三叉神经根临床解剖及电生理研究
发布时间：2018-07-25 14:44
【摘要】：第一部分乙状窦后入路三叉神经根临床解剖学观察 目的 通过乙状窦后入路，显微镜下观察三叉神经根及其周围结构，识别感觉主根、运动根，指导微血管减压手术。 资料和方法 收集广东省第二人民医院神经外科自2012年3月至2013年12月收治的行微血管减压的患者共220例,其中120例原发性三叉神经痛（TN）为实验组，100例原发性面肌痉挛（HFS）为对照组。通过乙状窦后入路进行手术，术中通过观察，将血管与三叉神经的关系分明显压迫型、接触型及无压迫型三类，将明显压迫型及接触型均称为有血管压迫。术中在显微镜下将三叉神经感觉主根分为8个区域：I为外侧区，II外上区，III中上区，IV内上区，V内侧区，VI内下区，VII中下区，VIII外下区（见图5）。探查并记录血管与三叉神经根的关系及类型，对比分析两组病人之间有无差别，统计责任血管压迫三叉神经的方位。然后，从两组病患中各选取20例，对三叉神经脑干角、三叉神经感觉主根及运动根进行详细观察及测量，对比两组病人三叉神经脑干角有无差别，同时得出感觉主根长、宽、厚度等详细数据，并记录运动根与感觉主根的位置关系。最后记录影响手术视野暴露的结构，桥前池、岩骨、岩上静脉。所有患者均行头部磁共振血管增强成像（MRA）检查，排除桥小脑角继发性病变，同时排除既往曾行伽马刀、三叉神经根选择性切断术等三叉神经手术的病患。 结果 1、术中血管压迫三叉神经，三叉神经痛组血管压迫率（81.7%）明显高于面肌痉挛组血管压迫率（8%）。 2、三叉神经痛组有血管压迫的98例（81.7%），其中5例为2支动脉血管压迫，1例为3支动脉血管压迫，3例为动静脉联合压迫，单纯静脉压迫2例，总计记录责任血管108条。责任血管中，小脑上动脉为主要责任血管，有82例（75.9%），且以上方压迫多见；其次为小脑前下动脉，13例（12.0%），主要从下方推移压迫三叉神经；椎基底动脉压迫7例（6.5%），多从内侧压迫三叉神经根；岩静脉压迫4例（3.7%），多从三叉神经根的外侧压迫三叉神经。其他责任血管有桥动脉及其他细小分支动脉2例（1.9%）。 3、两组病患三叉神经脑干角没有差别，角度变化范围均为10-80°，且多数为30-50°。 4、两组病患三叉神经感觉主根的长度、宽度、厚度无差别，其长度为12.8±1.5mm，宽度3.5±0.6mm，厚度2.7±0.3mm； 5、在术中可记录到独立的三叉神经运动根（或异行感觉根）根丝数目为3-14条，直径为0.3-1mm，自桥脑单独发出，发出点位于感觉主根内侧、内上方及内下方，与感觉主根伴行进入Meckel’s囊。运动根之根存在吻合，运动根与感觉根之间也存在吻合。 6、受解剖学及医学伦理学限制，对感觉主根无法分出第1、2、3支，也无法辨别异行感觉根与运动根。 结论 1、血管压迫是三叉神经痛的病因之一；桥前池狭小、岩骨隆起制约对于三叉神经根及Meckel’s囊的观察。 2、根据运动根的形态、起源点、分布规律以及与感觉主根的关系，可以镜下准确识别三叉神经运动根，，并加以保护。 第二部分三叉神经根电生理研究 目的 通过电生理监测，辨别三叉神经感觉纤维、运动纤维、异行感觉根，研究三叉神经根有传导功能的纤维的分布规律。 资料和方法 收集31例行乙状窦后入路微血管减压术的患者，其中18例为原发性三叉神经痛患者（实验组），13例为原发性面肌痉挛患者（对照组）。术中解剖分离三叉神经颅内段感觉主根、运动根(异行感觉根)；术中将感觉主根分为8个区域逐一给予0.2mA的电流刺激。其中I、II、VIII区为感觉主根的外侧，III、VII区为中部，IV、V、VI为内侧。在外周眶上孔、眶下孔、颏孔记录V1、V2、V3的复合神经动作电位（CNAP），在咬肌和颞肌处记录复合肌肉动作电位（CMAP）；以刺激时出现复合神经动作电位（CNAP）的区域为感觉神经纤维，以刺激时出现复合肌肉动作电位（CMAP）的区域为运动神经纤维；对比两组患者，神经纤维分布有无差别；最后根据复合神经动作电位及复合肌肉动作电位出现的频率确定三叉神经根有传导功能的纤维（感觉纤维、运动纤维）的空间分布规律。 结果 1.刺激三叉神经根，所有病例均可在外周眶上孔、眶下孔、颏孔处记录到稳定的复合神经动作电位，在咬肌和颞肌处记录到稳定的复合肌肉动作电位； 2.刺激感觉主根时，主要记录到的为复合神经动作电位； 3.刺激运动根或感觉主根内侧时，可以记录到咬肌和（或）颞肌的复合肌肉动作电位，同时伴有V1、V2、V3一支或多支的复合神经动作电位；但刺激运动根产生的复合肌肉动作电位波幅（60-90uV）高于刺激感觉主根内侧产生的复合肌肉动作电位波幅（30-60uV）； 4.刺激异行感觉根时，外周记录不到复合神经动作电位及复合肌肉动作电位，但并非所有的病例均可发现异行感觉根的存在。 结论 1、运用复合神经动作电位和复合肌肉动作电位能帮助识别三叉神经的感觉主根、运动根及异行感觉根，避免运动根的损伤。 2、刺激运动根，电信号在半月节内可泛化至外周感觉神经根，结合临床病例观察推测，三叉神经运动纤维参与了三叉神经痛的发生与发展。
[Abstract]:Part one clinical anatomic observation of trigeminal nerve root after retrosigmoid approach
objective
Through the retrosigmoid approach, the trigeminal nerve root and its surrounding structures were observed under microscope, and the sensory root and motor root were identified to guide microvascular decompression operation.
