面肌痉挛的病因及手术治疗的探讨

目的：探讨面肌痉挛的发病原因，寻求治疗面肌痉挛的有效术式。方法：观察30具成人正常脑标本中面神经与周围血管的显微解剖关系；对120例面肌痉挛患者行乙状窦后进路桥小脑角探查术，其中20例行面神经显微血管减压术，68例行面神经梳理术，32例行显微血管减压加面神经梳理术。结果：解剖发现60侧面神经中有41根神经共42次与动脉接触，神经接触率为68．3％。120例面肌痉挛患者，术中发现56例小脑前下动脉压迫面神经根，41例小脑前下动脉穿行第Ⅶ、Ⅷ脑神经之间，13例面神经周围蛛网膜粘连，10例未发现异常。20例行显微血管减压术者，随访3年5例复发；68例行面神经梳理术者，随访3年10例复发；32例行血管减压加面神经梳理术者，随访3年2例复发。结论：血管压迫可能是面肌痉挛的病因，但不是惟一原因；面神经显微血管减压术有一定的局限性，面神经梳理术加减压术的有效率高，对不同的患者要选择不同的术式以达到最佳疗效。     

桥小脑角内镜下神经减压术

目的：探讨内镜在治疗三叉神经痛、面肌痉挛、舌咽神经痛及部分桥小脑角肿瘤手术中应用的相关问题。方法：回顾性分析采用经内镜下耳后小切口乙状窦后入路桥小脑角神经减压术或肿瘤切除术进行治疗的973例患者的临床资料,其中420例三叉神经痛（含28例桥小脑角肿瘤）、487例面肌痉挛和66例舌咽神经痛。结果：420例三叉神经痛中,发现责任血管390例（92.9%）,用Teflon隔离;蛛网膜粘连但未发现责任血管2例（0.5%）;桥小脑角肿瘤继发三叉神经痛28例。487例面肌痉挛中486例有责任血管,用Teflon隔离。66例舌咽神经痛均采用舌咽神经切断加迷走神经减压术治疗。出现脑脊液耳鼻漏3例,小脑梗塞1例,小脑出血2例,颅内积气3例;均治愈。无其他并发症及死亡病例。随访1~5年,三叉神经痛复发4例,面肌痉挛复发4例,舌咽神经痛无复发。结论：内镜用于耳后小切口乙状窦后入路桥小脑角神经减压术治疗三叉神经痛、面肌痉挛、舌咽神经痛手术中可获得满意疗效,提高了责任血管的发现率,有助于脑组织和神经功能的保护,有临床推广应用价值。     

内镜在迷路后进路手术中的应用

目的探讨内镜在迷路后进路手术中的临床应用价值。方法回顾性分析2010年1月至2016年1月收治的32例侧颅底患者的临床病例资料,男19例,女13例,年龄35-69岁,其中颅神经疾病27例(梅尼埃病20例,面肌痉挛5例,三叉神经痛2例),桥小脑角胆脂瘤3例,听神经瘤2例。所有病例均采用内镜辅助下迷路后进路完成,术后均随访1~5年,对手术效果进行分析。结果 27例颅神经病变患者术后症状均消失,其中20例梅尼埃患者行前庭神经切断术,术后眩晕控制率100%;5例面肌痉挛患者行面神经微血管减压术,术后面部痉挛症状完全缓解;2例三叉神经痛患者行三叉神经微血管减压术,术后疼痛症状消失。以上27例颅神经病变患者的术后面神经功能良好,所有病例听力与术前相比均无明显下降,无并发症,随访1-5年,无复发。3例桥小脑角胆脂瘤患者,胆脂瘤均彻底切除,术后无一例出现面神经麻痹或其他颅脑并发症,术后1例患者出现听力丧失,2例保存实用听力,随访1-5年,胆脂瘤无复发。2例听神经瘤患者肿瘤均全切除,术后均保存实用听力,无一例出现面神经麻痹或其他颅脑并发症,随访1-5年,肿瘤无复发。结论内镜辅助的迷路后进路,在功能性颅神经手术中具有良好的应用价值,能够清晰显露责任血管和V~XI颅神经,手术效果好;在桥小脑角胆脂瘤及听神经瘤手术中,内镜可以多角度无死角地观察,并做到微创全切除病变。     

