Favorable outcome of decompression of the trigeminal nerve in a case of bilateral neuralgia

A case of the bilateral trigeminal neuralgia produced by compression of the V cranial nerve roots by the branch of the anterior lower cerebral artery and post-hemorrhagic aggregates is presented. Complete recovery was obtained in the result of 2-stage, intracranial relief of the right and left trigeminal nerve roots. Neurologists share the opinion that intracranial surgical relief of the V cranial nerve root produces favourable result in case of trigeminal neuralgia resistant to pharmacotherapy.     

Microvascular decompression: salient surgical principles and technical nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure--with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation. In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.     

Clinical review of nucleus caudalis dorsal root entry zone lesions for facial pain

Twenty-seven patients with intractable facial pain underwent dorsal root entry zone thermocoagulation lesion of the nucleus caudalis of the spinal trigeminal nucleus. Retrospective review revealed a success rate of 85% in the immediate postoperative period declining to 52% on subsequent follow-up. The best results were in the subgroup of patients with postherpetic neuralgia, of which 67% achieved definite relief. There tended to be some correlation of satisfactory results and pain quality as well as extent of pain along trigeminal territory. The operative morbidity was low although most patients were observed to have a mild transient ipsilateral dysmetria.     

Glial Plasticity in the Trigeminal Root Entry Zone of a Rat Trigeminal Neuralgia Animal Model

Neurochemical Research - The trigeminal root entry zone (TREZ) is the transitional zone of central and peripheral tissue compartments in the trigeminal root. Microvascular compression on the TREZ...     

Early trigeminal evoked potentials in tumours of the base of the skull and trigeminal neuralgia

Early scalp responses evoked by stimulation of the infraorbital nerve (W1, W2, W3) have been investigated in 23 patients affected by tumours of the base of the skull (parasellar area and cerebello-pontine angle) and in 38 patients suffering from ‘idiopathic’ trigeminal neuralgia. Differences in conduction times between healthy and affected side were evaluated and confronted with data obtained from 30 normal volunteers.Alterations of the response were found in all the patients with tumours of the base of the skull who had clinical signs in the trigeminal area and in 7 of the 12 cases without such signs. The usual pattern of alteration in cases with tumours of the parasellar area was a parallel involvement of W2 and W3 (both absent or delayed to the same extent), whereas in tumours of the cerebello-pontine angle W3 was more seriously affected than W2. Wave W1 was never altered. Pre- and post-operative recording sessions in 2 patients showed definite improvement of the responses after removal of the tumour.In 9 patients suffering from ‘idiopathic’ trigeminal neuralgia delays of conduction were found on the painful side, suggesting that damage to the trigeminal root, possibly at its entry zone into the pons, had taken place. Retrogasserian injection of glycerol was performed in 12 of the 38 patients with trigeminal neuralgia. Stimulation of the operated side showed disappearance of W2 and W3 in 9 cases, prolonged W1–W3 interval in 2 cases and no alterations in 1 case. The extent of response alteration usually paralleled the clinical results.     

改良微血管减压术治疗复发性三叉神经痛的疗效及安全性分析

目的:探讨改良微血管减压术(MVD)治疗复发性三叉神经痛的疗效及安全性。方法:回顾性分析2010年至2015年收治的50例复发性三叉神经痛患者,2012年前采取常规MVD手术方法(MVD组,n=22),2012年后采取改良MVD的手术方法(改良MVD组,n=28)。MVD组采用传统MVD对三叉神经根进行全程减压,即沿首次切口入路,依次切开皮下、肌筋膜,充分分离骨窗边缘的瘢痕组织,适当扩大骨窗直至硬脑膜充分暴露。切开硬膜,锐性分离蛛网膜后探查Meckel腔至神经出脑区(REZ),仔细探查三叉神经全段,分离压迫神经的责任血管以及首次手术置入的Teflon垫棉,对三叉神经进行全程减压。改良MVD组在此基础上,探查三叉神经颅内段及其周围结构,解剖三叉神经脑干延伸段,垫开小脑上动脉对三叉神经脑干延伸段的压迫。比较两组术后缓解率、并发症、复发情况。结果:改良MVD组术后缓解率为100.0%,显著高于MVD组72.7%(P0.05);两组术后并发症的发生率比较差异无统计学意义(P0.05);改良MVD组术后1年复发率为0%,显著低于MVD组22.7%(P0.05)。结论:MVD术中三叉神经根全程减压联合脑干延伸段减压治疗复发性三叉神经痛患者可有效缓解疼痛,降低术后复发风险,且不增加术后并发症。     

