CT引导下经皮穿刺三叉神经半月节毁损治疗重度三叉神经痛

目的：探讨在CT的定位引导下经皮穿刺三叉神经半月节，用药物毁损性阻滞治疗三叉神经痛的效果。方法：纳入首都医科大学宣武医院疼痛诊疗中心1994-03／2001—12采用CT引导下经皮穿刺三叉神经半月节毁损治疗的76例三叉神经痛患者。治疗前CT冠状及轴位扫描卵圆孔，除外继发性三叉神经痛。在穿刺卵圆孔过程中CT引导穿刺的方向并确认针尖的位置，经造影确保穿刺针准确位于神经节内，然后向三叉神经半月节注射神经阻滞破坏药阿霉素。在治疗后当日、治疗后第7天、第6个月和第12个月记录目测类比疼痛评分，生活质量评分和并发症。①目测类比疼痛评分：0分为无痛，10分为剧痛，1～3分为轻度疼痛，4-6分为中度疼痛，7～10分为重度疼痛。②疼痛缓解度：采用0-4数字疼痛缓解分级标准，0度：未缓解（疼痛未减轻）；1度：轻度缓解（疼痛减轻约1／4）；2度：中度缓解（疼痛减轻约1／2）：3度：明显缓解（疼痛减轻约3／4以上）；4度：完全缓解（疼痛消失）。③生活质量评分：就疼痛对食欲、睡眠、日常生活、精神状态、情绪、与人交往、生活兴趣等的干扰进行自我评价，以0～10分表示，0分为无干扰，10分为最严重干扰。结果：按实际处理分析，76例CT引导下经皮穿刺卵圆孔毁损疗法治疗三叉神经痛，除1例解剖变异未穿刺成功，其余病例均顺利完成穿刺和治疗。①治疗前后目测类比疼痛评分：治疗后低于治疗前[治疗前（8．7&;#177;2．7）分，治疗后第7天（1．6&;#177;2．1）分，治疗后6个月（2．1&;#177;0．9）分，治疗后12个月（2．3&;#177;0．7）分，P〈0．01]。②治疗后疼痛缓解情况：治疗后1周内疼痛完全缓解61例，不同程度减轻11例，无变化4例，其中2例改为神经外科手术治疗。治疗后12个月，完全缓解58例，11例未缓解。③治疗后生活质量评分：食欲、睡眠、日常生活、与人交往、生活兴趣治疗后第7天、6个月、12个月均低于治疗前[治疗前：（5．7&;#177;2．8），（4．0&;#177;2．0），（6．1&;#177;2．4），（6．1&;#177;2．4），（6．9&;#177;2．3）分；治疗后第7天：（2．5&;#177;1．5），（2．8&;#177;1．2），（3．5&;#177;2．3），（2．6&;#177;1．6），（4．8&;#177;2．3）分；治疗后6个月：（2．9&;#177;1．3），（2．0&;#177;0．7），（2．5&;#177;1．2），（3．1&;#177;1．5），（2.4&;#177;1．1）分；治疗后12个月：（2．2&;#177;1．1），（1．8&;#177;1．1），（2．3&;#177;1．6），（2．1&;#177;0．9），（1．8&;#177;1．0）分，P〈0．05或0．01]。结论：CT引导下经皮半月神经节毁损术对三叉神经痛效果明显。在CT引导下穿刺半月神经节，可使定位更准确，获得更好疗效。由于在局麻下操作，患者痛苦小，也可避免严重的并发症。     

