微血管减压术治疗三叉神经痛临床回顾

目的分析微血管减压术（MVD）治疗三叉神经痛的疗效及手术安全性。方法回顾复习微血管减压手术458例,对手术技术及责任血管的处理方法进行改良。结果手术早期的总有效率为98．2％,无一例发生脑脊液漏、听力丧失、颅内感染等严重并发症,2例因术后严重后颅窝水肿及脑干移位死亡。结论三叉神经痛应尽早治疗,微血管减压术是安全、有效的治疗方法,而静脉暂时阻断试验和神经电生理监测的应用有助于提高手术治疗的有效率和保证安全性。     

枕下乙状窦后入路手术治疗三叉神经痛的术式选择

目的探讨枕下乙状窦入路手术治疗三叉神经痛术中手术方式的选择。方法对39例原发性三叉神经痛患者的临床资料进行回顾性分析。其中31例患者术中有明确的血管压迫,仅行微血管减压术(MVD)手术;6例患者血管压迫不明显,行MVD+三叉神经梳理术(TNC);3例患者行三叉神经感觉根部分离断术(PSR),1例患者行二次手术。对患者术后的疗效及并发症进行分析。结果 31例行MVD手术患者,术后疼痛立即完全缓解26例,延迟缓解2例,无效3例,总有效率90.6%。6例行MVD+TNC的患者和3例行PSR手术的患者术后疼痛均立即缓解。结论为提高手术治疗三叉神经痛的治愈率,应根据术中不同情况决定不同的手术方式。对于老年人及不能耐受第二次手术的患者,更应积极行PSR手术。     

Surgical Management of Medically Refractory Trigeminal Neuralgia

The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis–related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.     

EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision

Background and objectives: This second European Federation of Neurological Societies Task Force aimed at updating the existing evidence about the pharmacological treatment of neuropathic pain since 2005. Methods: Studies were identified using the Cochrane Database and Medline. Trials were classified according to the aetiological condition. All class I and II randomized controlled trials (RCTs) were assessed; lower class studies were considered only in conditions that had no top‐level studies. Treatments administered using repeated or single administrations were considered, provided they are feasible in an outpatient setting. Results: Most large RCTs included patients with diabetic polyneuropathies and post‐herpetic neuralgia, while an increasing number of smaller studies explored other conditions. Drugs generally have similar efficacy in various conditions, except in trigeminal neuralgia, chronic radiculopathy and HIV neuropathy, with level A evidence in support of tricyclic antidepressants (TCA), pregabalin, gabapentin, tramadol and opioids (in various conditions), duloxetine, venlafaxine, topical lidocaine and capsaicin patches (in restricted conditions). Combination therapy appears useful for TCA‐gabapentin and gabapentin‐opioids (level A). Conclusions: There are still too few large‐scale comparative studies. For future trials, we recommend to assess comorbidities, quality of life, symptoms and signs with standardized tools and attempt to better define responder profiles to specific drug treatments.     

微血管减压术治疗原发性三叉神经痛

目的提出微血管减压术是治疗原发性三叉神经痛的最佳手术方式。方法报告了12例原发性三叉神经痛患者行微血管减压术,其中11例发现三叉神经入脑干区动脉压迫神经根,将压迫血管与神经根分离,在其间植入纤维蛋白海绵或聚四氟乙烯片维持分离状态,术后除1例疼痛减轻外,其余疼痛完全缓解,另1例术中未发现责任血管,但在神经根远侧段发现有粘连,将粘连松解,使神经根游离。结果所有患者术后疼痛减轻或缓解,所有病例无并发症。结论微血管减压术治疗原发性三叉神经痛是去除病因的手术方式,对已行微血管减压术后复发的患者再次行微血管减压术亦可获得满意疗效,作者还认为,神经内镜辅助微血管减压术顺应了当今微侵袭外科的趋势,将有望被更多地用来治疗原发性三叉神经痛。     

Percutaneous radiofrequency rhizotomy and neurovascular decompression of the trigeminal nerve for the treatment of facial pain

OBJECTIVE: To determine the outcomes of 354 radiofrequency rhizotomies and 21 neurovascular decompressions performed as treatment for 367 facial pain patients (290 idiopathic trigeminal neuralgia, 52 symptomatic trigeminal neuralgia, 16 atypical facial pain, 9 post-herpetic neuralgia). METHOD: Clinical findings and surgery success rate were considered for evaluation. A scale of success rate was determined to classify patients, which considered pain relief and functional/sensorial deficits. RESULTS: Radiofrequency rhizotomy was performed in 273 patients with idiopathic trigeminal neuralgia and in all other patients, except for trigeminal neuropathy; neurovascular decompression was performed in 18 idiopathic trigeminal neuralgia patients; 100% idiopathic trigeminal neuralgia, 96.2% symptomatic trigeminal neuralgia, 37.5% atypical facial pain and 88.9% post-herpetic neuralgia had pain relief. CONCLUSION: Both techniques for idiopathic trigeminal neuralgia are usefull. Radiofrequency rhizotomy was also efficient to treat symptomatic facial pain, and post-herpetic facial pain, but is not a good technique for atypical facial pain.     

