乙状窦后入路显微手术治疗原发性三叉神经痛的手术探查方向选择

Choice of exploring direction in microvascular decompression for primary trigeminal neuralgia via retrosigmoidal approach

目的探讨乙状窦后入路微血管减压术治疗原发性三叉神经痛手术探查方向的选择。方法回顾性分析2000年1月～2008年1月采用乙状窦后入路显微手术治疗86例原发性三叉神经痛的手术探查方向,将其分为两组,2000年1月～2005年3月期间治疗49例为A组,手术开始即行乙状窦后紧邻天幕下探查,其中46例(93.9%)需切断至少1支岩静脉属支;2005年4月～2008年1月期间治疗37例为B组,手术开始即行乙状窦后紧邻听神经根上方探查,其中7例(18.9%)需切断至少1支岩静脉属支。结果A组平均随访62个月,随访期间总有效率87.8%(43例);术后并发病侧听力障碍、复视各1例,随访期间好转;小脑出血1例,急诊行颅后窝减压小脑血肿清除后3d死亡。B组平均随访21个月,总有效率89.2%(33例);术后并发病侧听力障碍1例,随访期间好转;病侧听力丧失1例,随访8个月无好转。结论采用乙状窦后显微血管减压术治疗原发性三叉神经痛时,手术开始即选用紧邻听神经根上方探查,多数情况下不需处理岩静脉即可获得对三叉神经根区的良好显露,避免了岩静脉属支切断可能带来的严重并发症,但术后发生听力障碍并发症的可能性增大。

Objective To study the choice of exploring direction in microvascular decompression for primary trigeminal neuralgia via retrosigmoidal approach. Methods Directions of surgical exploration in microvascutar decompression were analyzed retrospectively in 86 patients with primary trigeminal neuralgia operated from January 2000 to January 2008. Patients were divided into two groups： from January 2000 to March 2005, 49 operations （group A） were performed via retrosigmoid infratentorial approach and the superior petrosal vein（s） was/were cut off in 46 cases （93.9%）. From April 2005 to January 2008, 37 operations （group B） were performed in the retrosigmoid supracochlear direction and the superior petrosal vein（s） was/were cut offin 7 cases （18.9%）. Results The mean follow-up period in group A was 62 months, with an efficacy rate of 87.8% （43 cases）. The postoperative complications included transient hearing disturbance in 1 case, transient diplopia in 1, and cerebellar hemorrhage in 1, in which emergency decompression of the cranial posterior fossa and removal of the hematoma were performed, but the patient died at the 3rd day afterwards. The mean follow-up period in group B was 21 months with an efficacy rate of 89.2% （33 cases）. The postoperative complications included transient hearing disturbance in 1 case, hearing loss of the ill side without improvement in 8 month of follow-up in 1. Conclusion Under most conditions, the trigeminal nerve root entry zoon （REZ） could be exposed satisfactorily via the retrosigmoid supracochlear approach without cutting the superior petrosal vein（s）, thus the severe complications due to the cutting of the petrosal vein（s） could be avoided. But the possibility of postoperative hearing disturbance may be increased.