治疗三叉神经痛安全、有效,能显著的缓解患者的疼痛,提高其生活质量。     

椎间盘内电热疗法治疗慢性腰椎间盘性疼痛

研究椎间盘内电热疗法对慢性持续性腰椎间盘疼痛患者的疗效。选择环破裂和 /或椎间盘突出 <5mm且对非手术治疗无效的慢性持续性腰椎间盘疼痛患者 33例 ,采用椎间盘内电热疗法 ,于治疗前后对患者背部和下肢的疼痛采用目测类比评分 (VAS)和Roland Morris功能障碍调查表 (RMDQ)进行评定。患者平均年龄 4 0岁、平均病程为 4 6个月 ,在平均 15个月的随访中 ,疼痛的缓解和躯体功能的改善体现在VAS平均改善 3.9分(P <0 .0 1) ,下肢VAS改善 3.7分 (P <0 .0 1) ,RMDQ平均改善 7.3分 (P <0 .0 1) ,75 .5 %患者对此疗法效果满意。2 4 %患者的疼痛完全缓解 ,4 6 %部分缓解。椎间盘内电热疗法对非手术治疗无效的慢性持续性腰椎间盘疼痛患者是一种安全、有效、微创的治疗手段     

微血管减压术治疗三叉神经痛9例围术期护理

目的:探讨微血管减压术(MVD)治疗三叉神经痛患者的围术期护理方法。方法:回顾9例三叉神经痛患者术前、术后的护理资料,进行总结分析。结果:本组6例痊愈,3例明显减轻(其中2例出现手术并发症,经治疗和护理基本缓解,1例有间歇性可忍痛)。出院后随访2~6个月无复发。结论:对MVD治疗三叉神经痛患者给予针对性围术期护理,可提高治愈率,减少并发症发生,提高患者的生活质量。     

联合化疗治疗成人慢性难治性特发性血小板减少性紫癜

目的评价小剂量联合化疗对难治性特发性血小板减少性紫癜(TIP)的疗效及安全性。方法回顾性分析应用小剂量联合化疗31例成人难治性TIP患者的临床资料,并进行长期随访。结果31例患者中13例(41.9%)完全缓解(血小板≥100×109/L);9例(29.0%)部分缓解(血小板>50×109/L);9例(29.0%)未缓解(血小板<50×109/L)。联合化疗有效率为71.0%。3例失访;在28例获得随访患者中12例(42.9%)完全缓解,7例(25.0%)部分缓解,9例(32.1%)未缓解,联合化疗有效率为67.9%。28例中有10例完全缓解和3例部分缓解的患者在未接受其他治疗的情况下到随访结束时仍持续缓解,其中4例持续缓解超过60个月,5例超过36个月,1例超过12个月,3例少于12个月(分别为3月、6月和9月)。在随访患者中,有4例在化疗数月后因持续的血小板减少而导致中枢和/或胃肠道出血而死亡。结论对于糖皮质激素和脾切除治疗无效的某些难治性TIP患者,小剂量联合化疗可能不失为一种有效的治疗方法。     

经皮半月节后根甘油阻滞治疗三叉神经痛3370例临床研究

目的:分析半月节后根甘油阻滞术(PRGR)治疗三叉神经痛的长期随访结果,评价疗效、复发率及主要并发症面部感觉障碍的恢复预后.方法:1983-2003年完成的PRGR手术3370例,随访3-23年,平均13.1年.结果:短期疼痛完全缓解率99.79%,随访2750例,死于其他疾病112例,失访508例,总复发率35%,1年内复发率0.3%,1～5年21%,5～10年7%,10～15年4%,15～23年3%.并发症主要为面部感觉迟钝,触觉重于痛觉,痛觉先于触觉恢复,除34例(1%)遗留永久性轻度感觉迟钝外,面部感觉半年内恢复.其他并发症包括失明1例,角膜炎6例,因角膜溃疡致失明1例,动脉性出血5例,咀嚼肌无力2例,继发于感染的面部畸形1例,无痛性感觉缺失和死亡病例.结论:半月节后根甘油阻滞治疗三叉神经痛是一种微创的外科治疗手段,操作简单,疼痛缓解快,主要并发症绝大多数呈损害可逆性,复发时限不一,可作为首次外科治疗推荐给药物治疗无效患者.     

