三叉神经半月节膨大部单分区临床穿刺技术研究

Study on clinical single region puncture technique in the trigeminal semilunar ganglion intumescentia

目的探索半月神经节膨大部的眼区、上颌区、下颌区的单分区分别穿刺技术,及分别胞体射频治疗不同分支的三叉神经痛的可行性研究。方法不设定适应于所有患者、某一分区的固定穿刺路径,而在基于前期对尸体解剖和CT影像解剖研究基础上,采用3D Slicer软件分析2020年8月至2021年7月南通大学附属建湖医院神经外科就诊的三叉神经痛患者23例的术前CT数据,依据个体患者的责任分区节膨大中心点位置和其特有的颅骨解剖特点,设计仅适用于该特定个体、特定靶点的穿刺路径,具体方法如下:(1)在三叉神经管内口冠切面,多数病例可觅及眼区、上颌区、下颌区的直接征象,其横径占比约为1∶2∶2,无直接征象的依比例划分,在各分区的中心点作一标识;(2)顺纤维矢切面二维图像,节膨大下界的特征性标志是节窝,上界为Meckel腔上壁;各分区中心点至出颅孔中心(眼区-眶上裂、上颌区-圆孔、下颌区-卵圆孔)连线的矢切面图像,在节窝凹陷最深-Meckel腔最宽处标识该分区节膨大中心,并穿越中心以节窝长度标识中轴纤维走向;(3)分区节膨大中心标识点-卵圆孔连线,向外延长至皮肤,为进针点,向内延长到分区交界,形成穿刺路径;(4)侧入路穿刺受下颌骨阻挡的,采用"闭口-张口-过度张口"位设计,使下颌骨发生不同程度的前移、下移并向下后旋转,移开阻挡、开放穿刺通道,获得经下颌骨前缘、后缘或下颌切迹内的全程软组织穿刺路径;(5)设计以5 mm长度直电极+最大离轴3 mm的弯曲电极,制作多个小靶灶组合成立体靶灶,抵达责任分区的各方边界。全身麻醉下手术,按术前设计,以Xper CT成像,Xper Guide引导穿刺;以直电极贯穿节膨大责任分区制作顺轴靶灶,以弯曲电极偏离穿刺方向制作离轴靶灶,损害责任分区全境。以视觉模拟评分(VAS)评估治疗结果。结果共完成三叉神经痛患者23例,行半月节膨大部单分区穿刺25次(1例分别穿刺上颌区和下颌区;1例穿刺上颌区和眼区),其中穿刺眼区2次、上颌区10次、下颌区13次。过程均顺利,对设计的依从性好,术中影像全部保存。65℃连续射频19例次;60℃连续射频2例次;50℃连续射频2例次(均为眼区);脉冲射频(手动55℃)2例次。23例术后24 h内VAS均为0分;随访1~13个月,短期(术后1~7 d)复发3例,其中2例为脉冲射频(2/2例);无长时间随访出现复发的病例,VAS均为0分。短期复发的3例VAS在2~6分,其中65℃连续射频1例存在靶点误差,70℃连续射频再手术疼痛消失,VAS为0分;脉冲射频2例均复发,1例予65℃连续射频仍短期复发,目前VAS为6分,另1例放弃射频选择微血管减压术。65℃射频术后次日为中度触觉减退,并长期存在轻中度触觉减退;随访6个月以上的,仍有近半患者存在术侧食物颊下残留和对侧咀嚼。60℃连续射频病例少、随访时间短,术后次日均存在责任分区轻度触觉减退,不影响咀嚼;1~2周后触觉减退不明显。50℃连续射频均用于眼区,全麻醒后额部头皮轻微触觉减退,次日触觉正常。结论影像学设计、引导下三叉神经半月节膨大部眼区、上颌区、下颌区的单分区穿刺行胞体射频治疗三叉神经各分支疼痛是一项准确、有效、可行的技术。