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。     

微血管减压治疗原发性三叉神经痛的手术技术探讨(附110例分析)

目的探讨原发性三叉神经痛微血管减压治疗的手术技巧。方法回顾性分析行微血管减压手术治疗的110例三叉神经痛病人的临床资料。术中运用无牵拉显露技术、电生理定位技术、责任血管减压技术及静脉保护技术。术中发现血管压迫107例,行血管减压;对3例未发现血管压迫者行神经梳理。结果术后疼痛完全消失105例(95.5%),明显减轻4例(3.6%),部分缓解1例(0.9%)。平均随访35个月,复发1例,经再次手术后治愈。结论应用解剖学与电生理学相结合,确定责任血管并予以妥善处理,是三叉神经微血管减压手术获得成功的关键;静脉保护不容忽视。     

The trigemino-cervical reflex in tension-type headache

To investigate the pathophysiology of tension-type headache (TTH) with special reference to central mechanisms and to the involvement of the trigeminal system. Short latency responses can be recorded in tonically active sternocleidomastoid muscle after stimulation of the infraorbital branch of the trigeminal nerve (the trigemino-cervical reflex). This brainstem reflex was studied in 15 healthy subjects, in 15 patients with episodic tension-type headache (ETTH) and in 15 patients with chronic tension-type headache (CTTH) outside of the pain attacks. The trigemino-cervical response was abnormal, in the size or latency, in 13 patients with CTTH and in only one patient with ETTH. This finding strongly suggests that only in the CTTH the underlying pathophysiology involves the trigeminal system. The trigemino-cervical reflex is a sensitive method to evaluate the involvement of the trigeminal brainstem neurones in TTH and their assessment may provide useful diagnostic and prognostic information.     

Preoperative detection of the neurovascular relationship in trigeminal neuralgia using three-dimensional fast imaging employing steady-state acquisition (FIESTA) and magnetic resonance angiography (MRA)

Microvascular decompression is an accepted treatment for trigeminal neuralgia (TN). Preoperative identification of neurovascular compression, therefore, could aid determination of the appropriate treatment for TN. To preoperatively visualize the neurovascular relationship, three-dimensional fast imaging employing steady-state acquisition (3D FIESTA) and magnetic resonance angiography (MRA) were performed on 37 patients with TN in our study. 3D FIESTA in combination with MRA identified surgically verified neurovascular contact in 35 of 36 symptomatic nerves. The offending vessel (artery or vein) was correctly identified in 94.4% of patients, and agreement between preoperative MRI visualization and surgical findings was excellent (k = 0.92; 95% confidence interval, 0.67–1.00). Thus, 3D FIESTA in combination with MRA is useful in the detection of vascular contact with the trigeminal nerve in patients with TN.     

EFNS guidelines on pharmacological treatment of neuropathic pain

Neuropathic pain treatment remains unsatisfactory despite a substantial increase in the number of trials. This EFNS Task Force aimed at evaluating the existing evidence about the pharmacological treatment of neuropathic pain. Studies were identified using first the Cochrane Database then Medline. Trials were classified according to the aetiological condition. All class I and II controlled trials (according to EFNS classification of evidence) were assessed, but lower-class studies were considered in conditions that had no top level studies. Only treatments feasible in an outpatient setting were evaluated. Effects on pain symptoms/signs, quality of life and comorbidities were particularly searched for. Most of the randomized controlled trials included patients with postherpetic neuralgia (PHN) and painful polyneuropathies (PPN) mainly caused by diabetes. These trials provide level A evidence for the efficacy of tricyclic antidepressants, gabapentin, pregabalin and opioids, with a large number of class I trials, followed by topical lidocaine (in PHN) and the newer antidepressants venlafaxine and duloxetine (in PPN). A small number of controlled trials were performed in central pain, trigeminal neuralgia, other peripheral neuropathic pain states and multiple-aetiology neuropathic pains. The main peripheral pain conditions respond similarly well to tricyclic antidepressants, gabapentin, and pregabalin, but some conditions, such as HIV-associated polyneuropathy, are more refractory. There are too few studies on central pain, combination therapy, and head-to-head comparison. For future trials, we recommend to assess quality of life and pain symptoms or signs with standardized tools.     

