| Trigeminal neuralgia is one of the common cranial nerve diseases in clinic.According to the International Headache Society(IHS),primary trigeminal neuralgia is defined as the sporadic facial laceration and cutting pain,in which the pain is distributed in one or more branches of the trigeminal nerve,with the presence of trigger points.Factors,such as washing face and brushing tooth,can induce primary trigeminal neuralgia,which has severely affected the patient work,learning and life.The current mainstream opinion suggests that,neurovascular conflict is the pathogenesis leading to trigeminal neuralgia;to be specific,the long-term compression of blood vessels on the trigeminal nerve results in demyelinating disease in trigeminal nerve,which induces the abnormal discharge of nerve,thus inducing trigeminal neuralgia.Based on the intensive investigation on the trigeminal neuralgia pathogenesis and the rapid development of mi cron euro surgery technique.microvascular decompression(MVD)has become the preferred method to treat trigeminal neuralgia.However.MVD has high requirements on the surgical skills of surgeons,operating room equipment and disease understanding level,which is associated with certain problems in the application process.Therefore,we have carried out a series of retrospective clinical studies on multiple clinical problems of microvascular decompression for primary trigeminal neuralgia.This series research was divided into 5 parts.Part 1Comparative analysis of the efficacy of microvascular decompression in the treatment of typical and atypical primary trigeminal neuralgiaOBJECTIVE:Microvascular decompression(MVD)is the major treatment for primary trigeminal neuralgia at present,but it attains distinct therapeutic effects on trigeminal neuralgia patients with different clinical symptoms.This paper compared the postoperative efficacy of MVD in treating typical and atypical trigeminal neuralgia patients,and explored the symptomatologic factors that affected the MVD efficacy,so as to screen suitable patients before surgery,normalize the indications of MVD in treating trigeminal neuralgia,and improve the surgical efficacy.METHODS:From January 2011 to December 2015,369 primary trigeminal neuralgia patients that received MVD in our hospital with complete follow-up data were collected.Patients were divided into typical and atypical trigeminal neuralgia according to symptomatologic classification,including 236 typical trigeminal neuralgia cases and 133 atypical trigeminal neuralgia cases.Besides,the clinical efficacy was compared.RESULTS:After the 12-month follow-up after MVD,147(62.28%)cases in typical group had cured pain,80(33.89%)had partial remission,6(2.54%)had obviously alleviated pain,and 3(1.27%)had unimproved pain,resulting in the pain remission rate of 96.18%(227/236),with the overall response rate of 98.73%(233/236).For the atypical group,16(12.03%)cases had cured pain after surgery,24(18.05%)had partial remission,78(58.65%)had obviously alleviated pain,and 15(11.28%)had unimproved pain,resulting in the pain remission rate of 30.08%(40/133),with the overall response rate of 88.72%(118/133).The pain remission rate and treatment overall response rate in typical group were apparently higher than those in atypical group,and the differences were statistically significant(P<0.05).CONCLUSION:MVD has remarkably superior efficacy in treating typical trigeminal neuralgia than atypical trigeminal neuralgia.Therefore,for patients with typical trigeminal neuralgia,MVD is selected as the major surgical intervention means,which provides reference for normalizing the indications of MVD in treating trigem inal neuralgia.Thereafter,MVD can be performed in the specially selected patients,thus better exerting the effect on treating primary trigeminal neuralgia.which is of great significance to improve the cure rate and save the medical resources.Part 2Application value of multi-modal image fusion technology in treating primary trigeminal neuralgia by microvascular decompressionOBJECTIVE:The currently used imaging examination methods are limited in the diagnosis and assessment of primary trigeminal neuralgia.This study proposed to explore the application value of multi-modal image fusion technology in treating primary trigeminal neuralgia by microvascular decompression(MVD).METHODS:The magnetic resonance imaging(MRI)results of 90 primary trigeminal neuralgia patients that received MVD in our hospital from June 20 14 to December 2015 with complete follow-up data were retrospectively analyzed,including the T1,T2.3D-TOF and 3D-FIESTA sequences.The 3D-slicer software was used preoperatively for the 3 D visualized reconstruction of the MRI results;besides,the presence or absence of blood vessels around thetrigeminal nerve,together with the responsible blood vessel source was judged,and