【作者】 刘宁涛；

【导师】 李世亭；

【作者基本信息】 同济大学 ， 神经外科， 2005， 硕士

【摘要】 随着现代显微神经外科技术的不断发展和提高，微血管减压术已逐渐成为治疗三叉神经痛的首选方法，而如何合理选择手术适应证，规范手术治疗方法，提高手术疗效，降低手术并发症等一直是众多临床医师关注的焦点。基于此目的，我们对微血管减压术治疗三叉神经痛开展了基础和临床的系列研究。本研究重点为：(1)研究与微血管减压术直接相关的三叉神经根周围岩静脉系统、动脉系统血管及其滋养血管解剖特点以及手术可能涉及的滑车神经、展神经的解剖特点。(2)结合患者临床特点和影像学检查，术前合理评估和选择合适病例。(3)术中观察压迫血管的来源、类型、部位以及神经血管压迫的程度，与三叉神经痛的临床特点有机地结合起来，提高手术水平。(4)通过术后疗效评估和随访资料，运用统计学方法系统分析影响手术疗效的关键因素，更好地指导临床治疗。通过本课题研究，可进一步规范微血管减压术治疗三叉神经痛的适应证，提高疼痛控制的有效率，降低术后并发症。第一部分微血管减压术治疗三叉神经痛相关显微解剖研究目的：为临床微血管减压术治疗三叉神经痛提供相关岩静脉、动脉血管及滑车神经、展神经的显微解剖学资料。材料与方法：解剖尸体头颅20例40侧：打开颅盖，去除大脑组织并打开小脑幕，显微镜下解剖观察①岩静脉形态、行径及其与三叉神经的毗邻关系；②三叉神经根与小脑上动脉、小脑前下动脉、基底动脉等周围血管的关系；③幕下滑车神经、展神经及其与三叉神经根毗邻关系等的解剖特征。结果：①总结岩静脉的显微解剖特征、走行及属支情况，测量了与手术有关的距离，提出了微血管减压术中处理岩静脉的指征与最佳方法。②与三叉神经根关系密切的血管包括小脑上动脉、小脑前下动脉及基底动脉的脑桥支。87.5％(35／40)的小脑上动脉主干和分支结合处距离三叉神经根最近。三叉神经根滋养动脉主要发自基底动脉的脑桥支、小脑前下动脉和小脑上动脉。③滑车神经、展神经距离三叉神经的最短距离分别为4.0mm±14.1mm和6.3±1.38mm。结论：①岩静脉和三叉神经根关系密切，明确其解剖特点后在微血管减压术中即能较好地处理岩静脉，为手术创造良好条件。②小脑上动脉、小脑前下动脉及其他基底动脉的脑桥支等分支血管在行经三叉神经根时，一方面可对神经根形成压迫，另一方面可发出分支营养三叉神经根。小脑上动脉主干和分支结合处距离三叉神经最近。③在微血管减压术中应重视滑车神经、展神经的解剖特点并加以保护。第二部份微血管减压术治疗三叉神经痛的术前评估目的：通过术前综合评估，探讨微血管减压术治疗三叉神经痛的适应征。材料与方法：分析62例经微血管减压术治疗的三叉神经痛患者的临床表现、发病特点、病程、既往其他治疗情况以及影像学检查，提出了典型和非典型三叉神经痛的分类标准，进行详细而全面的术前评估。结果：45例典型TN患者病程1月～10年，平均3.1年；疼痛初发年龄为30～84岁，平均60.3岁。20例(44.4％)为三叉神经单支分布范围内疼痛，25例(55.6％)为三叉神经二支或三支分布范围内疼痛。17例非典型TN患者的病程为5年～15年，平均8.7年；疼痛初发年龄为39岁～70岁，平均55.5岁，均为三叉神经二支或三支分布范围内疼痛。两组患者起病年龄及病程之间均存在显著统计学差异(P＜0.01)。结论：(1)扳机点位置与疼痛分布范围之间有对应关系；(2)随着病程的延长，典型三叉神经痛有向非典型三叉神经痛转变的趋势。(3) MRTA在三叉神经痛病因学诊断上具有独特作用。第三部分微血管减压术治疗三叉神经痛的术中观察目的：通过术中详细观察，探讨影响微血管减压术减压效果的各种可能因素。材料与方法：详细观察记录62例行MVD手术的TN患者术中压迫血管的类型、神经压迫部位和程度以及减压情况，将神经血管压迫程度分为：单纯接触、单纯粘连、接触和移位、粘连和移位、粘连移位和萎缩。结果：在62例患者中，47例为动脉血管压迫，包括SCA、AICA、PICA等；13例为动、静脉混合压迫；2例为不明血管压迫，其中45例典型TN患者中39例(86.7％)为动脉压迫，6例(13.3％)为动、静脉混合压迫。17例不典型TN患者中，10例(58.8％)为动脉压迫，7例(41.2％)为动、静脉混合压迫。压迫部位以三叉神经根部外侧和内侧压迫最为多见。62例患者血管神经压迫程度显示：有14例仅为接触压迫，7例为接触和移位，15例为粘连和移位，8例为粘连、移位和神经萎缩。62例TN患者中50例(80.6％)获得充分减压，12例(19.4％)仅部分减压。结论：颅内段三叉神经根部任何部位血管压迫均可能导致三叉神经痛，提倡术中进行三叉神经根部全程充分减压。在对压迫程度进行量化分类基础上提出了针对不同压迫情况的减压技术，使手术方案更加合理和有效。第四部份微血管减压术治疗三叉神经痛的术后研究目的：通过术后综合分析，探讨影响手术疗效的各种可能因素，规范微血管减压术治疗三叉神经痛的手术适应征。材料与方法：对62例经MVD治疗的TN患者采用单因素和多因素统计分析方法分别详细分析其性别、年龄、病程、临床表现、术中所见与手术疗效之间的关系，提出了更加符合临床实际的疗效评估体系：即刻缓解；延迟缓解；明显减轻；无效。结果：典型TN患者的疗效要明显优于非典型TN患者，而且病程在三年以上的患者都有转为不典型的趋势；对发病年龄、病程、临床症状、压迫程度和减压程度进行Logistic多元线性回归分析，提示上述5个影响因素均与手术疗效呈正相关，其中临床症状与手术疗效之间有相关性(P＜0.05)，而发病年龄、病程、压迫程度和减压程度与手术疗效之间呈显著相关性(P＜0.01)。结论：为了提高手术疗效，在患者临床症状转变为不典型之前就接受MVD手术更加合理，这也是MVD治疗三叉神经痛的最佳手术时机。新的疗效评估体系更有利于医师正确判断病情，及时调整治疗方案，从而提高患者的总体疗效。更多还原

【Abstract】 A Series of Studies on the Treatment of Trigeminal Neuralgia by Microvascular DecompressionAs modern microneurosurgery progresses and advances continuously, Microvascular Decompression (MVD) has increasingly been the first choice for the treatment of Trigeminal Neuralgia(TN) in the field of the neurosurgery. Whereas, how to determine the sound indication selection, standardize and regulate treatment method, improve efficacy and lower the occurrence of complications still remain the unsettled issue followed with interests by the clinicians undertaking neurosurgery. Given the topic stated above, we conducted a series of fundamental and clinical studies on the treatment of TN by MVD.Here follow the key points closely concerned with the studies above:①investigation on the anatomical features of the petrous venous and arteries along with its nutrient vessels that enclosing trigeminal nerve root directly pertinent to MVD and the trochlear and abducent nerve involved in MVD potentially.②sound preoperative appraisal and appropriate case selection in the light of the clinical manifestation and its correspondent presentation of the neuroimaging examination.③methodical combination between the observation information on the origin, type, site and severity of neurovascular conflict (NVC) during the operation with the clinical manifestation of TN for better treatment.