三叉神经根入脑干区MRI形态学研究

目的研究原发性三叉神经痛(TN)患者三叉神经根入脑干区(REZ)的形态结构及其临床应用价值。方法 36例TN患者和20例非TN患者作为健康对照纳入研究。所有受试对象采用3.0TMRI扫描,采用可变翻转角的三维快速自旋回波序列(3D-SPACE)分别扫描两侧REZ区的形态学结构。采取图像分析软件测量分析三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积和三叉神经脑池段面积。结果患侧三叉神经脑池段长度的均值、三叉神经脑桥角的均值、桥小脑角池面积的均值以及三叉神经脑池段面积的均值均小于健侧。对照组的三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积及三叉神经脑池段面积的均值均大于疾病组。结论三叉神经脑池段较短,三叉神经脑桥角锐利,易发生神经血管冲突,临床上易导致TN;三叉神经脑池段面积缩小提示三叉神经根的萎缩性改变。MRI形态学信息有利于疾病的诊断及手术决策的选择。     

The trigemino-cervical reflex in patients with trigeminal neuralgia

OBJECTIVES: To investigate the central trigeminal system in idiopathic trigeminal neuralgia (TN). MATERIALS AND METHODS: Short latency responses can be recorded in sternocleidomastoid (SCM) muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex was investigated in 40 healthy subjects and in 17 patients suffering from idiopathic TN before and after therapy for 2 months with carbamazepin. RESULTS: Before therapy, six patients presented abnormalities of SCM responses on the painful side, six patients with bilateral abnormalities, and five patients with normal responses. A significant variation in the responses after therapy was found only in the patients with unilateral abnormalities: these patients and the patients with normal reflexes before therapy also had a good response to the therapy with significant pain relief. CONCLUSIONS: Our findings suggest that the trigemino-cervical reflex could be useful in the clinical assessment of TN prior to instituting non-surgical treatment. The bilateral location of the abnormalities in some patients seems to point to a centrally located dysfunction; therefore, this study supports the idea that mechanisms in the central nervous system may play an important role in the pathophysiology of trigeminal neuralgic pain.     

Association of trigeminal neuralgia with multiple sclerosis: Clinical and pathological features

The clinical characteristics of facial pain in patients with trigeminal neuralgia (TN) and associated multiple sclerosis (MS) were studied. Among 900 patients with TN 22 (2.4%) had associated MS. Sixteen patients had typical TN, while six had atypical TN. Facial pain commenced at a younger age ( P < 0.05) and a significantly higher proportion had bilateral facial pain ( P < 0.01) in the group with MS compared to TN patients without MS. In three patients TN was the first manifestation of MS, in the remainder facial pain occurred on an average of 12 years after onset of MS. Seventeen patients had associated signs of brain-stem involvement. The facial pain was, however, indistinguishable from the pain in patients without brain-stem deficits. While sclerotic plaques in the central nervous system probably are of etiological significance for development of TN neither clinical nor neuropathological findings suggest that this is due to affection of trigeminal nuclei complex in the brain-stem.     

What is the best treatment of drug-resistant trigeminal neuralgia in patients affected by multiple sclerosis? A literature analysis of surgical procedures

Objective

Drug-resistant trigeminal neuralgia (TN) can complicate the clinical course of patients affected by multiple sclerosis (MS). Various surgical procedures have been reported for the treatment of this condition, but there is no agreement on the best management of these patients. To our knowledge, there is no critical literature analysis focusing on this particular topic. The aim of this study was to evaluate the clinical outcome of different surgical procedures utilized for drug-resistant TN in MS patients.

Methods

We reviewed the literature about the studies reporting on surgical treatment of drug-resistant TN in MS patients. Case reports and case series less than 4 patients were excluded from the analysis. Nineteen studies were selected for the statistical analysis. To reduce the variability of the data, the selected studies were evaluated for the following outcome parameters: acute pain relief rate (APR), rate of recurrence (RR), pain free at follow-up rate (PF at FU) and complication rate (CR). For the statistical analysis, chi-square statistic, using the Fisher's exact test was utilized.

Results

There was no procedure statistically superior in terms of APR rate in MS patients following the surgical treatment of TN. The highest RR was observed for percutaneous balloon compression (PBC) (60.2 ± 14.4%). This result was statistically significant when compared to gamma knife surgery (GKS) (p = 0.0129) and microvascular decompression (MVD) (p = 0.0281). MVD together with percutaneous radiofrequency rhizothomy (PRR) was associated with a statistically better PF at FU rate (56.5 ± 16.8% and 73.5 ± 14.2%, respectively). However PBC and MVD showed statistical significant minor CR compared to other techniques (no complications and 18.7 ± 17.4%, respectively).

