经皮下颌角入路卵圆孔穿刺半月神经节射频术治疗原发性三叉神经痛的临床应用

发布时间：2018-04-29 00:31

本文选题：下颌角 + 卵圆孔　；参考：《浙江大学》2015年硕士论文

【摘要】：目的原发性三叉神经痛(Trigeminal neuralgia, TN)好发于中老年人群,疼痛剧烈且顽固,口服卡马西平有效但易复发。国内外比较公认原发性三叉神经痛是由于三叉神经感觉根入髓区(Root entry zone, REZ)存在血管压迫和脱髓鞘改变,微血管减压术效果满意。但对于部分心肺功能较差或其他脏器功能不全的的患者开颅手术风险较大,以及术后复发的患者再次开颅手术的依从性欠佳,对于此类患者经皮卵圆孔穿刺半月神经节射频术是较理想的治疗手段。射频热凝治疗TN一般采用Hartel前入路卵圆孔穿刺法,入颅后结合电生理测试寻找射频治疗的靶点,文献报道存在4%的穿刺失败率且术中常伴随一定的神经血管损伤的并发症,远期存在一定的复发率。为进一步降低风险并提高治疗效果,本研究采用经皮下颌角入路颅底卵圆孔穿刺选择性半月神经节内靶点射频术治疗原发性三叉神经痛并评价其疗效和安全性。方法选择原发性三叉神经痛患者60例,疼痛视觉模拟评分(Visual analogue scale, VAS)大于或等于8分。采用随机数字表法将患者随机分为2组,H组(n=30)以Hartel前入路法进行颅底卵圆孔穿刺；G组(n=30)以患侧下颌角为穿刺点进行颅底卵圆孔穿刺,两组以同样的参数进行半月神经节内靶点测试和射频热凝。比较两组穿刺成功率和相关并发症发生率,记录术后Id、7d、1m、6m、12m、24m,36月VAS评分和巴罗神经学研究所疼痛分级(BNI pain score)评估比较两组镇痛治疗效果。结果 H组穿刺的成功率为96.7%,G组为93.3%(P0.05),H组穿刺时出现血肿3例,G组血肿1例(P0.05)；H组射频热凝累及正常三叉神经分支11例(36.7%),三叉神经运动纤维损伤8例(26.7%)；G组无一例累及正常三叉神经分支,三叉神经运动纤维损伤3例(10%),两组比较具有显著性差异(P0.05)。H组各时点有效率为96.7%、96.7%、96.7%、93.3%、83.3%、73.3%、70%,G组各时点有效率为96.7%、96.7%、96.7%、96.7%、96.7%、93.3%、86.7%；两组术后12月,24月和36月的有效率比较具有显著性差异(P0.05) 结论经皮下颌角入路卵圆孔穿刺半月神经节射频热凝术治疗原发性三叉神经痛具有穿刺径路合理、并发症少、更高的靶点选择性和更低的远期疼痛复发率等优势。
[Abstract]:Purpose Primary trigeminal neuralgia (TNN) occurs in the middle and elderly population. The pain is severe and stubborn. The oral administration of carbamazepine is effective but easy to relapse. It is generally acknowledged that primary trigeminal neuralgia is due to the presence of vascular compression and demyelinating changes in the sensory root of trigeminal nerve into the medullary area. The effect of microvascular decompression is satisfactory. But for some patients with poor cardiopulmonary function or other organ dysfunction, the risk of craniotomy was higher, and the compliance of patients with recurrent craniotomy was poor. For these patients, percutaneous foramen ovale puncture semilunar ganglion radiofrequency is an ideal treatment. Radiofrequency thermocoagulation (RFA) is commonly used in the treatment of TN by Hartel anterior approach foramen ovale puncture, posterior craniotomy combined with electrophysiological test to find the target of radiofrequency therapy. It is reported that there are 4% failure rate of puncture and some complications associated with nerve and vascular injury during the operation. There is a long-term recurrence rate. In order to further reduce the risk and improve the therapeutic effect, this study was conducted to evaluate the efficacy and safety of selective radiofrequency radiofrequency in the treatment of primary trigeminal neuralgia by percutaneous mandibular angle approach with selective puncturing the foramen ovale of the skull base. Method Visual analogue scale (vas) score of 60 patients with primary trigeminal neuralgia was greater than or equal to 8 points. The patients were randomly divided into 2 groups by random digital table. The patients were treated with Hartel's anterior approach to puncture the foramen ovale of the base of the skull. Group G was punctured with the mandibular angle of the affected side as the puncture point, and the foramen ovale of the base of the skull was punctured with the anterior approach of Hartel. The same parameters were used to measure the targets in the meniscus ganglion and radiofrequency thermocoagulation. The success rate of puncture and the incidence of related complications were compared between the two groups. The analgesic effect of the two groups was evaluated by VAS score at 36 months and the pain score by Barrow Institute of Neurology (BNI pain scorere). Result The success rate of puncture in group H was 96.7%. In group G, there were 3 hematoma in group G and 3 cases in group H. 1 case of hematoma in group G involved normal trigeminal nerve branch with radiofrequency thermocoagulation, 11 cases with normal trigeminal nerve branch, and 8 cases with motor fiber injury of trigeminal nerve in group G without involvement of normal trigeminal nerve branch. There were significant differences between the two groups in the effective rate of 96.77.796.79.70.The effective rate of each time point in group H was 96.77.79.79.76.70.The effective rate of the two groups was 96.796. 796. 796. 790. 7796. 7796. 7796. 7796. 7790. 790. 7790. 790. 790. 7 and 96.7. the effective rates of the two groups were 96.796. 796. 793. 3 and 86. 7 respectively. The effective rates of 24 months and 36 months after operation were significantly higher in the two groups than in the other two groups (P 0. 05, P 0. 05, P 0. 05, P 0. 05, P 0. 05, P 0. 05, P 0. 05, P 0. 05). Conclusion Radiofrequency thermocoagulation for the treatment of primary trigeminal neuralgia by percutaneous foramen ovale puncture has the advantages of reasonable puncture route, less complications, higher target selectivity and lower long-term pain recurrence rate.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R614

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