CT引导清醒镇静镇痛状态下经皮穿刺微球囊压迫术治疗三叉神经痛时球囊位置与形状及离体头颅标本观察

linical and head specimen observation about the position and shape of the balloon in the treatment of patients with trigeminal neuralgia by CT-guided percutaneous microballoon compression under conscious sedation and analgesia

目的观察经皮穿刺微球囊压迫术(PMC)治疗三叉神经痛时及离体头颅标本模拟穿刺时球囊的位置与形状。方法收集2019年6月至8月在嘉兴学院附属第一医院疼痛科就诊的原发性三叉神经痛患者7例,年龄57~83岁,男4例、女3例。在局麻清醒静脉镇静镇痛下,CT引导行PMC操作,以患者三叉神经原疼痛区出现明显麻木感为手术结束标准。拔出球囊导管后观察有无脑脊液从穿刺针尾溢出,并用CT扫描并三维重建显示球囊位置。再在2例开放的头颅标本上穿刺置入球囊导管模拟PMC,CT扫描后解剖标本,观察球囊的具体位置。结果7例患者接受了CT引导穿刺局麻清醒镇静镇痛下PMC治疗。注入造影剂碘海醇0.5 ml后球囊充盈呈尖端小底部大的倒"梨形",紧压贴在岩锥骨面的三叉神经压迹处。平均压迫时间达238 s时患者诉原疼痛区有明显麻木感即结束手术。退出导管后有2例患者可见脑脊液从针尾溢出。术后即刻镇痛有效率100%,随访1~3个月无复发。对2例头颅标本进行卵圆孔穿刺置管模拟PMC治疗时,CT扫描所得球囊位置与形状和临床在体PMC一致,解剖标本可见球囊位于三叉神经切迹外侧的硬脑膜和Meckel囊壁之间。结论微球囊压迫治疗三叉神经痛可以在清醒镇静镇痛下完成,CT引导穿刺更精准,三维重建图像可直视观察球囊位于颅中窝紧贴岩锥的三叉神经切迹;对离体头颅标本模拟PMC时也能再现活体时PMC的情景,解剖证实PMC时球囊位于三叉神经切迹外侧的Meckel腔内,介于Meckel腔外壁硬脑膜和腔内的Meckel囊壁之间。

Objective To observe the location of the balloon on clinical condition and head specimen in the treatment of patients with trigeminal neuralgia by percutaneous microballoon compression(PMC)under conscious sedation and analgesia.Methods Seven patients with primary trigeminal neuralgia,aged 57-83 years old,four male and three female,from June to August 2019,in the Department of Pain Medicine,the First Affiliated Hospital of Jiaxing University were enrolled in the study.Under the conscious sedation and analgesia and local anesthesia,all cases were treated with PMC guided by CT.The obvious numbness in the area of trigeminal neuralgia was taken as the end standard of operation.After pulling out the balloon catheter,whether there was cerebrospinal fluid overflowing from the puncture needle was observed,and CT scan and three-dimensional reconstruction displayed the position of the balloon.Two open head specimens were punctured and placed with balloon catheter to simulate PMC.After CT scanning,the specimens were dissected to observe the specific location of the balloon.Results Seven patients were treated with PMC under CT guided at local anesthesia with conscious sedation and analgesia.After 0.5 ml of iohexol was injected into the balloon,it was filled in an inverted"pear shape"with a small tip and a large bottom,and tightly pressed on the trigeminal nerve impression on the surface of talus cone.When the average compression time reached 238 s,the patient complained of obvious numbness in the original pain area,and the operation ended.Cerebrospinal fluid overflowed from the needle in 2 patients after catheter withdrawal.The effective rate of immediate postoperative analgesia was 100%,and no recurrence was found in 1-3 months follow-up.When two cases of head specimens were treated with puncture and catheterization to simulate PMC,the position and shape of the saccule obtained by CT scanning were consistent with that of clinical condition in vivo PMC.The anatomical specimens showed that the saccule was located between the dura mater and Meckel capsule wall on the lateral side of the trigeminal notch.Conclusion PMC can be completed under the local anesthesia with conscious sedation and analgesia,CT guided puncture is more accurate,3D reconstruction image can directly observe the location of the balloon,which was at trigeminal notch close to the talus cone in the middle cranial fossa.The scene of PMC in vivo can also be reproduced in the simulation of PMC in vitro,the anatomy of the specimen confirmed that the balloon is located in Meckel cave,between the extraluminal wall(dura mater)of Meckel cave and Meckel capsule wall outside the trigeminal notch.