微创手术切除小脑脑桥角肿瘤治疗继发性三叉神经痛

目的：探讨小脑脑桥角肿瘤与三叉神经痛的关系以及手术方案的选择。方法：采用耳后小切口乙状窦后入路进入小脑脑桥角切除小脑脑桥角肿瘤56例,对三叉神经进行减压。结果：55例一次性彻底切除肿瘤,1例切除2／3,术后三叉神经痛均立即消失,无严重并发症及死亡病例。结论：小脑脑桥角肿瘤压迫三叉神经根是引起三叉神经痛的原因之一,手术切除肿瘤可消除三叉神经痛。耳后小切口乙状窦后入路小脑脑桥角肿瘤切除术是理想的手术方式。内镜的使用可提高肿瘤的全切率,防止并发症。     

血管神经减压术治疗三叉神经痛和面肌痉挛15例报告

血管神经减压术治疗三叉神经痛和面肌痉挛１５例报告刘志涛，闫俊霞，于立新，王莉我科自１９８８年开始采用乙状窦后入路神经血管减压术治疗原发性三叉神经痛１０例，面肌痉挛５例，获得满意效果，现报告如下：１临床资料１．１三叉神经痛１０例，均为男性，年龄最大６８...     

三叉神经痛和舌咽神经痛外科治疗

目的探讨三叉神经痛、半面痉挛和舌咽神经痛的显微手术方法及疗效。方法回顾分析桥小脑角Ⅴ、Ⅶ、Ⅸ颅神经手术211例,其中原发性三叉神经痛178例,半面痉挛27例,舌咽神经痛6例。对桥小脑角探查有血管压迫神经的三叉神经痛、半面痉挛患者,以显微血管减压术为主,辅以神经梳理术;无血管压迫神经的三叉神经痛、半面痉挛患者,只作神经梳理术;对显微血管减压和/或神经根梳理术后无效或复发的三叉神经痛患者,作三叉神经感觉根部分切断术;舌咽神经痛患者,均作舌咽神经切断术。结果术后随访6～24个月,三叉神经痛、半面痉挛和舌咽神经痛的治愈率分别是94.3%、92.6%和100%。结论神经梳理术是显微血管减压术治疗三叉神经痛、半面痉挛的必要补充,神经切断术仍为治疗神经痛的有效方法。     

面神经

201879神经营养因子和面神经再生(综述)/李吉平…声中国中西医结合耳鼻咽喉科杂志一2000,8(2)一102一104201880乙状窦后进路手术治疗三叉神经痛30例报告/王锡温…//临床耳鼻咽喉科杂志一2000,14(3)一116~117 目的:探讨乙状窦后进路手术治疗三叉神经痛的疗效。方法:30例三叉神经痛患者,行三叉神经感觉根部分切断术26例,其中包括同时进行桥小脑角胆脂瘤摘除术和三叉神经第I支梳理术各2例;三叉神经显微血管减压术4例。结果:随访1~7年,仅1例三叉神经显微血管减压术患者1年后复发。结论:乙状窦后进路手术治疗三叉神经痛效果满意,其并发症的处理…     

内镜下面神经血管减压术治疗面肌痉挛

目的：探讨治疗面肌痉挛的功能性手术方式,讨论如何提高手术成功率、增加手术安全性及减少并发症等有关微创的相关问题。方法：回顾性分析286例面肌痉挛患者的临床资料,采用经内镜下耳后小切口乙状窦后入路小脑脑桥角血管减压术进行治疗。结果：术中发现责任血管285例（99．7％）,其中为小脑下前动脉264例,基底动脉21例,用Teflon隔离;蛛网膜粘连但未发现责任血管1例（0．3％）。术后面肌痉挛立即消失。术后1周面神经功能1／6级196例,2／6级62例,3／6级23例,4／6级4例,5／6级1例;术后半年面神经功能1／6级274例,2／6级10例,3／6级2例。术后1个月听力无明显变化238例,下降〈20dB 35例,20～〈50dB 10例,≥50dB 3例。出现脑脊液耳鼻漏2例,均治愈。无其他并发症及死亡患者。随访1～4年,面肌痉挛复发3例（1．0%）,1例再次手术治愈。结论：内镜下耳后小切口乙状窦后入路小脑脑桥角血管减压术是治疗面肌痉挛的理想术式。内镜应用提高了责任血管的发现率,有助于脑组织和神经功能的保护。     