螺旋CT引导下经皮穿刺卵圆孔行阿霉素联合无水酒精阻滞治疗三叉神经痛

[目的]探讨螺旋CT引导下经皮穿刺卵圆孔注射阿霉素联合无水酒精毁损疗法治疗三叉神经痛的技术及临床应用价值.[方法]本院收治的45例三叉神经痛患者采用螺旋CT引导经皮穿刺卵圆孔,缓慢注射无水酒精和阿霉素0.2~0.5 mL.采用视觉模拟疼痛评分 （VAS）测定疼痛强度.[结果]45例治疗后,即刻疼痛完全缓解者8例（17.8%）;一周后疼痛完全缓解39例（86.8%）,明显缓解5例.经治疗后6个月、12个月随访观察,有效率分别为 97.8%,97.8%.并发症少而轻微.[结论]螺旋CT引导下经皮穿刺卵圆孔注射阿霉素联合无水酒精毁损疗法对三叉神经痛具有定位准确,无痛苦,操作简单、安全,并发症少的优点,具有临床推广应用价值.     

腹腔镜骶前神经切除在子宫内膜异位症疼痛治疗中的应用

目的 探讨腹腔镜骶前神经切除术(LPSN)治疗子宫内膜异住症(内异症)疼痛的安全性及效果.方法 2004年5月～2005年4月对26例子宫内膜异位症重度痛经患者行LPSN,采用视觉模拟评分法(VAS)进行疼痛疗效评价.结果 26例LPSN平均手术时间为(38.15±5.89)min,术中出血(39.23±21.39)mL,术中无1例发生并发症.平均住院时间(5.23±1.24)d.每例患者均随访24个月.术后无严重并发症出现.术后随访1、6和12个月疼痛缓解率均为92.30%(24/26),其中完全缓解率为80.77%(21/26);随访24个月时疼痛缓解率为76.92%(20/26),其中完全缓解率为57.69%(15/26).结论 本研究范围内发现采取LPSN是安全的,能有效治疗内异症重度疼痛.     

Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression. (Heidelberg College of Medicine, Heidelberg, Germany) Neurosurgery. 2001;48:1261–1267.

The purpose of this study was to evaluate the long‐term outcome of patients after either percutaneous trigeminal rhizotomy or microvascular decompression (MVD) for idiopathic trigeminal neuralgia at a single institution. Overall, the results of the study showed that there was a 50% risk of recurrence of pain 2 years after percutaneous radiofrequency rhizotomy. Conversely, 64% of the patients who underwent MVD remained completely pain free 20 years postoperatively. Patients without sensory impairment after MVD were pain free significantly longer than patients who experienced postoperatively hypesthesia or partial rhizotomy. Conclude that because it is curative and nondestructive, MVD is considered the treatment of choice for trigeminal neuralgia in otherwise healthy people. In this study, it was proved to be a more effective and long‐lasting procedure for patients with typical trigeminal neuralgia than radiofrequency rhizotomy. Patients without postoperative sensory deficit remained pain free significantly longer, which is a strong argument against the “trauma” hypothesis of this procedure. Comment by Ron Pawl, M.D. This paper is noteworthy in that comparing the follow‐up on 225 of 378 patients who underwent microvascular decompression (MVD) with 206 of 316 who underwent radiofrequency thermocoagulation (RFT), the RFT group stood a 50% risk of recurrent pain by 2 years after the procedure, whereas 64% of those undergoing MVD were pain‐free after 20 years. Furthermore, after MVD, those patients with no postoperative sensory deficit, measured with von Frey hairs, remained pain‐free longer than those with a sensory deficit. This latter finding flies in the face of the concept that to be effective, surgery for trigeminal neuralgia must damage the nerve. The whole concept of RF lesioning of the nerve is to damage it enough to deaden the trigger zone of the affected nerve branch. However, in this study it is noted that postoperative hypesthesia was only temporary after RF lesioning, which might well explain the high rate of pain recurrence in this series. Although the long‐term pain relief in the MVD group is excellent, it must be weighed against the complications. In the MVD group, there were 3 mortalities, diminished hearing in 5%, loss of hearing in 2.6%, facial paralysis in 4 patients, and tinnitus in 4 patients, none of which occurred in the RF group.     

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     

Defining the role for gabapentin in the treatment of trigeminal neuralgia: a retrospective study.

