C型臂X光机引导穿刺联合神经电生理分支定位技术在三叉神经半月节射频热凝术中的应用价值

Application Value of Puncture Guided by C- arm X- ray Machine Combining Nerve Electrophysiology Branch Positioning Technique in Trigeminal Semilunar Ganglion Radio Frequency Thermocoagulation

目的探讨C型臂X光机引导穿刺联合神经电生理指导三叉神经半月节射频热凝术治疗三叉神经痛(TN)的效果。方法选取2013年6月—2014年9月于首都医科大学宣武医院行C型臂X光机引导穿刺三叉神经半月节射频热凝术治疗的TN患者110例。采用随机数字表法将患者分为试验组和对照组,各55例。C型臂X光机扫描下确定卵圆孔,根据患者疼痛反应以及X线影像,调整射频针方向与深度,直至达卵圆孔内约3 mm。对照组根据给予电刺激时患者出现病变部位强烈的疼痛或感觉异常、肌肉抽动,确定针尖部位位于病变支。试验组分别于眶上孔、眶下孔、颏孔连接经皮记录电极,分别给予高、低频电刺激,多功能电流记录仪记录各支电位。以波幅较其他支波幅显著增高,确定针尖位置位于病变支。记录术后即刻、48 h疼痛视觉模拟评分(VAS)、麻木VAS及范围、并发症发生情况。分别于术后第1周及第1、3、6个月进行电话随访,记录疼痛VAS评分、麻木范围及复发情况。对照组和试验组分别完整随访53、47例。结果试验组术后即刻疼痛消失患者比例高于对照组,差异有统计学意义(P<0.05)。两组术后48 h、1周及1、3、6个月疼痛消失患者比例比较,差异无统计学意义(P>0.05)。试验组和对照组术后即刻麻木VAS分别为(7.3±1.4)、(8.5±1.5)分,差异有统计学意义(t=4.120,P<0.001)。对照组术后即刻、48 h、1周及1、3个月麻木超出预期范围患者比例高于试验组,差异有统计学意义(P<0.001)。对照组术后48 h呕吐发生率高于试验组,差异有统计学意义(P<0.05)。两组眩晕、恶心、复视、皮肤麻木及咀嚼肌无力发生率比较,差异均无统计学意义(P>0.05)。对照组1例患者于术后2周复发,试验组随访期间无复发患者。两组复发率比较,差异无统计学意义(P>0.05)。结论与电刺激患者反应引导穿刺技术比较,C型臂X光机引导联合神经电生理指导射频卵圆孔穿刺,病变支定位准确性较好,术后麻木超出预期范围的风险降低。

Objective To investigate the effect of puncture guided by C- arm X- ray machine combining nerve electrophysiology in the treatment of trigeminal neuralgia（ TN） by trigeminal semilunar ganglion radio frequency thermocoagulation. Methods We enrolled 110 TN patients who underwent trigeminal semilunar ganglion radio frequency thermocoagulation with puncture guided by C- arm X- ray machine in Xuanwu Hospital,Capital Medical University from June2013 to September 2014. By random number table method,the subjects were divided into trial group and control group,with 55 patients in each group. Oval foramen was confirmed by the scan of C- arm X- ray machine,and the direction and depth of radio frequency needle were adjusted according to patients＇ pain reaction and X- ray image until the needle reached 3 mm inside ovalforamen. For control group,whether the needle tip was positioned in lesion branch was determined by whether strong pain or paresthesia appeared and muscle twitch when electrical stimulation was given. For trial group,percutaneous recording electrodes were connected at supraorbital foramen, infraorbital foramen and mental foramen, after which high- frequency electrical stimulation and low- frequency electrical stimulation given, and electric potential of each branch was recorded by multi-functional galvo- recorder; whether the needle tip was located in lesion branch was determined by whether the wave amplitude of a branch was evidently higher than other branches. The VAS pain score,the VAS numbness score,the range of numbness and the incidence rates of complications were recorded immediately and 48 hours after surgery. Telephone follow- up was conducted 1week,1 month,3 months and 6 months after surgery,during which the VAS pain score,range of numbness and relapse were recorded. The number of patients who completed the follow- up was 53 for control group and 47 for trial group. Results Trial group was higher（ P 〈0. 05） than control group in the proportion of patients whose pain disappeared immediately after surgery.The two groups were not significantly different（ P 〉0. 05） in the proportions of patients whose pain disappeared 48 hours,1week,1 month,3 months and 6 months after surgery. The VAS score of immediate numbness was（ 7. 3 ± 1. 4） for trial group and（ 8. 5 ± 1. 5） for control group（ t = 4. 120,P 〈0. 001）. Control group was higher than trial group in the proportions of patients whose numbness outreached the expected range immediately,48 hours,1 week,1 month and 3 months after surgery were higher than trial group（ P〈 0. 001）. Control group was higher（ P 〈0. 05） than trial in the incidence of emesis 48 hours after surgery. The two groups were not significantly different（ P 〉0. 05） in the incidence of dizziness,nausea,diplopia,skin numbness and masticatory muscle weakness. One patient in control group relapsed after surgery,and no patient relapsed during follow- up in trial group. The two groups were not significantly different in recurrence rate（ P 〉0. 05）. Conclusion Compared with puncture guided by patients＇ response to electric stimulation,oval foramen puncture guided by C- arm X- ray machine combining nerve electrophysiology is more accurate in the positioning of lesion branch and leads to lower risk in numbness outreaching expected range after surgery.