乙状窦后入路神经血管减压术后的颅内压测定

经乙状窦后入路行神经血管减压梳理术治疗三叉神经痛、面肌痉挛、舌咽神经痛等已在临床广泛开展，但术后脱水剂的应用较为混乱。为防止术后并发症的发生，指导脱水剂及有关药物的使用，促进恢复，我们对6o例行神经血管减压术患者由乙状窦入路行颅内压测定，对观察术后病情取得较好效果。报告如下。1资料与方法本组6O例中，男22例，女38例；年龄33～73（平均57）岁。其中，三叉神经血管减压梳理术4o例，面神经血管减压梳理术2o例。手术均经耳后小切口乙状窦后八路进入桥小脑角，顺利完成。术后不用脱水剂，液体量控制在15oo～2oooml／d；应…     

后颅窝神经根疾病再手术

目的 探讨后颅窝神经根疾病术后复发再手术的临床特点和再手术的处理原则.方法 回顾分析2000至2007年临床收治的术后复发的后颅窝神经根疾病病例14例,包括三叉神经痛5例,面肌痉挛5例,舌咽神经痛4例,总结其临床和再手术术中发现特点.结果 5例三叉神经痛患者术后复发者,微血管减压术(microvascular decompression,MVD)2例,疼痛复发部位与术前相同,3例三叉神经感觉根第2、3支切断术后患者均为同侧第一支复发,其中4例接受再次感觉根部分切断手术,术后疼痛消失,随访2～11年未复发.5例而肌痉挛患者,4例再次梳理术后症状部分改善,1例没有改善.4例舌咽神经痛术后复发患者,2例发现舌咽神经再生吻合,1例发现舌咽神经近侧断端和迷走神经粘连,还有1例术中未发现舌咽神经再生及粘连情况,再次手术探查,切断再生神经及相邻2支迷走神经纤维根丝,随访2～5年无复发.术区一般病理改变包括:小脑与岩骨脑膜粘连严重;新生血管丰富,极易出血;行MVD患者的神经与周围相关血管和术中放置的涤纶布等减压材料粘连紧密,无法分离,初次手术部位局部瘢痕粘连,失去正常解剖结构,明显增加再次手术操作风险.结论 三义神经痛和面肌痉挛术后复发病因不明,舌咽神经痛复发可能的原因为神经纤维再生吻合、粘连及临近迷走神经纤维交通支引起.三叉神经痛、舌咽神经痛术后复发再次行神经纤维切断疗效确切.面肌痉挛复发再次面神经梳理手术效果较差.     

桥小脑角神经根减压术的并发症

目的　报告桥小脑角神经根显微血管减压术和(或)选择性神经根切断术的并发症。方法　回顾性分析322例行Ⅴ、Ⅶ、Ⅸ颅神经根减压、梳理及选择性切断术患者的并发症。其中半面痉挛164例, 96例行单纯面神经梳理术, 68例行面神经梳理术+显微血管减压术;三叉神经感觉根减压及选择性切断术128例;舌咽神经根减压术及切断术30例。结果　322例接受手术的患者中,死亡2例( 0 .6% );中重度神经性聋21例( 6. 5% ),听力完全丧失3例( 0 .9% );脑脊液漏20例(6.2% )。结论　尽管显微血管减压术及神经根切断术是相当安全的手术,但仍可发生死亡及其他并发症。注重手术细节的处理对降低脑损伤及颅内出血的发生至关重要;尽量避免牵拉及触动耳蜗神经以及术中应用ABR监测可有效防止术后神经性聋的发生。     