Application of stereotactic principles to the treatment of trigeminal neuralgia.

The application of neuroanatomical and neurophysiological principles to the functional surgery of the trigeminal nerve is discussed. Particular attention has been directed toward correlating the three-dimensional anatomical features of the trigeminal nerve and the surrounding structures to the two-dimensional radiograph of this same region. In this regard, 20 trigeminal nerves, including the surrounding neurovascular structures from 10 cadaver sphenoid blocks, were examined. Measurements of the third, fourth and sixth cranial nerves in relation to the profile of the clivus were made from lateral radiographs of the sphenoid blocks. The position of the internal carotid artery in relation to these structures was also noted. These neurovascular relationships are of clinical importance when using the percutaneous thermocoagulation technique for the treatment of trigeminal neuralgia.     

Microsurgical Vascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm

Vascular cross-compression of cranial nerves has been proposed as the cause of cranial neuropathies, including trigeminal neuralgia and hemifacial spasm. Over the last decade we have used microsurgical vascular decompression to treat these two disorders. Results in 50 patients treated for trigeminal neuralgia have been excellent in 42, good in 5 and poor in 2; and 1 patient was cured after a second operation. Results in 22 patients treated for hemifacial spasm have been excellent in 18, good in 2 and fair in 1. One patient died. There were no late recurrences of symptoms.The pathophysiological mechanisms of trigeminal neuralgia and hemifacial spasm remain unknown.     

Effectiveness of radiofrequency thermocoagulation in recurrent trigeminal neuralgia after previous retrogasserian rhizotomy

Between 1974 and 1984, 428 trigeminal neuralgia cases were treated by controlled radiofrequency thermocoagulation (RFTC). 29 had recurrent trigeminal neuralgia after intracranial surgery. 26 of the 29 patients were treated by retrogasserian rhizotomy and 3 by posterior fossa exploration. Among the 26 recurrent trigeminal neuralgia following retrogasserian rhizotomy, RFTC was effective in 23 cases (88.5%), and in 3 cases (11.5%) RFTC was effective for a short period. Repeated RFTC was unable to control the pain attacks which were later relieved by posterior fossa exploration and root section. Of the 3 recurrent trigeminal neuralgia following posterior fossa exploration, RFTC was effective in 2 cases (66.6%).     

Sensorimotor and Pain Modulation Brain Abnormalities in Trigeminal Neuralgia: A Paroxysmal,Sensory-Triggered Neuropathic Pain

Objective

Idiopathic trigeminal neuralgia (TN) is characterized by paroxysms of severe facial pain but without the major sensory loss that commonly accompanies neuropathic pain. Since neurovascular compression of the trigeminal nerve root entry zone does not fully explain the pathogenesis of TN, we determined whether there were brain gray matter abnormalities in a cohort of idiopathic TN patients. We used structural MRI to test the hypothesis that TN is associated with altered gray matter (GM) in brain areas involved in the sensory and affective aspects of pain, pain modulation, and motor function. We further determined the contribution of long-term TN on GM plasticity.

Methods

Cortical thickness and subcortical GM volume were measured from high-resolution 3T T1-weighted MRI scans in 24 patients with right-sided TN and 24 healthy control participants.

Results

TN patients had increased GM volume in the sensory thalamus, amygdala, periaqueductal gray, and basal ganglia (putamen, caudate, nucleus accumbens) compared to healthy controls. The patients also had greater cortical thickness in the contralateral primary somatosensory cortex and frontal pole compared to controls. In contrast, patients had thinner cortex in the pregenual anterior cingulate cortex, the insula and the orbitofrontal cortex. No relationship was observed between GM abnormalities and TN pain duration.