Information and methods
220 cases of microvascular decompression were collected from the Department of Neurosurgery of Guangdong No.2 People's Hospital from March 2012 to December 2013. 120 cases of primary trigeminal neuralgia (TN) were used as the experimental group and 100 cases of primary hemifacial spasm (HFS) as the control group. The operation was carried out through the retrosigmoid sinus approach, and the vessels and trigeminal nerve were observed during the operation. The relationship clearly showed three types of compression type, contact type and no oppression type. The obvious compression type and contact type were all called vascular compression. Under the microscope, the main root of trigeminal nerve was divided into 8 regions: I in the lateral region, II upper region, upper III, IV upper region, V inside region, VI inner subregion, VII middle and lower region, VIII outer and lower region (see Figure 5). The relationship between the blood vessels and the trigeminal nerve root was recorded and the difference between the two groups was compared, and the position of the trigeminal nerve was compressed by the statistical responsible blood vessels. Then, 20 cases were selected from two groups of patients. The trigeminal brainstem angle, the trigeminal sensory root and the motor root were observed and measured in detail, and the trigeminal nerves were compared to the two groups of the trigeminal gods. At the same time, the length, width, thickness and other detailed data of the sensory root were obtained, and the relationship between the moving root and the position of the sensory root was recorded. Finally, the structure of the surgical field, the anterior pontine, the rock bone, and the upper rock vein were recorded. All the patients were examined by head magnetic resonance blood Guan Zengqiang imaging (MRA), and the secondary venereal disease in the cerebellopontine angle was excluded. Meanwhile, patients with trigeminal neurosurgery who had undergone gamma knife surgery and trigeminal selective rhizotomy were excluded.
Result
1, intraoperative vascular compression of trigeminal nerve, trigeminal neuralgia group vascular compression rate (81.7%) was significantly higher than that of hemifacial spasm group vascular compression rate (8%).
