【作者】 张斌；

【导师】 朱树干； 张良文；

【作者基本信息】 山东大学 ， 外科学（神经外科）， 2016， 硕士

【摘要】 第一部分显微血管减压术治疗原发性三叉神经痛的预后因素分析背景：原发性三叉神经痛(Trigeminal Neuralgia, TN)是常见的神经外科疾病,表现为面部发作性剧痛,可由说话、咀嚼、洗脸等轻微动作诱发,发病率较高。显微血管减压术(Microvascular Decompression, MVD)因其较高的治愈率,已逐渐成为治疗原发性TN的首选方案,但目前仍有部分患者即使术中彻底减压,术后疗效仍不甚理想,甚至短期内没有变化,国内外多家医疗中心报道的术后不缓解率可达6%-7.6%。目的：探讨影响MVD治疗原发性TN临床疗效的预后因素,并根据分析结果,研究MVD治疗原发性TN的手术技巧和方案,并总结经验。方法：回顾性分析山东大学齐鲁医院神经外科2011年6月至2015年6月由同一医师收治的153例施行MVD手术的原发性TN患者的病例资料,对可能影响MVD术后疗效的相关因素行单因素X2检验,并对单因素X2检验分析有意义的指标行Logistic多因素回归分析,用以评价影响MVD治疗原发性TN临床疗效的独立危险因素。结果：本组患者总计153例,其中男性为78例,女性为75例；年龄从24岁至77岁,平均约57岁；病程为2个月至30年；临床表现为右侧发病者88例,左侧发病者65例,无双侧发病的患者。疼痛累及V1支分布区7例(4.6%),V2支分布区20例(13.1%),V3支分布区27例(17.6%),V1、V2支分布区20例(13.1%),V1、V3支分布区2例(1.3%),V1、V2、V3支分布区13例(7.8%),V2、V3支分布区64例(42.5%)。疼痛完全消失125例,疼痛明显缓解26例,未愈2例。104例单纯受动脉压迫,40例动静脉联合压迫,8例单纯静脉压迫,1例无明显责任血管,单纯静脉压迫的患者术后疼痛治愈率(62.5%),动静脉联合压迫的患者为(67.5%),二者较单纯动脉压迫者(89.4%)低,且差异有统计学意义(P=0.003<0.05)；临床仅表现V2支分布区疼痛的患者,术后疼痛治愈率(55%)较其他疼痛分布区患者低,差异有统计学意义(P=0.024<0.05),且V2支疼痛的患者,责任血管多自三叉神经的腹侧压迫(50%),且差异有统计学意义(P=0.041<0.05)；对单因素X2检验分析有意义的因素行Logistic多因素回归分析,结果显示,静脉因素和V2支疼痛是影响MVD治疗原发性TN临床疗效的独立危险因素(P<0.05)。结论：1、静脉因素是三叉神经痛的致病因素之一,且有静脉压迫的患者术后治愈率较单纯动脉压迫者低,故术前的影像学诊断、术中仔细而系统的责任血管探查,对提高有静脉压迫的患者手术成功率是十分重要的。2、V2支疼痛的患者MVD术后疼痛治愈率较低,且V2支疼痛的患者其责任血管多自三叉神经腹侧压迫,我们可以根据疼痛累及范围于术前制定合理的手术策略,同时更加准确地判断患者预后。第二部分MVD与MVD+PSR治疗静脉压迫的原发性三叉神经痛的对比研究背景：通过对MVD治疗原发性TN术后临床疗效的相关因素分析,我们发现有静脉压迫的原发性TN患者行MVD术后,治愈率较差。为了提高有静脉压迫的原发性TN患者MVD手术的治愈率,我们在MVD手术的基础上,施行三叉神经感觉根部分切断术(Partial Sensory Rhizotomy, PSR),试图对比研究MVD和MVD+PSR两种手术治疗有静脉压迫的原发性TN临床疗效间的差异。目的：对比MVD和MVD+PSR两种手术治疗有静脉压迫的原发性TN临床疗效间的差异,为提高有静脉压迫的患者术后疗效提供切实可行的治疗方案。方法：回顾性分析山东大学齐鲁医院神经外科2011年6月至2015年6月由同一医师收治的73例有静脉压迫(包括单纯静脉压迫和动静脉联合压迫)的原发性TN患者的病例资料,其中48例行MVD,25例行MVD+PSR手术。通过单因素X2检验对比两种手术方式的治愈率,用以明确MVD及MVD+PSR两种手术方式治疗有静脉压迫的原发性TN患者临床疗效的差异。结果：静脉压迫的73位患者中,48例行MVD术,治愈32例,好转15例,1例无效,手术治愈率为66.7%；25例行MVD+PSR术,治愈22例,好转3例,无效者无；手术治愈率为88%,临床疗效明显好于单纯行MVD术的患者,且差异有统计学意义(P=0.042<0.05)。结论：1、对于有静脉压迫的原发性TN患者,在MVD的基础上,施行PSR术,可以有效地提高治愈率。2、对于有静脉压迫,年龄较大,二次手术机会小,可以耐受术后面部麻木及感觉异常的患者应积极施行MVD+PSR手术。更多还原