CT引导下经皮穿刺三叉神经半月节毁损治疗重度三叉神经痛

目的:探讨在CT的定位引导下经皮穿刺三叉神经半月节,用药物毁损性阻滞治疗三叉神经痛的效果。方法:纳入首都医科大学宣武医院疼痛诊疗中心1994-03/2001-12采用CT引导下经皮穿刺三叉神经半月节毁损治疗的76例三叉神经痛患者。治疗前CT冠状及轴位扫描卵圆孔,除外继发性三叉神经痛。在穿刺卵圆孔过程中CT引导穿刺的方向并确认针尖的位置,经造影确保穿刺针准确位于神经节内,然后向三叉神经半月节注射神经阻滞破坏药阿霉素。在治疗后当日、治疗后第7天、第6个月和第12个月记录目测类比疼痛评分,生活质量评分和并发症。①目测类比疼痛评分:0分为无痛,10分为剧痛,1～3分为轻度疼痛,4～6分为中度疼痛,7～10分为重度疼痛。②疼痛缓解度:采用0～4数字疼痛缓解分级标准,0度:未缓解(疼痛未减轻);1度:轻度缓解(疼痛减轻约1/4);2度:中度缓解(疼痛减轻约1/2);3度:明显缓解(疼痛减轻约3/4以上);4度:完全缓解(疼痛消失)。③生活质量评分:就疼痛对食欲、睡眠、日常生活、精神状态、情绪、与人交往、生活兴趣等的干扰进行自我评价,以0～10分表示,0分为无干扰,10分为最严重干扰。结果:按实际处理分析,76例CT引导下经皮穿刺卵圆孔毁损疗法治疗三叉神经痛,除1例解剖变异未穿刺成功,其余病例均顺利完成穿刺和治疗。①治疗前后目测类比疼痛评分:治疗后低于治疗前[治疗前(8.7±2.7)分,治疗后第7天(1.6±2.1)分,治疗后6个月(2.1±0.9)分,治疗后12个月(2.3±0.7)分,P<0.01]。②治疗后疼痛缓解情况:治疗后1周内疼痛完全缓解61例,不同程度减轻11例,无变化4例,其中2例改为神经外科手术治疗。治疗后12个月,完全缓解58例,11例未缓解。③治疗后生活质量评分:食欲、睡眠、日常生活、与人交往、生活兴趣治疗后第7天、6个月、12个月均低于治疗前[治疗前:(5.7±2.8),(4.0±2.0),(6.1±2.4),(6.1±2.4),(6.9±2.3)分;治疗后第7天:(2.5±1.5),(2.8±1.2),(3.5±2.3),(2.6±1.6),(4.8±2.3)分;治疗后6个月:(2.9±1.3),(2.0±0.7),(2.5±1.2),(3.1±1.5),(2.4±1.1)分;治疗后12个月:(2.2±1.1),(1.8±1.1),(2.3±1.6),(2.1±0.9),(1.8±1.0)分,P<0.05或0.01]。结论:CT引导下经皮半月神经节毁损术对三叉神经痛效果明显。在CT引导下穿刺半月神经节,可使定位更准确,获得更好疗效。由于在局麻下操作,患者痛苦小,也可避免严重的并发症。     

半月神经节联合射频治疗三叉神经痛的临床研究

目的:观察CT引导下半月神经节脉冲射频联合连续射频治疗三叉神经痛的临床效果。方法:90例原发性三叉神经痛患者随机分为对照组(CRF组,单纯采用75℃连续射频进行治疗,N=45)和联合射频组(采用42℃脉冲射频和75℃连续射频进行治疗,CRF+PRF组,N=45),比较治疗前、治疗后1d、3d、7d、3个月、6个月、1年、2年的视觉模拟评分(VAS)、疼痛缓解率,以及治疗前、治疗后3个月、6个月、1年、2年的生存质量评分(QOL)、麻木评分和并发症发生率。结果:治疗后两组患者的VAS评分均较治疗前明显降低(P<0.05),随访2年两种方法治疗的有效率均达100%(P>0.05);治疗后7d联合射频组的VAS显著低于CRF组(P<0.05),但治疗后2年联合射频组的VAS评分较对照组明显增高(P<0.05);治疗后2年联合射频组的麻木发生率和麻木评分均较对照组明显降低(P<0.05)。结论:半月神经节脉冲射频联合连续射频可有效缓解三叉神经痛,尽管短期疗效超过了连续射频,但长期疗效低于连续射频,并发症的发生率明显低于连续射频。     

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.     

