原发性三叉神经痛微血管减压术中困难减压的处理

目的 探讨原发性三叉神经痛（PTN）微血管减压术（MVD）出现困难减压的处理方法以及疗效。方法 回顾性分析2013年1月至2019年12月采用MVD治疗的408例PTN的临床资料。术中出现困难减压56例，常规减压352例。对于困难减压病人，综合采取包括安置腰大池引流、神经内镜辅助、扩大松解桥小脑角区蛛网膜粘连、经小脑水平裂-小脑桥脑裂入路解剖显露，以及“架桥”等方法妥善处理。结果 术后随访0.5~5年。常规减压组术后即刻缓解37例，延迟缓解14例，无效5例；困难减压组术后即刻缓解267例，延迟缓解62例，无效23例。常规减压组术后即刻缓解率（75.85%，267/352）与困难减压组（66.07%，37/56）无统计学差异（P>0.05），常规减压组术后有效率（93.54%，329/352）与困难减压组（91.07%，51/56）无统计学差异（P>0.05）。常规减压组术后总并发症发生率（7.7%，27/352）与困难减压组（10.7%，16/56）无统计学差异（P>0.05）。两组均无手术死亡病例及严重后遗症。结论 PTN病人MVD中出现的困难减压并不是影响MVD疗效的决定性因素，只要术中处理得当，困难减压病人术后也可以取得很好的疗效。术前应熟悉和掌握常见的困难减压的应对方法，并且秉持适可而止的理念，减少手术并发症，可进一步提高手术疗效。

Treatment of difficult decompression during micro-vascular decompression for primary trigeminal neuralgia

Objective To explore the treatment methods and their efficacies for the patients with primary trigeminal neuralgia (PTN) under the condition of difficult decompression during microvascular decompression (MVD). Methods The clinical data of 408 PTN patients who underwent MVD from January 2013 to December 2019 were analyzed retrospectively. Of 408 PTN patients, 56 suffered from the condition of difficult decompression during MVD (difficult group) and 352 patients receiced the conventional decompression (convertional groups). For the patients in difficult group, comprehensive measures, including placement of lumbar cistern drainage, neuroendoscopy assistance, enlargement and release of arachnoid adhesions in the cerebellopontine angle area, anatomical exposure through the horizontal split-cerebellopontine split approach, and "bridging", were used to treat various types of difficult decompression. Results All the patient were followed up for 0.5~5 years. In difficult group, 37 patients had immediate remission, 14 delayed remission, and 5 no effect. In conventional group, 267 patients had immediate remission, 62 delayed remission, and 23 no effect. There was no statistical differences in immediate remission rate [75.85%(267/352) vs. 66.07% (37/56)], effective rate [93.54%(329/352) vs. 91.07%(51/56)] and total postoperative complication rate [7.7%(27/352) vs. 10.7%(16/56)] between conventional and difficult groups (P>0.05). Conclusions The difficult decompression in MVD for PTN patients is not a decisive factor affecting the efficacy of MVD, and good outcomes can also be achieved as the measures are used properly. Before surgery, we should be familiar with and master the common difficult decompression response methods, and uphold the concept of affordable treatment, which can reduce the surgical complications and improve the surgical efficacy.