the results were compared with the intraoperative findings.so as to evaluate the consistency between these two.RESULTS:The sensitivity and specificity of multi-modal image fusion technique in diagnosing the presence/absence of vascular compression of primary trigeminal neuralgia were 98.87%(88/89)and 100%(1/1),respectively.Compared with intraoperative observational results,there was good consistency in the preoperative diagnosis of the responsible blood vessel source,with the Kappa value of 0.875.Besides,it allowed to simulate the surgical approach,provide the 3D visualized imaging data for operator,and guide the implementation of MVD.CONCLUSION:Multi-modal image fusion technique can well display the relationship between trigeminal nerve and the responsible blood vessel,which displays high sensitivity and specificity,and has favorable consistency compared with the intraoperative findings.That technique is convenient in operation and has great practicability,which can provide valuable information for treating primary trigeminal neuralgia through MVD.Part 3Clinical and follow-up research on the effect of microvascular decompression on treating primary trigeminal neuralgia induced by simple venous compressionOBJECTIVE:Microvascular decompression(MVD)has been verified to be the effective method to treat primary trigeminal neuralgia.Most previous studies report trigeminal neuralgia induced by artery as the responsible blood vessel.However,we discovered in clinical practice that,simple venous compression may also account for the etiology of primary trigeminal neuralgia,while few related reports are available at present.Therefore,this study proposed to explore the features and efficacy of surgical treatment for trigeminal neuralgia induced by simple venous compression,so as to improve the ability to diagnose and treat such patients.METHODS:In this study,we retrospectively analyzed the 5-year MVD experience in treating primary trigeminal neuralgia induced by simple venous compression.A total of 34 patients with primary trigeminal neuralgia induced by venous compression were collected,their symptoms,surgical condition,efficacy and related complications were analyzed.RESULTS:Trigeminal neuralgia induced by simple venous compression had different features compared with those with arterial compression as the responsible blood vessel,and MVD also attained satisfactory efficacy.In all the 34 patients,19(55.88%)were typical trigeminal neuralgia patients,with the second branch of trigeminal nerve being the most frequently involved.Most cases(20/34,58.82%)had grade III venous compression.Petrosal vein and its branch were the most commonly seen responsible blood vessels(21/34,6 1.76%).10(29.41%)cases had venous compression in the brain stem end of trigeminal root,1 8(52.94%)had compression in the cistern segment of trigeminal nerve,and 11(32.35%)had compression in the Michael cavity.The follow-up results suggested that,26(76.47%)patients were cured,4(32.35%)achieved partial remission(PR),2 were apparently alleviated(5.88%),and 1(2.94%)was ineffective.As for the complications,cerebrospinal fluid leak had the highest incidence(5.9%),and no death was reported.CONCLUSION:Venous compression of trigeminal nerve is one of the causes of trigeminal neuralgia,and vein may be the direct responsible blood vessel.MVD is safe and effective on trigeminal neuralgia induced by simple venous compression.Part 4Complications and prognosis influence factors of microvascular decompression in treating primary trigeminal neuralgiaOBJECTIVE:To explore the clinical effect of MVD on treating primary trigeminal neuralgia,summarize the postoperative complications and management strategies,and screen the risk factors that affected prognosis,so as to reduce the incidence of complications and improve the surgical efficacy.METHODS:369 trigeminal neuralgia patients with complete follow-up data that received MVD in the Neurosurgery of our hospital from January 2011 to December 201 5 were retrospectively analyzed.The clinical efficacy and postoperative complications were analyzed;moreover,single factor chi-square test and logistic multiple regression analysis were carried out,respectively,so as to screen the independent risk factors that affected the effect of MVD on treating trigeminal neuralgia.RESULTS:351 cases achieved effective effect during the 12-month follow-up after surgery,while 18 cases were ineffective.Meanwhile,the temporary complications included facial numbness(n=22,5.96%),disequilibrium(n=5,1.36%),dizziness and headache(n=31,8.40%),cerebrospina]fluid leak(n=9,2.44%),intracranial infection(n=8,2.1 7%),and epileptic seizure(n=1,0.27%).Aggressive symptomatic treatments were carried out for the discovered complications,and all symptoms were recovered or cured.The permanent complications included facial numbness(n=19,5.1 