Choice of open or percutaneous procedures in the surgical treatment of trigeminal neuralgia

The aim of this study was to define criteria for the selection of patients for percutaneous or open operations for the cure of drug-resistant trigeminal neuralgia (TN). Trigeminal percutaneous radiofrequency thermorhizotomy (TPRT) has an established place because of its safety in elderly patients, while microvascular decompression (MVD) has appeal in younger patients beause of its non-destructive nature and because it attacks what is believed to be the primary etiology of tic douloureux. Nevertheless, MVD is a successful operation only when true neurovascular conflict (NVC) is ascertained, rather than a simple arterial loop and neurovascular contract. Probably, many immediate failures and early relapses are the consequence of the inadequate patient selection for MVD on the presumption that this operation is in any case the ideal cure. The inadequate selection can be explained by the difficult preoperative diagnosis of NVC in the past. Indeed, angiography and computed tomography showed the neurovascular contact but not the size of compression. Fortunately, today magnetic resonance imaging is a reliable instrument to ascertain NVC. So, the diatribe between the supporters of percutaneous techniques and MVD can be concluded with the following: (1) percutaenous techniques are indicated for patients without demonstrated NVC (including patients with TN in multiple sclerosis) and in those with NVC if MVD is contraindicated by ill-health or refused by the informed patient; and (2) MVD is incated for patients with ascertained NVC who are in good health and who, informed of the surgical risk, favor this operation desiring no sensory deficit. Received: 23 June 2001 / Accepted in revised form: 24 August 2001     

Diagnosis and treatment of trigeminal neuralgia

Trigeminal neuralgia is a disease affecting older individuals. The clinical hallmark of trigeminal neuralgia is a sudden, excruciating paroxysm of pain in the area of the trigeminal nerve. Drug therapy is considered the first line of treatment for trigeminal neuralgia. Anticonvulsant carbamazepine has been used. If relevant pharmacotherapy has been tried without any effect, other procedures are selected. These procedures are microvascular decompression(a radical technique), glycerol trigeminal rhizotomy, percutaneous trigeminal nerve decompression and nerve block. Nerve block with neurolytic solutions and radiofrequency thermocoagulation is a simple, less invasive therapy. In order to avoid hypesthesia and dysesthesia, nerve block using a high concentration of local anesthetics is recommended. In recent years, stereotactic radiosurgery for trigeminal neuralgia has emerged as a new therapeutic modality.     

Surgical treatment of trigeminal neuralgia

Trigeminal neuralgia nearly always can be relieved initially with drug therapy. Long-term relief, however, is achieved in only 25 percent of patients. When medical therapy fails, surgery may be necessary. Percutaneous rhizotomy is an effective technique for pain relief, with few medical contraindications. Posterior fossa exploration and neurovascular decompression or sensory root sectioning is reserved for those patients who do not improve after rhizotomy and for selected younger patients.     

Surgical treatment of trigeminal neuralgia

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TRIGEMINAL NEURALGIA, which is unilateral electric shock or knifelike pain occurring in one or more branches of the trigeminal nerve, is evoked by stimulation of the face, lips, or gums caused by activities such as shaving, brushing the teeth, or moving trigger zones.

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IT GENERALLY IS ACCEPTED that classic trigeminal neuralgia is a consequence of vascular compression and demyelination of the trigeminal nerve. Although medical therapy is available, it gradually becomes less effective because of the progressive nature of trigeminal neuralgia.

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MICROVASCULAR DECOMPRESSION of the trigeminal nerve to treat trigeminal neuralgia is discussed in this article. Perioperative care, expected course of recovery, and potential complications are described. AORN J 78 (November 2003) 744-758.

     

Percutaneous procedures for trigeminal neuralgia: microcompression versus radiofrequency thermocoagulation. Personal experience

This paper reports the results achieved in the treatment of trigeminal neuralgia using two different percutaneous procedures: radiofrequency (RF) thermocoagulation (33 patients) and the new percutaneous microcompression (PMC; 74 patients) of the trigeminal ganglion. Acute pain relief was accomplished in 93.2% of the patients treated with PMC and in 81.8% of those treated with the RF method. Two years after the operation, neuralgia had recurred in 56% of the PMC patients and in 42.4% of the RF patients. The average recurrence time was 6.5 months after PMC and 18.5 months after RF. Side effects were essentially of 2 kinds: marked dysaesthesia that occurred after RF lesion in 24.2% and after PMC in 6.7% of the patients, and weakness of the masticatory muscles that was fairly common after PMC, although clinically relevant in only 1 case. The procedure has the benefit of simplicity and fewer side effects. The results obtained by using different compression times in different patients indicates that the most suitable compression time is between 4 and 6 min. When pain recurred the procedure was repeated unless the pain was in the third division, in which case an RF lesion was made. If the pain recurred a second time, RF lesions were made if the pain was in the second or third division.     