Conclusion

Our study shows no differences in the short term results among different procedures for TN in MS patients. Each technique demonstrate advantages and limits in terms of long term pain, recurrence rate and complication rate. Each patient should be accurately informed on pros and cons of each procedure in order to be involved in the most appropriate choice.     

微血管减压术治疗原发性三叉神经痛

目的综合评价三叉神经微血管减压术治疗原发性三叉神经痛的近远期疗效及手术风险。方法回顾性分析三叉神经微血管减压术治疗的原发性三叉神经痛25例患者临床资料。手术采用乙状窦后入路,术中分离血管神经后用Teflon补片分隔。结果术中发现24例有血管压迫,18例为小脑上动脉压迫,1例为基底动脉,3例为小脑前下动脉,1例为岩静脉压迫,1例为小脑上动脉和岩静脉压迫,另1例未发现血管压迫。结论三叉神经显微血管减压术临床适应证广泛,对神经损伤小,临床疗效满意,但手术风险不容忽视。     

Tongue somatosensory-evoked potentials in microvascular decompression treated trigeminal neuralgia

Somatosensory-evoked potentials of the tongue (tSSEP) provide useful information about trigeminal-afferent pathway. The aim of this study was to evaluate tSSEP in trigeminal neuralgia (TN) treatment with microvascular decompression. Two patients with trigeminal neuralgia refractory to conservative treatment underwent microvascular decompression of the trigeminal nerve. tSSEP was performed a month prior to surgery and in the month after the surgery in both patients. Pain frequency and tSSEP were analyzed before and after surgery. In both patients, a complete resolution of pain occurred. In patient 1, tSSEP latencies became shorter than before surgery and wave N1 appeared. The intensity of stimulation necessary to reach the threshold was 4 mA before the surgery and 1 mA after the surgery. A complete recovery of tSSEP after the operation was achieved in patient 2. The results of present study demonstrate potential value of tSSEP in pre-surgery evaluation and post-surgery follow-up of TN patients.     

Altered structure and functional connection in patients with classical trigeminal neuralgia

Classical trigeminal neuralgia (TN) is a specific type of neuropathic orofacial pain of which the plasticity of brain structure and connectivity have remained largely unknown. A total of 62 TN patients were included and referred to MRI scans. Voxel‐based morphometry was used to analyze the change of gray matter volume. Resting‐state functional imaging was used to analyze the connectivity between brain regions. The results showed gray matter volume reduction in components of the prefrontal cortex, precentral gyrus, cerebellar tonsil, thalamus, hypothalamus, and nucleus accumbens among right TN patient and in the inferior frontal gyrus, precentral gyrus, cerebellum, thalamus, ventral striatum, and putamen among left TN patients. The connections between the right superior frontal gyrus and right middle frontal gyrus were lower in right TN patients. The connection between the left precentral gyrus and the left superior frontal gyrus was lower while the connection between bilateral thalamus was higher in left TN patients. The changes of volume in bilateral thalamus of right TN patients and left ventral striatum of left TN patients, and the connectivity between bilateral thalamus of left TN patients were moderately correlated with pain duration. These findings suggest that brain regions such as the thalamus may not only be involved in processing of pain stimuli but also be important for the development of TN. The left hemisphere may be dominant in processing and modulation of TN pain signal. Chronification of TN induces volume changes in brain regions which are associated with emotional or cognitive modulation of pain. Hum Brain Mapp 39:609–621, 2018. © 2017 Wiley Periodicals, Inc.     

The trigemino-cervical reflex in patients with trigeminal neuralgia

Abstract

Objectives: To investigate the central trigeminal system in idiopathic trigeminal neuralgia (TN).

Materials and methods: Short latency responses can be recorded in sternocleidomastoid (SCM) muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex was investigated in 40 healthy subjects and in 17 patients suffering from idiopathic TN before and after therapy for 2 months with carbamazepin.

Results: Before therapy, six patients presented abnormalities of SCM responses on the painful side, six patients with bilateral abnormalities, and five patients with normal responses. A significant variation in the responses after therapy was found only in the patients with unilateral abnormalities: these patients and the patients with normal reflexes before therapy also had a good response to the therapy with significant pain relief.

Conclusions: Our findings suggest that the trigemino-cervical reflex could be useful in the clinical assessment of TN prior to instituting non-surgical treatment. The bilateral location of the abnormalities in some patients seems to point to a centrally located dysfunction; therefore, this study supports the idea that mechanisms in the central nervous system may play an important role in the pathophysiology of trigeminal neuralgic pain.