④adoption of the statistical principle to systemically analyze the key factor that may exerts great influences on treatment efficacy in virtue of the datum gleaning in the follow-up survey for valuable instruction to ameliorate clinical treatment.In sum, it is promised to further regulate the indication for TN treatment by MVD, improve the efficacy of pain relief or even mitigation and avoid the occurrence of post-operative complications by means of the study here focused.Part One:Microanatomic study in the Treatment of Trigeminal Neuralgia by Microvascular DecompressionObjective:To provide micranatomic datum concerned with petrous venous and arterial vessels as well as trochlear and abducent nerve for the treatment of TN by MVD.Material and Methods:We dissected 20 cadaver skulls(40 hemispheres): To begin with, opened the calvaria and removed the entire cerebrum, then opened the tentorium of cerebellum and observed by microscope: (1) the morphology and course of petrous vein as well as its syntopy with trigeminal nerve; (2) the syntopy between the trigeminal nerve and its peripheral blood vessels such as SCA, AICA, BA and so on; (3) the anatomical features on the syntopy between subtentorial trochlear and abducent nerve with trigeminal nerve.Results:(1) In terms of the microsurgical anatomic features such as course and divisions of petrous vein and distance measurement relating to the operation program, we advance the treatment indication and optimal management of the petrous vein during MVD period;(2)There are some blood vessels closely related to trigeminal nerve root including SCA, AICA and pontine branch of basilar artery. And, there are about 87.5% (35/40) of the junction points between SCA trunk and division that are nearest to trigeminal nerve root. Nutrient artery of the Trigeminal nerve root mainly stems from the pontine branch, AICA and SCA of the basilar artery;(3)4.0mm±14.1mm and 6.30mm±1.38mm are the shortest distance measurement between trochlear, abducent nerve and trigeminal nerve respectively.Conclusions:(1) Since petrous venous is contiguous to the trigeminal nerve root, with definite illustration of its anatomical features available, we can manage the petrous venous in a better way so as to initiate a favorable exposure and create a favorable condition for operation;(2) As a coin has two sides, the divisional blood vessels such as SCA, AICA and the pontine branch of basilar artery, while passing by the trigeminal nerve root, may not only compress the nerve root, but also spread its branch to nourish the trigeminal nerve root. It is the shortest span from the trigeminal nerve to the junction point where SCA trunk and its division intersects than any other exhibit;(3) Within the MVD we should attach importance to the anatomical features of trochlear and abducent nerve for better protection.Part Two:Pre-operative Appraisal on the Treatment of Trigeminal Neuralgia byMicrovascular DecompressionObjectives:To explore and argue the indication on the treatment of TN by MVD according to the pre-operative appraisal.Material and Methods:To analyze the clinical manifestation,pain onset, duration, anamnesis and the neuroimaging examination of the 62 patients who once suffered from TN and undergone MVD later and subsequently propose the classification criteria for typical and atypical TN and thereby conduct detailed and comprehensive pre-operative assessment.Results:Of 45 patients with typical trigeminal neuralgia,the mean duration is 3.1 years and the mean age of pain onset is 60.3 years.Single trigeminal division was involved in 20 patients(44.4%),and 2 or 3 divisions were involved in the other 25 patients(55.6%).As for 17 patients with atypical trigeminal neuralgia,the mean duration and the mean age of pain onset is 8.7 years and 55.5 years respectively.2 or 3 trigeminal divisions were involved in all of atypical patients. There is remarkable statistical discrepancy (p＜0.01) between the two groups of patients listed above.Conclusions: (1) the location of trigger point does correspond to the distribution region of the neuralgia;(2) As the duration of TN progresses, we can disclose a trend of transition from typical to atypical TN;(3) MRTA is of unique application in the diagnosis on the etiology