2, there were 98 cases of vascular compression in the trigeminal neuralgia group (81.7%), of which 5 cases were compressed by 2 arteries, 1 cases were oppressed by 3 arteries, 3 cases were combined with arteriovenous compression, 2 with pure vein compression, and 108 vessels of responsible vessels. In the responsible vessels, the superior cerebellar artery was mainly responsible for vessels, 82 cases (75.9%), and oppressive above. The second was the inferior cerebellar inferior artery, 13 cases (12%), which mainly oppressed the trigeminal nerve from the lower part; the vertebral basilar artery oppressed 7 cases (6.5%), oppressed the trigeminal nerve root mostly from the medial, 4 cases (3.7%) oppressed the vein, and more from the lateral of the trigeminal nerve root. The other vessels had the bridge artery and the other small branch arteries in 2 cases (1.9%).
3, there was no difference in the trigeminal nerve stem angle between the two groups, the angle variation range was 10-80 degrees, and most of them were 30-50 degrees.
The length, width and thickness of the sensory root of the 4 trigeminal nerve in two groups were not different, the length was 12.8 + 1.5mm, the width was 3.5 + 0.6mm, and the thickness was 2.7 + 0.3mm.
5, the number of the independent trigeminal motor root (or the sensory root) of the trigeminal nerve (or the sensory root) was 3-14, and the diameter was 0.3-1MM. It was produced separately from the bridge brain. The emit point was located inside the sensory root, above and below the inner part of the sensory root. The root of the motor root was in anastomosis with the root of the sensory root. There was a kiss between the root and the sensory root, and there was a kiss between the moving root and the sensory root. Close.
6, restricted by anatomy and medical ethics, it is impossible to distinguish the 1,2,3 branch from the sensory main root, nor can it distinguish the root and the moving root of the diverting sensation.
conclusion
1, vascular compression is one of the causes of trigeminal neuralgia. The anterior bridging pool is small and the bony bone protuberance restricts the observation of the trigeminal nerve root and the Meckel 's capsule.
2, according to the morphology, origin, distribution and the relationship with the sensory root, we can accurately identify the motor roots of trigeminal nerve and protect them.
The electrophysiological study of the second part of the trigeminal nerve root
objective
By electrophysiological monitoring, the trigeminal sensory fibers, motor fibers and abnormal sensory roots were distinguished, and the distribution of fibers with conduction function in trigeminal nerve roots was studied.
Information and methods
31 patients with posterior sigmoid microvascular decompression were collected, of which 18 were patients with primary trigeminal neuralgia (experimental group), 13 were patients with primary hemifacial spasm (control group). Intraoperative anatomical separation of the sensory main root of the trigeminal nerve and the moving root (sensory root) was dissected during the operation, and the sensory root was divided into 8 regions to give 0.2mA one by one. Current stimulation. The I, II, and VIII areas are the lateral of the sensory root, and the III, VII region is the middle, IV, V, VI are inside. In the peripheral orbital foramen, the suborbital hole, and the mental pore record the V1, V2, V3 compound nerve action potential (CNAP) and the region of the compound nerve action potential at the masseter and temporal muscles. Sensory nerve fibers, the region of the complex muscle action potential (CMAP) that appears as a motor nerve fiber at the time of stimulation; compared to the two groups of patients, the distribution of nerve fibers is different; finally, according to the frequency of the compound nerve action potential and the frequency of the complex muscle action potential, the fibers of the trigeminal root have the conduction function (sensory fiber, sports fiber). The spatial distribution of dimensions.
Result
1. stimulation of the trigeminal nerve root, all cases were able to record a stable compound nerve action potential at the peripheral orbital foramen, suborbital foramen and mental hole, and a stable complex muscle action potential was recorded at the masseter and temporalis muscles.
2. when stimulating the sensory root, the compound nerve action potential was recorded.