Keyhole microsurgery for trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia

The aim of the study was to describe and evaluate the efficacy of the keyhole microsurgery to manage patients with trigeminal neuralgia (TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN). Two hundred and seven patients underwent microvascular decompression (MVD) and neurotomy via retrosigmoid keyhole approach in our department clinic: MVD for trigeminal neuralgia 169 cases, hemifacial spasm 31 cases, glossopharyngeal neuralgia 4 cases and neurotomy for glossopharyngeal neuralgia 3 cases. There was no serious complication such as deaths or infarction in the cerebellum or the brainstem. Complete and partial symptoms relief was obtained in 160 (94.7%) cases and failure 9 (5.3%) cases with MVD for trigeminal neuralgia, postoperatively. Meanwhile, complications occurred in one case with cerebellar hematoma only. The postoperative results of MVD for hemifacial spasm with symptoms relief was noted in 29 (93.5%) cases and failure 2 (6.5%) cases. Postoperative complications occurred in one case with moderate hearing loss, another three cases complained of transient facial paralysis. Symptoms relief achieved in all 7 (100%) cases undergone MVD or neurotomy for glosspharyngeal neuralgia. Postoperative complications occurred in one case with moderate vocal paralysis. We think that microsurgery via retrosigmoid keyhole approach is safe and effective for CPA hyperactive cranial nerve dysfunction syndromes.     

乙状窦后锁孔手术治疗三叉神经痛、半面痉挛和舌咽神经痛

目的 评价锁孔术治疗三叉神经痛（TN）,半面痉挛（HFS）和舌咽神经痛（GPN）的疗效。方法 对207例患者实施乙状窦后锁孔入路微血管减压术（MVD）和神经切断术,其中三叉神经痛169例,半面痉挛31例,舌咽神经痛7例。结果 三叉神经痛治愈和好转160例（94.7％）,失败9（5.3％）;半面痉挛患者症状治愈29例（93.5％）,失败2例（6.5％）;舌咽神经痛患者症状治愈7例（100％）。术后未发生严重并发症,如死亡或小脑或脑干梗死等。其它并发症包括有小脑血肿1例,中度听力损失3例,暂时性面瘫3例,一侧声带不完全性麻痹1例。结论 经乙状窦后锁孔入路微血管减压和神经切断术安全有效。     

内窥镜在桥小脑角手术中的应用

在桥小脑角手术中为了扩大暴露，减少术中误判，增加手术的安全性，在手术中配合应用了内窥镜。报道24例（半面痉挛11例、三叉神经痛9例、舌咽神经痛2例、顽固性外周性眩晕及听神经瘤各1例）内窥镜下桥小脑角（CPA）手术的体会。内窥镜扩展了对桥小脑角结构的暴露，提供较手术显微镜更加清晰的术野。可将窥镜推至病变神经根部仔细观察，利于查明责任血管。在不改变神经血管位置的情况下可方便地进行神经根减压梳理及选择性切断。介绍了内窥镜下的手术方法、技巧及注意事项，认为内窥镜手术是目前客观评价桥小脑角显微血管压迫和实施神经根手术的理想方法。     

乙状窦后进路手术治疗三叉神经痛30例报告

探讨乙状窦后进路手术治疗三叉神经痛的疗效。方法：３０例三叉神经痛患者,行三叉神经感觉根部分切断术２６例,其中包手同时进行桥小脑角胆脂瘤摘除术和三叉神经第Ⅰ支梳理术各２例;三叉神经显微血管减压术４例。结果随访１－７年,仅１例三叉神经显微血管减压术患者１年后复发。     

Microvascular decompression of cochlear nerve for tinnitus incapacity: pre-surgical data,surgical analyses and long-term follow-up of 15 patients