Conclusions

TN is associated with GM abnormalities in areas involved in pain perception, pain modulation and motor function. These findings may reflect increased nociceptive input to the brain, an impaired descending modulation system that does not adequately inhibit pain, and increased motor output to control facial movements to limit pain attacks.     

Five-and-a-half years' experience with percutaneous retrogasserian glycerol rhizotomy in treatment of trigeminal neuralgia

The results of treating trigeminal neuralgia with percutaneous retroganglionic glycerol rhizotomy in 319 patients from an overall series of 394 patients with 459 operations carried out over a period of 5 1/2 years are reported. Idiopathic trigeminal neuralgia was the diagnosis in 252 patients. 34 patients had trigeminal neuralgia associated with multiple sclerosis. The remaining 33 patients suffered from symptomatic trigeminal neuralgia or atypical facial pain. 230 patients (91.3%) with idiopathic trigeminal neuralgia and 30 patients (88.2%) with multiple sclerosis reported complete freedom from pain. In 12 patients (4.8%) of those with tic douloureux and in 1 patient (2.9%) with multiple sclerosis, pain was alleviated, and the patients required a reduced pharmacotherapy. 10 patients (3.9%) and 3 patients (8.8%) were considered to be treatment failures. The rate of recurrences within the first 2 years was 10.9 and 40.0%, respectively. In the long-term, the rate of recurrences in patients with tic douloureux was 36.9%. 144 patients (45.1%) noticed a hypesthesia. 132 patients (41.4%) had hypalgesia following the procedure, and there was a decrease of symptoms in the long-term observation in 20.0% of the patients. 59 patients (18.5%) developed dysesthesia postoperatively which regressed only to an inappreciable extent in the long-term course. In 16 patients (5.0%) exclusively with a preexisting organic lesion or who had received surgical pretreatment, there was a loss of corneal sensation. The investigation showed on the one hand the effectiveness of the method, but on the other hand also the possibility of marked sensory disorder in selected cases.     

Percutaneous Radio-Frequency Rhizotomy in the Treatment of Trigeminal Neuralgia

A percutaneous technique of selective partial trigeminal root coagulation was evaluated in the treatment of 38 patients suffering from trigeminal neuralgia, 1 patient with pain secondary to oral carcinoma and 1 patient with atypical facial pain. The pain of trigeminal neuralgia was relieved in 94.7 percent of patients. Pain was relieved in the patient with oral carcinoma, but not in the patient with atypical facial pain. There was no mortality and no permanent morbidity outside of the trigeminal nerve lesion. The procedure requires only a brief hospital stay without the time, expense and hazards of open cranial surgical procedures.     

微球囊压迫介入治疗三叉神经痛

目的：三叉神经痛是口腔科常见疾病之一,病因不清。令患者难于忍受。多年来人们探索出很多的治疗手段,这些方法均不同程度伴有疗效、副损伤及并发症上的各种缺点。经研究经介入方法利用微球囊能改变了三叉神经半月节的解剖位置从而缓解其周围压力,进而治疗了三叉神经痛且疗效很好。结论：微球囊加压介入治疗三叉神经痛是目前有效治疗三叉神经痛的方法。     

Lesions of spinal and trigeminal dorsal root entry zone for deafferentation pain. Experience of 35 cases

Spinal and trigeminal dorsal root entry zone destruction (DREZ-tomy) was performed on 35 patients with deafferentation pain of various types. Overall, satisfactory pain relief was obtained in 65.5% of spinal DREZ-tomy cases in the follow-up observation. The result in the brachial plexus avulsion group was the best (82.4% improved), followed by the limb pain group without root avulsion (50.0%), but the truncal or visceral pain group showed the worst result (33.3%). Two patients with postherpetic trigeminal neuralgia were completely relieved of pain in the average follow-up period of 32 months, while in 2 patients with postrhizotomy facial pain, pain recurred 4 months after the operation in 1, and, in the other, pain in the medial part of the face remained unchanged. Complications were seen in about 60% of the patients, which were, however, all mild, except for 2 cases of death due to gastrointestinal disease.     

