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.     

Auditory brain-stem responses in Marcus Gunn ptosis

The auditory brain-stem response (ABR) can detect anomalies both in the auditory pathways and in structures adjacent to these pathways. Patients with Duaneś retraction syndrome, associated with hypoplasia of the abducens nerve in the brain-stem, and patients with hemifacial spasm, due to compression of the facial nerve in the brain-stem, have been found to have abnormal ABRs. Marcus Gunn ptosis with ‘jaw winking’ is considered to be due to misconnection of oculomotor, trigeminal and other cranial nerves. Suspecting that perhaps some ‘jaw-winking’ phenomena may be due to detectable brain-stem anomalies we tested 7 patients with Marcus Gunn ptosis. Three of the patients demonstrated abnormal ABRs indicative of pontine pathology.     

The shadow

Blepharospasm, the most frequent feature of cranial dystonia, and hemifacial spasm are two involuntary movement disorders that affect facial muscles. The cause of blepharospasm and other forms of cranial dystonia is not known. Hemifacial spasm is usually due to compression of the seventh cranial nerve at its exit from the brain stem. Cranial dystonia may result in severe disability. Hemifacial spasm tends to be much less disabling but may cause considerable distress and embarrassment. Patients affected with these disorders are often mistakenly considered to have psychiatric problems. Although the two disorders are quite distinct pathophysiologically, therapy with botulinum toxin has proven very effective in both. We review the clinical features, proposed pathophysiologic features, differential diagnosis and treatment, including the use of botulinum toxin, of cranial dystonia and hemifacial spasm.     

微血管减压术治疗面肌痉挛术后相关并发症的临床分析

目的:总结面肌痉挛患者的术后并发症的发生情况并分析其原因。方法:回顾性分析了1548名在我院行微血管减压术治疗面肌痉挛的患者的临床资料,所有患者接受电话随访或者门诊随访,随访时间均超过2年,总结其临床疗效及术后并发症的发生情况。结果:微血管减压术后痊愈率及明显缓解率分别为92.5%及4.2%。249名(16.09%)患者出现不同的并发症,其中最常见的并发症为面瘫及术后手术区域皮肤感觉障碍,无死亡及重大并发症患者。听力损害发生率为3.5%。其他并发症包括脑脊液漏、后组颅神经损伤、外展神经损伤、颅内出血等。结论:微血管减压术是治疗面肌痉挛的安全有效操作,以手术区域感觉障碍及迟发性面瘫是主要的并发症,持久性的或者严重的并发症比较少见。     

A 型肉毒毒素治疗半侧面肌痉挛的临床疗效评价

目的：观察A型肉毒毒素对面肌痉挛患者的痉挛程度、抑郁症状和焦虑症状的改善。方法：对58例面肌痉挛患者进行局部注射A型肉毒毒素。在治疗前后对痉挛程度改善情况进行评定以及用汉密顿焦虑量表（HAMA）、汉密顿抑郁量表（HAMD）对焦虑状态、抑郁状态进行评分,并对药物的副作用进行观察。结果：A型肉毒毒素明显改善面肌痉挛患者的痉挛程度,治疗后2周的HAMA、HA肋评分较治疗前明显下降,且差异具有统计学意义（P〈0．01）。结论：局部注射A型肉毒毒素可迅速缓解或消除面肌痉挛患者肌肉痉挛及相关的抑郁和焦虑状态,提高患者的生活质量。     

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.     

A型肉毒毒素治疗偏侧面肌痉挛和头颈部肌张力障碍的疗效观察

为评估Ａ型肉毒毒素治疗偏侧面肌痉挛和头颈部肌张力障碍的疗效,本文对４２例偏侧面肌痉挛及３４例头颈部肌张力障碍（后者包括１８例眼睑痉挛,１２例Ｍｅｉｇｅ氏病、４例痉挛性斜颈）病人进行Ａ型肉毒毒素肌肉多点注射治疗,并治疗前后的病情分级对比。结果表明,Ａ型肉毒毒素治疗有效率为１００％,疗效持续８～２６周,可重复注射,并再次取得疗效。部分病人局部出现轻度肌无力,数周后均可恢复,无全身毒副作用。结论认为Ａ型肉毒毒素能治疗偏侧面肌痉挛和头颈部局限性肌张力障碍,不失为一种有效安全简便易行的治疗手段。     

Microsurgical Treatment of Hemifacial Spasm

Five cases of idiopathic hemifacial spasm have been successfully treated by operative manipulation of arterial branches compressing the VIIth nerve in the posterior fossa. Terminology, clinical presentation, pathology and therapeutic approaches to hemifacial spasm are discussed. Hearing loss due to operatively induced vascular impairment of the inner ear, a complication in our first case, should be avoidable.Our experience indicates that hemifacial spasm reflects mild chronic compression of the facial nerve. The proposed mechanism is transaxonal excitation between afferent and efferent fibers.     

