原发性和继发性三叉神经痛临床特征及手术效果分析

Analysis on clinical features and surgical outcome of primary and secondary trigeminal neuralgia

目的探讨原发性和继发性三叉神经痛的临床特征及手术效果。方法共105例三叉神经痛患者,包括原发性三叉神经痛90例和继发性三叉神经痛15例,前者行微血管减压术,后者行原发病变切除术和三叉神经脑池段探查术并微血管减压术,评价术后疗效并记录术后神经系统并发症(听力下降、症状性缺血性卒中、面神经损伤)。结果 90例原发性三叉神经痛患者中85例行微血管减压术,均采取患侧枕下经乙状窦后入路(85例,100%);81例(95.29%)术中可见责任血管;84例(98.82%)术后疼痛缓解;1例(1.18%)术后出现神经系统并发症,为患侧听力下降。15例继发性三叉神经痛患者均行原发病变切除术和三叉神经脑池段探查术并微血管减压术,12例(12/15)采取枕下经乙状窦后入路,3例(3/15)采取颞下经天幕入路;术中除切除原发病变外,同时探查三叉神经脑池段,3例(3/15)可见责任血管;术后均疼痛缓解(15/15);7例(7/15)术后出现神经系统并发症,分别为患侧听力下降5例、症状性缺血性卒中1例、面神经损伤6例;术后除1例(1/15)蛛网膜囊肿未行病理学检查外,余14例(14/15)病理诊断均与术前诊断相符,包括听神经瘤5例(5/15)、表皮样囊肿4例(4/15)、内皮型脑膜瘤(WHOⅠ级)2例(2/15)和过渡型脑膜瘤(WHOⅠ级)2例(2/15)、小脑动-静脉畸形1例(1/15)。原发性三叉神经痛患者首发症状发病年龄高于[(51.61±12.21)岁对(44.87±11.87)岁;t=1.988,P=0.049]、术前听力下降比例低于[0(0/90)对7/15;校正χ~2=37.813,P=0.000]、枕下经乙状窦后入路比例高于[100%(85/85)对12/15;校正χ~2=11.327,P=0.001]、术中可见责任血管比例高于[95.29%(81/85)对3/15;校正χ~2=48.325,P=0.000]、术后并发症发生率低于[1.18%(1/85)对7/15;校正χ~2=29.934,P=0.000]继发性三叉神经痛患者。结论原发性和继发性三叉神经痛临床表现存在一定差异,听力下降作为早期症状提示继发性三叉神经痛的原发病变,从而选择适宜手术入路,同时行三叉神经脑池段探查术并微血管减压术;术后疼痛缓解率较高,但继发性三叉神经痛患者术后易出现神经系统并发症。

Objective To explore clinical features and surgical outcome of primary and secondary trigeminal neuralgia（TN）.Methods A total of 105 cases of TN,including 90 primary and 15 secondary TN cases,were treated with microvascular decompression（MVD）or primary lesion resection and trigeminal nerve detection followed by necessary MVD,respectively.The postoperative effect and neurological complications（including hearing loss,symptomatic ischemic stroke and facial nerve injury）were evaluated.Results Of all 90 cases of primary TN,85 cases underwent MVD via suboccipital retrosigmoid approach（85 cases,100%）,offending vessels were detected in 81 cases（95.29%）,neuralgia was relieved in 84 cases（98.82%）after surgery,and neurological complications were detected in one case（1.18%）manifested as hearing loss.Of 15 cases of secondary TN,primary lesions were resected with surrounding vessels exploration[12 cases（12/15）through suboccipital retrosigmoid approach and 3 cases（3/15）through infratemporal tentorial approach].Primary lesion resection and trigeminal nerve detection were applied followed by necessary MVD.Offending vessels were detected in 3 cases（3/15）,all 15 cases（15/15）had neuralgia relieved,and 7 cases（7/15）had neurological complications in secondary TN,including hearing loss in 5 cases,symptomatic ischemic stroke in one case,and facial nerve injury in 6 cases.Postoperative pathological examination showed acoustic neuroma in 5 cases（5/15）,epidermoid cyst in 4 cases（4/15）,endothelioid meningioma（WHOⅠ）in 2 cases（2/15）,transitional meningioma（WHOⅠ）in 2 cases（2/15）and cerebellar arteriovenous malformation in one case（1/15）.One case（1/15）with arachnoid cyst did not perform pathological examination.In the primary TN cases,the age at initial symptom onset was older[（51.61±12.21）years vs.（44.87±11.87）years;t=1.988,P=0.049],the ratio of cases with preoperative hearing loss was lower[0（0/90）vs.7/15;adjusted37.813,P=0.000],the ratio of surgeries through suboccipital retrosigmoid approach was higher[100%（85/85）vs.12/15;adjusted11.327,P=0.001],the ratio of offending vessels detected during surgery was higher[95.29%（81/85）vs.3/15;adjusted48.325,P=0.000],the ratio of postoperative complications was lower[1.18%（1/85）vs.7/15;adjusted29.934,P=0.000]than those in secondary TN cases,respectively.Conclusions Differences are noted in clinical features between primary and secondary TN.Hearing loss considering as early symptom may suggest primary lesion in secondary TN.Appropriate surgical approach should be selected for surgery according to specific lesions.During surgery,all surrounding vessels of cisternal segment of trigeminal nerve should be explored to achieve sufficient decompression of trigeminal nerve.The rate of pain relief after operation is high in both primary and secondary TN,while neurological complications may occur in secondary TN after surgery.