乙状窦后进路手术治疗原发性三叉神经痛术式选择及其临床价值分析

To study the clinical valuation of different operation methods in treatment primary trigeminal neuralgia by retrosigmoidal approach

目的:探讨乙状窦后进路不同术式治疗原发性三叉神经痛的临床价值。方法:165例原发性三叉神经痛患者,术前常规头颅MRI(B-FFE序列)检查,均行乙状窦后进路手术,依患者面部感觉及术中情况,采取电凝、微血管减压、梳理或几种方法联合应用。结果:①三叉神经感觉根部分切断加梳理术组7例,术前均有不同程度的面部麻木及感觉缺失症状,其中6例为三叉神经周围支撕脱术,1～6年后复发;1例为三叉神经半月节射频热凝术,1年后复发,术后疼痛消失,面部麻木及感觉缺失症状仍然存在,无咀嚼肌功能障碍,角膜反射正常。随访3.5～5.0年,疼痛无复发。②三叉神微血管减压梳理术组145例,本组患者术前头颅MRI检查均有血管压迫神经征象。三叉神经专科检查:角膜反射正常,面部感觉对称,痛温觉存在,咬肌有力,下颌反射正常,亦无其他阳性神经体征。术后136例疼痛完全消失,7例疼痛好转,2例无效。术后30%患者无面部感觉异常;70%患者存在轻、中度麻木。随访3～5年,有19例复发,3例再次手术后疼痛消失;面部麻木的患者中有75%面部麻木消失。③三叉神经电凝梳理术组13例,术中见5例有多血管压迫神经征象,但均不宜施行微血管减压;8例无血管压迫神经征象。术后疼痛症状完全消失,面部痛温觉存在,4例术后有轻、中度面部麻木。随访3.2～5.0年,1例复发,面部麻木患者均恢复正常。本文165例患者中死亡2例,分别为术中或术后脑出血所致。结论:根据患者面部感觉,配合MRI检查及术中所见三叉神经根周围的具体情况,采用1种或几种术式联合进行治疗,可提高疗效,但手术风险不能被忽视。

Objective：To study the clinical valuation of different operation methods in treatment primary trigeminal neuralgia by retrosigmoidal approach. Method：The clinical data of 165 cases with primary trigeminal neuralgia were studied, all head MRI（B-FFE） examination was made before surgery. According to patients＇ face sensation and cerebellopontine angle conditions, different operation methods were choosed. Result： Among of 165 cases,7 cases with face numbness and sensory loss symptom before surgery, were treated with partial rhizotomy of trigeminal sensory root and nerve combing and all cured, followed-up study 3. 5 to 5.0 years and no relapse and face sequelae is same as before; 145 cases with blood vessel compression and no face sequelae were treated with mi- crovascular decompression and nerve combing of trigeminal nerve sensory root, 144 cases were cured and 1 case relieve, 15 cases with herpes simplex were cured after 1 - 2 weeks, 4 cases with oral lips or tongue numbness were cured after 1 -3 months. Followed-up study 3 to 5 years,3 cases relapse and after second same operation methods cured. Among of 13 cases without face sequelae, 5 cases with artery compression were not suit to microvascular decompression and 8 cases without blood vessel compression. All these cases were treated with surface coagulation and nerve combing of trigeminal nerve sensory root, 2 cases with herpes simplex were cured after one week. Followed-up studying of 3.2 to 5.0 years, one case relapse, All 13 cases were cured and no neuralgia relapse and no severe sequelae. Among the 165 cases, two cases died of hematencephalon in operation or postoperation. Conclusion： It is a safe and effective way to choose different methods combine to treat primary trigeminal neuralgia according to patients＂ face sensation and cerebellopentine angle conditions, but the risk of operation should not be ignored.