3. the compound muscle action potential of the masseter and / or temporal muscle can be recorded at the medial part of the motor root or the sensory root of the sensory root, with the combined action potential of one or more branches of V1, V2, V3, but the amplitude (60-90uV) of the compound muscle action potential (60-90uV) produced by the stimulation of the motor root is higher than that of the compound muscle action potential produced on the inside of the sensory primary root. Amplitude (30-60uV);
4. when the sensory roots were stimulated, the peripheral nerve action potential and the complex muscle action potential were not recorded in the peripheral blood, but not all the cases could find the existence of the sensory root of the alien line.
conclusion
1, using the combined action potential and the complex muscle action potential can help to identify the sensory root of the trigeminal nerve, the moving root and the sensory root of the different lines, and avoid the injury of the motor root.
2, stimulates the movement root, the electrical signal can be generalized to the peripheral sensory nerve root in the semilunar node. Combined with clinical case observation, it is conjectured that trigeminal motor fibers participate in the occurrence and development of trigeminal neuralgia.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R322.85
本文编号：2144146
[Abstract]:Part one clinical anatomic observation of trigeminal nerve root after retrosigmoid approach
objective
Through the retrosigmoid approach, the trigeminal nerve root and its surrounding structures were observed under microscope, and the sensory root and motor root were identified to guide microvascular decompression operation.
Information and methods
220 cases of microvascular decompression were collected from the Department of Neurosurgery of Guangdong No.2 People's Hospital from March 2012 to December 2013. 120 cases of primary trigeminal neuralgia (TN) were used as the experimental group and 100 cases of primary hemifacial spasm (HFS) as the control group. The operation was carried out through the retrosigmoid sinus approach, and the vessels and trigeminal nerve were observed during the operation. The relationship clearly showed three types of compression type, contact type and no oppression type. The obvious compression type and contact type were all called vascular compression. Under the microscope, the main root of trigeminal nerve was divided into 8 regions: I in the lateral region, II upper region, upper III, IV upper region, V inside region, VI inner subregion, VII middle and lower region, VIII outer and lower region (see Figure 5). The relationship between the blood vessels and the trigeminal nerve root was recorded and the difference between the two groups was compared, and the position of the trigeminal nerve was compressed by the statistical responsible blood vessels. Then, 20 cases were selected from two groups of patients. The trigeminal brainstem angle, the trigeminal sensory root and the motor root were observed and measured in detail, and the trigeminal nerves were compared to the two groups of the trigeminal gods. At the same time, the length, width, thickness and other detailed data of the sensory root were obtained, and the relationship between the moving root and the position of the sensory root was recorded. Finally, the structure of the surgical field, the anterior pontine, the rock bone, and the upper rock vein were recorded. All the patients were examined by head magnetic resonance blood Guan Zengqiang imaging (MRA), and the secondary venereal disease in the cerebellopontine angle was excluded. Meanwhile, patients with trigeminal neurosurgery who had undergone gamma knife surgery and trigeminal selective rhizotomy were excluded.
Result
1, intraoperative vascular compression of trigeminal nerve, trigeminal neuralgia group vascular compression rate (81.7%) was significantly higher than that of hemifacial spasm group vascular compression rate (8%).
2, there were 98 cases of vascular compression in the trigeminal neuralgia group (81.7%), of which 5 cases were compressed by 2 arteries, 1 cases were oppressed by 3 arteries, 3 cases were combined with arteriovenous compression, 2 with pure vein compression, and 108 vessels of responsible vessels. In the responsible vessels, the superior cerebellar artery was mainly responsible for vessels, 82 cases (75.9%), and oppressive above. The second was the inferior cerebellar inferior artery, 13 cases (12%), which mainly oppressed the trigeminal nerve from the lower part; the vertebral basilar artery oppressed 7 cases (6.5%), oppressed the trigeminal nerve root mostly from the medial, 4 cases (3.7%) oppressed the vein, and more from the lateral of the trigeminal nerve root. The other vessels had the bridge artery and the other small branch arteries in 2 cases (1.9%).
3, there was no difference in the trigeminal nerve stem angle between the two groups, the angle variation range was 10-80 degrees, and most of them were 30-50 degrees.
The length, width and thickness of the sensory root of the 4 trigeminal nerve in two groups were not different, the length was 12.8 + 1.5mm, the width was 3.5 + 0.6mm, and the thickness was 2.7 + 0.3mm.