The level of success of neurovascular decompression in ponto-cerebellar angle for hemifacial spasm and trigeminal neuralgia has already established the reality of the pathology to explain such symptoms. However, cochlear nerve compression syndrome by vascular loop is still a controversial topic. We have performed a retrospective cases review with long-term follow-up (5–7 years) concerning the results of microvascular decompression surgery of the cochlear nerve via an endoscopy assisted retrosigmoid approach on 15 patients suffering from unilateral incapacitating tinnitus with abnormal auditory brainstem response and an offending vessel on magnetic resonance imaging. During the surgery, a vascular compression was found on every patient. In a long-term follow-up, 53.3% (8 cases) of our tinnitus cases improved and 20% (3 cases) of them were completely cured. The ABR returned to normal in all patients who had good clinical results (diminished or disappeared tinnitus). When a vertebral artery loop (5 cases) was concerned we obtained 80% of good clinical results. No one showed amelioration or sudden aggravation of their hearing. Three cases required surgical correction of cerebrospinal fluid leak and one case developed spontaneously regressive swallowing problems. Such microvascular decompression surgery of the cochlear nerve appears to be successful in treating incapaciting tinnitus in particular when a vertebral artery loop is observed. Therefore, in such a case, one might recommend neurovascular decompression surgery, keeping in mind that the complications of this surgery should be minimized by a careful closure of the retrosigmoid approach. In order to ensure a better selection of patient more accurate cochlear nerve monitoring and functional MRI should be a promising assessment.     

Neurovascular conflicts

Neuro-vascular conflict is a pathophysiologic phenomenon which is implicated in several cranial neuropathies. The most common are trigeminal neuralgia and hemifacial spasm. Spasmodic torticolis, glosopharyngeal neuralgia, disabling positional vertigo may be due to neural compression as well, but other pathologies such as neurogenic hypertension and limited cases of tinnitus, although rare, highly susceptible to the neurovascular conflict, should be taken into considerration. Current diagnostic approach comprises clinical and radiological evaluation. Along with thorough otoneurological examination, MRI scans are essential to diagnose the conflict. This provides information about the presence of neuro-vascular conflict and involved structures. The microvascular decompression (MVD) is a treatment of choice, based on the separation of offending vessel from the nerve. Those procedures are safe, with high rate success according to the literature ranging from 70-90%. Additionaly, in early 90. a new minimally invasive approach with use of rigid endoscopes were proposed. Those gave the possibility to reduce morbidity and improve results by providing wider insight into the operating field with smaller intraoperative injury. Authors present 9 patients diagnosed with neuro-vascular conflict in the ENT department in Poznań. Clinical findings comprised 5 cases of hemifacial spasm, 3 with unilateral tinnitus and 1 with trigeminal neuralgia. Due to variety of symptoms, it is proposed that specialized centers should be formed to diagnose and treat cranial nerves neuropathies. Team approach composed of neurologist, neurosurgeon, radiologist and otologist is essential in terms of good treatment results. Authors describe symptomatology, diagnosis and treatment options of neuro-vascular conflicts.     

Efficacy of microsurgical vascular decompression in trigeminal neuralgia

ObjectivesAnalysis of the long-term efficacy of microvascular decompression surgery in trigeminal neuralgia.Material and methodsA single-center retrospective study included patients undergoing microvascular decompression surgery for trigeminal neuralgia after failure of well-conducted medical or complementary therapy, with visualization of nerve compression syndrome on MRI.ResultsEighty-seven patients were included. Nerve compression was alleviated without interposition of polytetrafluoroethylene in 79.3% of cases. Postoperative efficacy on pain was immediate in 97.7% of cases. There were no postoperative deaths, and the rate of severe complications was low (2.3%). The efficacy of microvascular decompression surgery was total at 2 years in 90.8% of cases and at 10 years in 92.3%, without resumption of medical treatment. The failure rate was 10.3%; 26.3% of these patients had been previously treated by a lesional technique (P: 0.043) and 33.3% by interposition of polytetrafluoroethylene (P: 0.003).ConclusionsWith confirmed clinical and radiological diagnosis, microvascular decompression surgery for trigeminal nerve compression was safe, with total effectiveness in the immediate, short and long terms. It should be considered in first line in case of failure or intolerance of well-conducted medical treatment.