5%),hearing disturbance and tinnitus(n?6,1.63%),dizziness(n=2,0.54%),disequilibrium(n?4,1.08%),hearing loss(n=3,0.81%),and death(n=1,0.27%).Singe factor analysis suggested that the trigeminal neuralgia pain type,with or without vascular compression in preoperative imaging examination,compressed part and with or without responsible blood vessel intraoperatively were the factors affecting the clinical effect of MVD on treating trigeminal neuralgia.Multi-factor results demonstrated that,the risks of ineffective prognosis of atypical trigeminal neuralgia,no vascular compression and no responsible blood vessel were 8.032(95%CI:3.827-16.842),3.939(95%CI:2.505-6.195)and 9.134(95%CI:4.295-19.426)folds of those of typical trigeminal neuralgia,with vascular compression and with responsible blood vessel,respectively.CONCLUSION:It is safe and effective to treat primary trigeminal neuralgia by MVD,among which,the atypical clinical manifestations,no vascular compression and non-arterial factor are the independent risk factors that affect prognosis.It is of great significance to summarize the complications after MVD and management strategies to reduce the incidence of postoperative complications and to improve the surgical efficacy.Part 5Efficacy of percutaneous balloon compression of trigeminal ganglia in treating trigeminal neuralgia with ineffective MVD or recurrenceOBJECTIVE:To explore the safety and therapeutic effect of percutaneous balloon compression of trigeminal ganglia on treating primary trigeminal neuralgia patients with ineffective MVD or recurrence.METHODS:Clinical data and efficacy of 15 primary trigeminal neuralgia patients with ineffective MVD or recurrence who underwent percutaneous balloon compression in the Neurosurgery of our hospital from June 2014 to June 2017 were retrospectively analyzed.RESULTS:For the patients in this study,the average length of stay was 5 days,and no severe surgical complication was reported.13 cases achieved complete remission of pain after surgery,1 had pain occasionally with no need of medication,and 1 had controllable pain after taking medicine.11 cases had hypesthesia in the affected face after surgery,9 had masticatory weakness,6 had labial herpes,and the symptoms were improved or disappeared within 1-6 months after symptomatic treatment for rehabilitation.The patients were followed up for an average of 21.6 months,and 3 cases had recurrence.CONCLUSION:Percutaneous balloon compression of trigeminal ganglia can serve as an ideal minimally invasive remedy treatment for ineffectiveness after MVD or recurrent trigeminal neuralgia,which is ascribed to its advantages of rapid operation,safety,minimally invasive nature,effectiveness,and implementation under general anesthesia.The major achievements and significance in this project are summarized as follows.1.It normalizes the surgical ind ications for MVD in treating primary trigeminal neuralgia through comprehensively evaluating the preoperative symptomato logic features and analyzing the postoperative efficacy of patients of various subtypes.2.It employs multi-modal image fusion technique for accurate preoperative assessment,so that the patients are accurately diagnosed,and this can also provide reference for the design of surgery program.3.It summarizes the clinical features of trigeminal neuralgia induced by special responsible blood vessel and the surgical efficacy,and believes that simple venous compression can also be the responsible blood vessel in patients with primary trigeminal neuralgia;besides,it is safe and effective to implement MVD.4.It carefully analyzes the complications after MVD,and proposes corresponding prevention and management strategies.5.It comprehensively analyzes the patient clinical data and follow-up data and adopts the related statistical methods to obtain that,atypical clinical manifestations,no vascular compression in preoperative imaging examination,and no definite responsible blood vessel intraoperatively are the independent risk factors affecting prognosis.6.It puts forward individualized diagnosis and treatment schemes for patients failing the MVD or with recurrence trigeminal neuralgia,and percutaneous balloon compression is a reasonable remedy treatment for patients who refuse a second surgery.This project was based on clinical problems and the research has carefully analyzed and summarized multiple aspects of MVD in treating trigeminal neuralgia preoperatively intraoperatively and postoperatively,which can further normalize the indications of MVD in treating trigeminal neuralgia,improve the surgical efficacy,and prevent the occurrence of postoperative complications.Importantly,it makes it possible to safely and effectively treat trigeminal neuralgia patients that fail the MVD or with recurrence. |
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