The preferred treatment for trigeminal neuralgia consists of antiepileptic drugs. Among them, gabapentin has shown promise in relieving some forms of neuropathic pain. This retrospective review examined 194 consecutive cases of trigeminal neuralgia, many of whom had paroxysmal facial pain resistant to previous surgical interventions or treatment with multiple medications. Of the 92 who had received a trial of gabapentin, 43 reported reduction in facial pain. This benefit was complete in 16, nearly complete in 9, moderate in 12, and partial in 6. Onset of pain relief occurred generally within 1 to 3 weeks, depending on the rate and end point of dose titration. The effective range of stable daily dosing varied from 100 to 2400 mg divided 3 times a day, with a mean of 930 mg. Pain relief was sustained in two thirds during a mean follow-up time of 8 months. The fact that gabapentin was well-tolerated and without serious side effects is an important advantage when prescribing for elderly patients. The present study suggests that gabapentin can be effective as first or second line treatment of trigeminal neuralgia, even in cases resistant to traditional treatment modalities.     

Stereotactic radiosurgery for the treatment of trigeminal neuralgia.

Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with medically refractory trigeminal neuralgia (TN). The authors began use of this technique at our center in 1992 and have evaluated outcomes serially. Independently acquired data from 220 patients with idiopathic TN that had Gamma Knife radiosurgery was reviewed. The median radiosurgery dose was 80 Gy with a range of 60 to 90 Gy. Most patients had features of typical TN, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had prior surgery. Patients were followed to a maximum of 6.5 years (median, 2 years). Complete or partial pain relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9 % of patients at 6 months, 70.3% at 1 year, and 75.4% patients at 33 months. Patients with an atypical pain component had a lower rate of achieving pain relief ( p = 0.025). Due to recurrences, 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance or prior surgery correlated with an increased proportion of patients in complete or partial pain relief over time. Ten percent of patients developed new or increased subjective facial paresthesia or facial numbness. Radiosurgery for idiopathic TN was safe and effective, and provided benefit to a patient population with a high frequency of prior surgical intervention. It is an important addition to the surgical armamentarium for TN.     

微血管减压术治疗三叉神经痛疗效观察

目的：探讨微血管减压术治疗三叉神经痛的适应症，手术方法，疗效，方法：枕下入路手术治疗三叉神经痛92例，其中77例发现有血管压迫，行微血管减压术，结果：77例中，68例术后疼痛立即消失，3例疼痛减轻，6例无效，40例随访68个月－5a，疼痛复发7例。结论：三叉神经微血管减压术有较肯定疗效，可保留三叉神经功能，但需开颅，有一定风险，有一定的复发率。     

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.     

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.     

Percutaneous controlled thermocoagulation in the treatment of trigeminal neuralgia

This study reviews the results and complications of 162 percutaneous thermocoagulations of the gasserian ganglion in 124 patients with typical idiopathic trigeminal neuralgia. The mean duration of follow-up observation was 3.7 years (range, 1-6 years). One hundred eighteen of 124 patients continued to show complete pain relief 1 month after the operation, and at the end of follow-up observation, 83 of 124 patients (67%) continued to enjoy complete pain relief (recurrence rate, 28.2%). Anesthesia dolorosa occurred in 3% of cases, dysesthesia in 3%, and paresthesia in 17%; neuroparalytic keratitis with permanent reduction of visual acuity was observed in 2% of cases, permanent diplopia in 1%, permanent hearing deficit in 3%, and permanent impairment of mastication in 3%. We compare thermocoagulation with other surgical procedures (microvascular decompression, glycerol injection, and percutaneous decompression) used in the treatment of trigeminal neuralgia.     

Surgical treatment of chronic cluster headache

Chronic cluster headache, also known as chronic migrainous neuralgia, is frequently unresponsive to medical management. Although neuronal factors may be involved in the pathogenesis of this form of recurrent hemicranial pain, vasodilatation within the distribution of the trigeminal nerve is believed to be important. Attempts to provide relief by surgical means have primarily involved interruption of the vasodilator pathways of the greater superficial petrosal nerve and the sphenopalatine ganglion. A more direct approach of interrupting the pain pathways of the trigeminal nerve has been attempted sporadically for more than 50 years. Recent interest in the role of substance P in the production of pain in cluster headache suggests that trigeminal ablative procedures might have a dual role in the relief of medically intractable cases. Among 26 patients who underwent posterior fossa trigeminal sensory rhizotomy or percutaneous radio-frequency trigeminal gangliorhizolysis at our institution, relief of pain was excellent in 14 (54%), fair to good in 4 (15%), and poor in 8 (31%).