显微血管减压术治疗责任血管为小脑后下动脉的舌咽神经痛

Microvascular decompression for glossopharyngeal neuralgia with posterior inferior cerebell arartery as offending artery

目的探讨显微血管减压术治疗原发性舌咽神经痛(GNP)的技术要点及其疗效。方法回顾性连续纳入2011年7月至2016年10月,首都医科大学宣武医院神经外科采用显微血管减压术治疗原发性GNP患者18例。所有患者术前接受MR血管成像(MRA)检查,明确舌咽和迷走神经与周围血管的解剖关系,其中17例采用枕下乙状窦后入路,1例采用远外侧入路;对患者均未行神经根丝切断术。结果 18例患者术前均有典型的舌根、咽部、扁桃体或外耳道深部等部位的发作性剧烈疼痛。术前MRA提示并且在术中证实,患者的责任血管均为小脑后下动脉主干或其分支。术中直视下将责任血管移离舌咽神经和迷走神经的出脑干区,确保血管与神经不再相互接触。手术无致残致死,无脑脊液漏、颅内感染等并发症。术后所有患者均得到随访,随访期为1~62个月。其中17例患者疼痛症状完全消失,疼痛数字量表评分(NRS)为0分;1例疼痛未缓解,出院时NRS评分同术前的8分。3例患者术后出现轻微的声音嘶哑、咽部不适,随访期内逐渐缓解。结论显微血管减压术是治疗GNP安全、有效的方法,小脑后下动脉是最为常见的责任血管,术前影像学检查、术中明确减压非常重要,对舌咽神经和迷走神经切断需慎之又慎。

Objective To investigate the key technical points of microvascular decompression （MVD） for the treatment of primary glossopharyngeal neuralgia （GPN） and its efficacy. Methods From July 2011 to October 2016,18 consecutive patients with primary GPN treated with MVD at the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University were enrolled retrospectively. All patients received magnetic resonance angiography （MRA） examination before procedure. The anatomical relationship between glossopharyngeal nerve/vagus nerve and peripheral blood vessels were identified. Seventeen of them were treated via suboccipital retrosigmoid approach, one were treated via far lateral approach. None of the patients were treated with nerve root rhizotomy. Results Eighteen patients had paroxysmal severe pain in tongue, pharynx, tonsil or deep ear canal and other parts before procedure. Preoperative MRA indicated and confirmed in the surgery that the offending vessels were the trunks or their branches of the posterior inferior cerebellar artery in this group of patients. During the operation ,the offending vessels were removed from the out brainstem areas of the glossopharyngeal nerves and vagus nerves under the direct vision in order to ensure that the blood vessels and nerves no longer contacted with each other. There were no complications, such as disability and death, cerebrospinal fluid leakage, and intracranial infection. All the patients were followed up after procedure;the mean follow-up periled was 1-62 months. The symptom oof pain disappeared completely in 17 of them. The Numberieal Rating Scale （NRS） score for pain were 0. The pain in one patient was not relieved. The NRS score was 8 at discharge; it was the same as before procedure. Three patients had mihl hoarseness,fill＇oat discomfort after procedure. They were relieved gradually in the follow- up period. Conclusion MVD is a safe and effective method for the treatment of GPN. Posterior inferior cerebellar artery is the most common offending artery. Preoperative imaging examination and clear decompression during the procedure arc very important. The cutting off of glossopharyngeal nerves and vagus nerves needs to be handled with care.