Objective To explore the feasibility of single region puncture technique in the ocular region,maxillary region,mandibular region of the trigeminal semilunar ganglion intumescentia and different cell body radiofrequency treatment for different branches of trigeminal neuralgia.Methods Instead of setting a fixed puncture path suitable for all patients and a certain region,based on the previous autopsy and CT imaging anatomy study,3D slicer software is applied to analyze the preoperative CT data of 23 patients with trigeminal neuralgia who were treated in the Department of Neurosurgery of Jiangsu Jianhu People's Hospital Affiliated to Nantong University from August 2020 to July 2021.According to the position of the central point of the trigeminal semilunar ganglion intumescentia in the responsible region of an individual patient and its unique skull anatomical characteristics,a puncture path only applicable to the specific individual and specific target is designed.The specific methods are as follows:(1)In most cases,the direct signs of ocular region,maxillary region,and mandibular region can be seen at internal foramen of trigeminal nerve's coronal section;the proportion of transverse diameter is about 1:2:2;the region without direct signs should be proportionally divided.Make a sign at the central point of each region.(2)Based on the 2D-image of fiber sagittal section,the characteristic symbols of trigeminal semilunar ganglion intumescentia lower bound and upper bound are semilunar fossa and Meckel cavity superior wall,respectively.In the sagittal image presented by connecting the central point of each region to the center of cranial foramen(ocular region-superior orbital fissure,maxillary region-circular hole,mandibular region-oval foramen),make the sign of the trigeminal semilunar ganglion intumescentia of the region at the deepest part of semilunar fossa introcession-the widest part of Meckel cavity,and pass through the center to mark the direction of axial fiber with the semilunar fossa length.(3)Connect a line between the central sign point of the region of trigeminal semilunar ganglion intumescentia to the oval foramen.Then,extend it outward to the skin,that is the inserted point.Extend it inward to the region boundary to form the puncture path.(4)If the puncture adopting the lateral approach is obstructed by the mandible,the design of"closed mouth-open mouth-excessive open mouth"position should be applied,which makes the mandible move forward and down,rotate down-backward in different degrees.It can remove the block and open the puncture channel to provide a puncture path in full-soft tissues passing through mandibular front,back or within mandibular incisure.(5)In the design,straight electrodes(5 mm)+curved electrodes(maximum off-axis:3 mm)are applied to make multiple small target focusing to constitute 3D target focuses,which are placed at each boundary of each responsible region.General anesthesia surgery is adopted.According to the preoperative design,Xper CT is selected for imaging,and Xper Guide is selected for guided puncture;take the straight electrode running through the responsible region of trigeminal semilunar ganglion intumescentia to make the along-axis target focus,and take the curved electrode deviating from the puncture direction to make the off-axis target focus.The damage covers the full range of responsible regions.Visual analogue scale(VAS)is used to evaluate the treatment results.Results A total of 23 patients with trigeminal neuralgia accepted puncture in the single region of trigeminal semilunar ganglion intumescentia for 25 times(1 of which separately accepted puncture in the maxillary region and mandibular region;1 of which accepted puncture in the maxillary region and ocular region).In detail,there were 2 times of puncture in the ocular region,10 times of puncture in the maxillary region and 13 times of puncture in the mandibular region.All the processes were smooth.The compliance to the design was great and the intraoperative imaging was preserved.There were 19 cases accepting conventional radiofrequency under 65℃,2 cases accepting conventional radiofrequency under 60℃,2 cases accepting conventional radiofrequency(in ocular region)under 50℃,and 2 cases accepting pulsed radiofrequency(manually,under 55℃).All 23 cases had a VAS score of 0 within 24 hours after surgery.In the 1-13 month follow-up,there were 3 cases of short-term(1-7 days after surgery)recurrence,2 of which accepted pulsed radiofrequency(2/2);there was no case of long-term recurrence in the follow-up.All had a VAS of 0 score.Three cases of short-term recurrence had VAS scores of 2-6,including one case had target error with conventional radiofrequency under 65℃,the reoperation pain disappeared with conventional radiofrequency under 70℃,and had a VAS of 0 score.Two cases of pulsed radiofrequency both recurred,one case was given conventional radiofrequency under 65℃and still recurred for a short period of time,and the current VAS was 6 score.The other case gave up radiofrequency and chose microvascular decompression.For patients accepting radiofrequency under 65℃,moderate hypesthesia occurred next day after surgery,and long-term mild-moderate hypoaesthesia also occurred;for patients followed up for more than 6 months,there were still subbuccal residue of food at the operative side and contralateral chewing in nearly half of patients.The number of patients accepting conventional radiofrequency under 60℃was less and the time for follow-up was short.Next day after surgery,the mild hypoaesthesia in responsible regions occurred in all patients,while which had no influence on the chewing;after 1-2 weeks,hypoaesthesia became unconspicuous.The conventional radiofrequency under 50℃was used in the ocular region.After waking up under general anesthesia,mild hypoaesthesia occurred in frontal scalp,which recovered to normal next day.Conclusions Through image design and image guide,the single region puncture of the ocular region,maxillary region,and mandibular region of the trigeminal semilunar ganglion intumescentia with cell body radiofrequency treatment for different branches of trigeminal neuralgia is an accurate,effective,and feasible technique.