【Abstract】 Part I Microvascular decompression for primary trigeminal neuralgia and analysis of curative factorsBackground:Primary trigeminal neuralgia (TN) is a common disease of neurosurgery department. It performs paroxysmal facial pain induced by slight movements such as speaking, chewing, washing the face, et al. The morbidity is also very high. Since the high curative rate, microvascular decompression (MVD) has become the perfectest treatment of TN. However, the postoperative effect is not always ideal or without any changes even though a complete decompression is done in the progress of surgery. The unremission rate of syndromes can reach 6%-7.6% reported by many domestic and foreign medical centers.Objective:The aim of this thesis is to explore the curative factors of TN treated by MVD, and to investigate the technique and experience associated with theses factors of microsurgery for primary TN.Methods:The clinical materials of 153 primary TN patients from the neurosurgery department of Qilu Hospital Shandong University operated by the same doctor from June 2011 to June 2015 were analyzed retrospectively. All TN patients were treated by MVD. The risk factors about clinical curative effect were evaluated by single factor analysis of chi-square test and logistic regression analysis.Results:In this series,78 patients were male and 75 were female. The age of patients varied from 24 to 77 years old,57 years old on average. The course of disease were between two month to thirty years. Clinical manifestations of pain occurred on the right side were 88 cases, another 65 cases were in the left side, without bilateral cases.7 cases (4.6%) occurred in the dominated range of VI branch,20 cases (13.1%) were in the range of V2 branch,27 cases (17.6%) were in the range of V3 branch,20 cases (13.1%) were in the range of V1V2 branches, 2 cases (1.3%) were in the range of V1V3 branches,13 cases (7.8%) were in the range of V1V2V3 branches,64 cases (42.5%) were in the range of V2V3 branches. Pain vanished in 125 cases, obviously relieved in 26 cases, not changed in 2 cases.104 cases were compressed by artery alone,40 cases had a venous-artery conflict, 8 cases had only venous conflict,1 case had no obvious conflict. The pain-free rate of venous alone conflict (62.5%) and venous-arterial conflicts (67.5%), were both obviously lower than the artery alone (89.5%), with significant differences in statistics (P=0.003<0.05). The pain-free rate of V2 was obviously lower than others (P=0.024<0.05), with significant difference in statistics; The 50% patients of V2 had their conflicts at the ventral site of the nerve, with significant difference in statistics (P=0.041<0.05). The results of logistic regression analysis showed the vein and V2 were independent risk factors about curative effect (P<0.05).Conclusions:(1) The compression of vein was one of the cause of primary trigeminal neuralgia. Compared with purely arterial conflict, the pain free rate of venous conflict TN patients was lower. Therefore, the careful preoperative imaging diagnosis and systematic surgical exploration of responsible vascular in the operation were important to improve the rate of success. (2) The pain of V2 branch treated by MVD could not eliminate completely. Furthermore, the ventral site was the crucial conflict site of the V2 patients. According to these conclusions, we could make effective surgical strategies and judge the prognosis of patients more accurately than before.Part II Comparison of effectiveness between MVD and MVD+PSR of primary trigeminal neuralgia offended by veinBackground:By the analyze of curative factors of primary trigeminal neuralgia (TN) patients treated by microvascular decompression (MVD), we summarized the conclusion that primary TN caused by venous pathogenicity was hard to cure completely. To improve the curative rate, we did MVD+partial sensory rhizotomy (PSR) instead of MVD and discussed the differences between two surgical strategies.Objective:To evaluate the effectiveness of MVD and MVD+PSR on the treatment of primary TN caused by venous factor (offended by vein alone and vein-artery).Methods:73 TN patients caused by venous factor were retrospectively analyzed in this series, there were 48 cases underwent MVD and 25 cases were operated by MVD+PSR.Results:In MVD group, pain completely vanished in 32 cases, obviously relieved in 15 cases,1 case without any changes, the pain free rate is 66.7%. In MVD+PSR group, pain completely vanished in 22 cases, obviously relieved in 3 cases,0 case not changed. The pain free rate of MVD+PSR is 88%, which is higher than MVD, with significant difference in statistics (P=0.042<0.05).*Conclusions:1 For primary trigeminal neuralgia patients who offended by venous factor, MVD+PSR was obviously superior to MVD in pain free rate.2 For primary trigeminal neuralgia patients who are old enough, offended vessel include vein, can tolerate the feeling of numbness or paresthesia after surgery, MVD+PSR is priority.更多还原