静脉压迫致三叉神经痛分型及手术策略

Classification and surgical strategies of trigeminal neuralgia caused by venous compression

目的探讨静脉压迫致三叉神经痛（TN）显微血管减压术（MVD）中的责任静脉分型、手术策略及临床疗效。方法2012年1月至2017年1月安徽医科大学附属省立医院神经外科采用MVD治疗原发性TN患者1456例，回顾性纳入其中静脉压迫致TN者64例（4．4％）。对责任静脉压迫进行分型，并制定相应的减压方法。结果64例中，按责任静脉与神经根的空间位置分为横跨压迫型（30例，46．9％）、伴行压迫型（18例，28．1％）、盘绕压迫型（8例，12．5％）、贯穿压迫型（5例，7．8％）、复合压迫型（3例，4．7％）；按责任血管的构成分为动静脉联合压迫型（51例，79．7％）和单纯静脉压迫型（13例，20．3％）；按神经根被压迫程度分为依附型（49例，76．6％）、有压痕型（9例，14．1％）、扭曲型（6例，9．4％）；按神经根被压迫部位分为脑池段压迫型（27例，42．2％）、近脑干区压迫型（21例，32．8％）、近Meckel腔压迫型（12例，18．8％）和混合压迫型（4例，6．3％）。术后随访3～60个月，平均（44．3±12．0）个月。64例患者中，51例疼痛消失，总有效率为79．7％。13例（20．3％）疗效不佳者均接受再次手术（其中2例为疼痛部分缓解，11例为复发）。8例附加三叉神经感觉根部分切断的患者均出现患侧面部感觉减退。颅内感染1例（1．6％），患侧听力下降1例（1．6％）。结论MVD中对责任静脉的分型有助于手术策略的制定，责任静脉充分减压可以取得良好的治疗效果。少数无法充分减压的患者可附加三叉神经感觉根部分切断术。

Objective To explore the classification of different kinds of venous neurovascular conflict （NVC）, to present surgical strategies of microvascular decompression （MVD） for the treatment of trigeminal neuralgia （TN） due to venous compression, and to evaluate its clinical outcomes. Methods A total of 1 456 patients with idiopathic TN underwent MVD at Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, from January 2012 to January 2017, were retrospectively analyzed. Venous compression was identified in 64 cases （4. 4% ）, which were further classified and corresponding surgical strategies were decided. Results The intra-operative findings of NVC were described as follows： spatial relationship： riding-compression： 30 cases （46. 9% ）, accompanying compression： 18 cases （28. 1% ）,twining compression： 8 cases （ 12. 5% ）, penetrating compression ： 5 cases （7.8%） and complex compression ： 3 cases （4.7%）; categories of offending vessels： combination of vein and artery （51 cases, 79.7%）, venous compression （ 13 cases, 20. 3% ） ; degrees of compression： simply accompanying （49 cases, 76. 6% ）, with compression dent on nerve root （9 cases ,14. 1% ）, distortion of nerve root （6 cases, 9. 4% ） ; compression sites： the cistemal portion （27 cases, 42. 2% ）, trigeminal root entry zone （21 cases, 32. 8% ） ,the petrous segment （12 cases, 18.8% ）,and mixed type （4 cases, 6.3% ）. The patients were followed up for 3 -60 months with an average of 44.3 months. Pain disappeared in 51 patients and the ＂excellent＂ rate was 79.7%. The 13 patients without satisfactory pain relief underwent re-operation. Postoperative complications included 8 cases of facial numbness after partial sensory rhizotomy of trigeminal nerve, 1 case of intracranial infection, 1 case of hearing impairment. Conclusions Classification of offending veins during MVD would facilitate surgical choice. Sufficient venous decompression could result in good outcomes. For cases in which insufficient decompression could not be achieved, partial sensory rhizotomy of trigeminal nerve root might be taken into consideration.