5, the number of the independent trigeminal motor root (or the sensory root) of the trigeminal nerve (or the sensory root) was 3-14, and the diameter was 0.3-1MM. It was produced separately from the bridge brain. The emit point was located inside the sensory root, above and below the inner part of the sensory root. The root of the motor root was in anastomosis with the root of the sensory root. There was a kiss between the root and the sensory root, and there was a kiss between the moving root and the sensory root. Close.
6, restricted by anatomy and medical ethics, it is impossible to distinguish the 1,2,3 branch from the sensory main root, nor can it distinguish the root and the moving root of the diverting sensation.
conclusion
1, vascular compression is one of the causes of trigeminal neuralgia. The anterior bridging pool is small and the bony bone protuberance restricts the observation of the trigeminal nerve root and the Meckel 's capsule.
2, according to the morphology, origin, distribution and the relationship with the sensory root, we can accurately identify the motor roots of trigeminal nerve and protect them.
The electrophysiological study of the second part of the trigeminal nerve root
objective
By electrophysiological monitoring, the trigeminal sensory fibers, motor fibers and abnormal sensory roots were distinguished, and the distribution of fibers with conduction function in trigeminal nerve roots was studied.
Information and methods
31 patients with posterior sigmoid microvascular decompression were collected, of which 18 were patients with primary trigeminal neuralgia (experimental group), 13 were patients with primary hemifacial spasm (control group). Intraoperative anatomical separation of the sensory main root of the trigeminal nerve and the moving root (sensory root) was dissected during the operation, and the sensory root was divided into 8 regions to give 0.2mA one by one. Current stimulation. The I, II, and VIII areas are the lateral of the sensory root, and the III, VII region is the middle, IV, V, VI are inside. In the peripheral orbital foramen, the suborbital hole, and the mental pore record the V1, V2, V3 compound nerve action potential (CNAP) and the region of the compound nerve action potential at the masseter and temporal muscles. Sensory nerve fibers, the region of the complex muscle action potential (CMAP) that appears as a motor nerve fiber at the time of stimulation; compared to the two groups of patients, the distribution of nerve fibers is different; finally, according to the frequency of the compound nerve action potential and the frequency of the complex muscle action potential, the fibers of the trigeminal root have the conduction function (sensory fiber, sports fiber). The spatial distribution of dimensions.
Result
1. stimulation of the trigeminal nerve root, all cases were able to record a stable compound nerve action potential at the peripheral orbital foramen, suborbital foramen and mental hole, and a stable complex muscle action potential was recorded at the masseter and temporalis muscles.
2. when stimulating the sensory root, the compound nerve action potential was recorded.
3. the compound muscle action potential of the masseter and / or temporal muscle can be recorded at the medial part of the motor root or the sensory root of the sensory root, with the combined action potential of one or more branches of V1, V2, V3, but the amplitude (60-90uV) of the compound muscle action potential (60-90uV) produced by the stimulation of the motor root is higher than that of the compound muscle action potential produced on the inside of the sensory primary root. Amplitude (30-60uV);
4. when the sensory roots were stimulated, the peripheral nerve action potential and the complex muscle action potential were not recorded in the peripheral blood, but not all the cases could find the existence of the sensory root of the alien line.
conclusion
1, using the combined action potential and the complex muscle action potential can help to identify the sensory root of the trigeminal nerve, the moving root and the sensory root of the different lines, and avoid the injury of the motor root.
2, stimulates the movement root, the electrical signal can be generalized to the peripheral sensory nerve root in the semilunar node. Combined with clinical case observation, it is conjectured that trigeminal motor fibers participate in the occurrence and development of trigeminal neuralgia.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R322.85
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相关期刊论文 前3条
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2 朱亚文;乔威;;三叉神经根与周围血管关系及其临床意义[J];中国临床解剖学杂志;2006年06期
3 柏根基,王鹤鸣,韩群颖,姜平,童鑫康,方实邦;三叉神经桥池段的断层解剖及其临床意义[J];中国临床解剖学杂志;1999年02期
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