原发性三叉神经痛的外科治疗

目的:明确三叉神经的解剖与外科治疗的相关关系,从而有效地干预三叉神经痛。资料来源:应用计算机检索Medline,Embase1977/2004期间与三叉神经痛相关的文献,检索词为“Trigeminalneuralgia”。同时检索CHKD期刊全文库1994/2004期间相关文章,检索词为“三叉神经痛”。限定文章语言种类为英文及中文。资料选择:对资料进行初审,选取涉及三叉神经解剖及外科治疗相关的文章,共收集到有关三叉神经痛治疗的文章1327篇,对外科治疗三叉神经痛相关文献查找全文,然后筛除明显不随机临床试验,重点引用文献20篇。资料提炼:对于检索到的关于三叉神经痛外科治疗的研究文章中相关信息进行归类分析。常用的治疗方法有:三叉神经根微血管减压术、经皮三叉神经半月节穿刺术(射频温控热凝术、注射甘油或无水乙醇)及立体定向放射治疗(γ刀或X刀)。资料综合:三叉神经痛治疗的理论与技术的发展速度很快,近年有了很多新的研究与进展,外科治疗包括手术、徒手穿刺及γ刀等的治疗。这都为三叉神经痛的治疗提供了很好的治疗思路,为总结出有效、安全、复发率低的治疗方法提供数据。结论:对于三叉神经痛的治疗,其镇痛率高、复发率低、并发症少是目前治疗的目标,各种外科治疗手段各有优缺点。按实际情况选用不同的治疗方法,可以使患者得到     

Pharmacotherapy of trigeminal neuralgia.

The efficacy of the anticonvulsant drug carbamazepine in the management of trigeminal neuralgia is evidenced in several controlled trials, and the numbers needed to treat to obtain one patient with at least 50% pain relief (NNT) is 1.7. Single small trials have shown that baclofen alone provides pain relief (NNT = 1.4) and that lamotrigine has an additional effect in patients with insufficient relief using carbamazepine or phenytoin (NNT = 2.1). Uncontrolled observations and clinical practice indicate that phenytoin, clonazepam, sodium valproate, gabapentin, and lidocaine will also relieve trigeminal neuralgia. In case of lacking effect of a single drug, combination of two or more drugs may be used, but with the exception of the lamotrigine-carbamazepine combination, this is not evidence-based medicine. Acute exacerbation has successfully been treated with intravenous loading with phenytoin or lidocaine, but again these procedures have not been tested in controlled trials. In conclusion, carbamazepine is the mainstay of pharmacotherapy of trigeminal neuralgia, and secondary drug choices are baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin, and sodium valproate. Controlled trials testing the effect of some of these drugs, new drugs, and drug combinations are needed.     

DZY-C型三叉神经立体定向仪治疗三叉神经痛的特点

背景经皮三叉神经半月穿刺损毁术是治疗原发性三叉神经痛的方法之一.因其穿刺技术操作上的难度,可导致误伤及一些严重的并发症.DZY-C型三叉神经立体定向仪治疗原发性三叉神经痛具有穿刺准确度高、并发症低等特点,可减少误伤周围血管、神经的机会.目的评价应用DZY-C型三叉神经立体定向仪治疗三叉神经痛的疗效.设计以患者为研究对象,前后对照研究.单位一所市级中医院的脑外科和一所市级医院.对象2001/2003佛山市中医院门诊或住院部就诊的原发性三叉神经痛患者90例,男39例,女51例;年龄21～90岁.干预所有患者按要求在DZY-C型三叉神经立体定向仪的引导下,经皮穿刺三叉神经半月节,注射甘油.疗效根据视觉模拟评分法(visual ana1ogue scale,VAS)在患者治疗前及治疗后30 min对疼痛程度进行评估.主要观察指标疗效评定结果.结果应用DZY-C型三叉神经立体定向仪,对90例原发性三叉神经痛患者进行三叉神经半月节穿刺,均一次穿刺成功,注射甘油后,原三叉神经疼痛消除90例,优良率达100%.结论DZY-C型三叉神经立体定向仪的结构设计合理,手术操作简易,调节灵活,组织损伤少,使用安全,可明显消除三叉神经痛.