CT引导下立体定向射频热凝三叉神经半月节对原发性三叉神经痛的疗效分析

目的：分析CT引导下立体定向射频热凝三叉神经半月节对原发性三叉神经痛的疗效,探讨其临床适用性。方法：选择从2011年5月至2012年12月于我院住院治疗原发性三叉神经痛的58例患者,在三维CT引导下采用通过BrainLAB手术计划系统经前入路卵圆孔穿刺三叉神经半月神经节,术中根据疼痛分布范围射频热凝三叉神经半月节。观察并比较治疗前后的VAS评分,临床疗效,术中和术后不良反应情况。结果：58例患者的穿刺手术均成功,术后1d、3d、6d的VAS评分均较治疗前显著降低（P〈0．01）;1周后58例患者中,有53例患者疼痛完全消失,l例患者偶然出现疼痛,但无需服用药物处理,共显效54例;4例患者疼痛有所减轻或疼痛发作频率降低,但仍需服用药物,或服用药物剂量较治疗前明显减少;疼痛无改善或者非用药不能缓解的持续痛仅1例。总有效例数为57例,总有效率达98．26％。术中发生不良反应6例,在术后均有所缓解。术后发生各种并发症共15例,均未明显影响手术效果。结论：CT引导可以较为准确的进入穿刺部位,使立体定向射频热凝三叉神经半月节手术更加顺利,达到治疗原发性三叉神经痛的理想效果,适合临床长期推广应用。     

Trigeminal Neuralgia and Dental Malocclusions

Out of 39 patients with intractable trigeminal neuralgia seven have had continuing relief for over three years after dental treatment. Five out of six recent consecutive edentulous patients had immediate improvement. More radical treatment, such as ganglion injection or nerve root section, has been at least postponed.     

家族性三叉神经痛

三叉神经痛是一种临床常见疾病,典型的三叉神经痛主要表现为阵发性、闪电样的疼痛发作,疼痛剧烈,常无法忍受,呈电灼、针刺、撕裂样,每次发作持续时间数秒至数分钟不等。疼痛多发生于单侧,常有扳机点表现,其多表现为散发,而家族性三叉神经痛报道罕见,至今世界范围内报道仅50余个家系,其临床表现及发病特点与散发性三叉神经痛存在明显差别,尽管散发三叉神经痛患者的病因为责任血管压迫三叉神经REZ区已被普遍接受,但关于家族性三叉神经痛的病因是否为血管压迫存在争议,其遗传模式也没有达成一致的意见,文章复习了相关文献,并通过对这些文献进行分析综合,结合我们治疗三叉神经痛的经验,对其病因、发病机制、诊断和治疗原则、遗传模式等作了系统综述。     

Mesencephalic root fibers of the trigeminal nerve in the cat

The trigeminal nerve has three motor roots and one sensory root in the cat. One of the motor roots can be divided into two bundles: the larger and the smaller. These motor roots form the common root with the sensory root at the exit from the pons, sometimes being separated partially by the subarachnoidal space between the medial and the ventral part of the common root. The mesencephalic root fibers are observed numerously in all the motor roots. Some degenerated fibers are observed in the sensory root. The transitional zone of the trigeminal nerve root between central and peripheral nervous system is occupied by interlocking processes of the fibrous astrocyte.     

Microcirculatory changes in experimental trigeminal neuralgia in rats

Biomicroscopic studies of mesentery in trigeminal neuralgia rats caused by creation of a generator of pathologically enhanced excitation in trigeminal nerve caudal nucleus (injection 0.25-1.0 DLM Tetanus toxin) have shown the microcirculatory disorders, venular permeability, mast cells degranulation, and an increase in lymphatic contractile activity. Microcirculatory disorders intensity and adaptation reaction appearance correlated with trigeminal neuralgia clinical picture.