of TN.Part Three:Intraoperative observation during the treatment of Trigeminai Neuralgia by Microvascular DecompressionObjectives:Relying on elaborate observation, it is expected to explore and argue each potential affecting factor in MVD treatment efficacy.Material and Methods:Observe and record all detailed datum about the type, site and severity of the neurovascular conflict along with decompression condition carefully in the MVD treatment of 62 patients who once suffered from TN. Neurovascular conflicts(NVC) were classified into five categories: single contact,contact and indentation,single adhesion,adhesion and indentation,and trigeminal nerve atrophy.Results:Of the 62 cases, 47 are classified as arterial vessel compressed by those such as SCA, AICA, PICA, etc; 13 are of arterial and venous simultaneously; 2 are of unidentified. It is the lateral and medial position where neurovascular compression frequently observed.During operation of typical TN, artery compression was found in 39 patients(86.7%),and the combined artery and venous compression was found in 6 patients(13.3%).As for 17 patients with atypical TN,artery compression occurred in 10 patients(58.8%),and the combined artery and venous compression were found in 7 patients(41.2%).Of the all 62 TN, 14 are single contact, 7 are contact and indentation; 15 are adhesion and indentation, 8 are adhesion, indentation and nerve atrophy. Of the 62 cases who underwent MCD, complete decompression were achieved in 50(80.6%)patients while the remaining 12(19.4%) got incomplete decompression.Conclusion:Any microvascualr compression on the intracranial trigeminal nerve root is conducive to lead to onset of TN, therefore,careful exploration should be considered along the root of trigeminal nerve to avoid any offending vessel,especially in the region of medial to trigeminal root and lateral portion of trigeminal root near Meckel’s cave. And it is also promised to rationalize, substantiate and validate the operative scheme when MVD responds to the specific compression on the basis of the quanlification and classification of compression degree and severity of NVC.Part Four:Post-operative study on the Treatment of Trigeminal Neuralgia by Microvascular DecompressionObjectives:By means of comprehensive post-operative assay and analysis,we explore the potential influencefactors during operation to regulate the indication of MVD in the treatment of TN. Material and Methods:As for the 62 TN cases underwent MVD, we adopt single and multi-factor statistical analysis to explicate the relationship on the basis of the datum such as gender, age, duration, clinical presentation, intraoperative presentation and treatment efficacy, whereafter, we frame the efficacy appraisal structure scales which far tally with the clinical practice than before:post-operative complete pain relief(excellent),delayed post-operative complete pain relief(better),significant pain relief(good) and no response to MVD(poor).Results:It is remarkably demonstrated that typical TN cases get more notable mitigation treatment than that of the atypical ones, moreover, which are apt to transit into atypical TN especially those with duration of over 3 years, we conduct Logistic multi-factor linear regression analysis for the initial age of pain onset, duration, manifestation and degree of the compression and decompression, which suggest the positive correlation between the five factors mentioned above and the treatment efficacy—positive correlation between clinical manifestation and efficacy (P＜0.05) and significant positive correlation between the remaining four and efficacy (P＜0.01).Conclusions:To better treatment efficacy, it is more appropriate to conduct MVD surgery before the transition from the typical TN developing into atypical TN, which is the most opportune to implement. So, it is far favorable for neurosurgeon to make correct judgment and adjust treatment plan in time so as to improve the overall efficacy when the establishment of the brand-new appraisal system and scales comes into being.更多还原