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%).     

Click-evoked responses from the cochlear nucleus: a study in human

Recordings from the vicinity of the cochlear nucleus in 9 patients undergoing microvascular decompression operations to relieve hemifacial spasm, trigeminal neuralgia, tinnitus, and disabling positional vertigo were conducted by placing a monopolar electrode in the lateral recess of the fourth ventricle (through the foramen of Luschka), the floor of which is the dorsolateral surface of the dorsal cochlear nucleus. The click-evoked potentials recorded by such an electrode display a slow negative wave with a peak latency of about 6–7 msec on which several sharp peaks are superimposed. None of the peaks in the recordings from the vicinity of the cochlear nucleus coincided with any vertex-positive peaks of the brain-stem auditory evoked potentials. In recordings from the lateral aspect of the floor of the fourth ventricle near the cochlear nucleus 1 patient showed 2 positive peaks, the earliest of which had a latency close to that of peak II and the second of which had a latency close to the negative peak between peaks III and IV of the brain-stem auditory evoked potentials. There is a distinct negative peak in the responses recorded from the midline of the floor of the fourth ventricle, the latency of which is only slightly shorter than that of peak V of the brain-stem auditory evoked potentials, supporting earlier findings that the sharp tip of peak V of the brain-stem auditory evoked potentials is generated by the termination of the lateral lemniscus in the inferior colliculus.     

Causes of variations in the pathway of the basilar and vertebral arteries

Artery loops at the root exit zones of cerebral nerves are regarded as causes of certain diseases, e.g. trigeminal neuralgia or hemifacial spasm. The factors, which may cause such loops and displacements of arteries, however, are still not known sufficiently. In order to find out more about such causes, 60 corpses were examined. We recorded the variations in the positions of vertebral and basilar arteries and correlated them with the respective age at the time of death. We found that those showing atypical artery positions and loops were generally of older age. We further examined possible influences of blood flow factors on variations of artery positions. Our sample indicated such influence of flow factors on displacements of basilar artery, but they seemed to be of lesser importance than the effect of ageing.     

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。     

原发性三叉神经痛和疱疹后三叉神经痛临床特征及射频热凝术后效果分析

摘要 目的：探讨原发性三叉神经痛（PTN）和疱疹后三叉神经痛（PHN）的临床特征,并比较经卵圆孔射频热凝术（RF-TC）治疗PTN和PHN的临床疗效。方法：随机选取2019年1月至2020年8月在我院治疗的三叉神经痛患者123例,其中原发性三叉神经痛90例,带状疱疹后神经痛33例。所有患者均通过RF-TC进行治疗,治疗后通过视觉模拟量表（VAS）、巴罗神经研究所疼痛强度量表对面部疼痛评分进行疼痛评估,通过巴罗神经研究所麻木评分进行麻木评定,通过健康问卷-9对患者抑郁情况进行评估,通过匹斯堡睡眠质量指数测量患者心理状态。结果：PTN患者发病年龄显著低于PHN患者（P<0.05）,而病程显著高于PHN患者（P<0.05）;PHN患者的眼支发生率高于PTN患者（39.39% vs 8.89%, P<0.05）。两组患者经RF-TC治疗前后VAS评分无显著差异（P>0.05）。PHN组从轻度到重度影响睡眠质量的比例显著高于PTN组（30.30% vs 10.00%, P<0.05）。PTN组患者治疗后中重度抑郁患者比例显著高于PHN组患者（21.11% vs 9.09%, P<0.05）。两组患者经RF-TC治疗后,临床治疗有效率、面麻木程度以及巴罗神经研究所疼痛强度量表评定的面部疼痛无显著差异（P>0.05）。结论：经卵圆孔射频热凝术治疗原发性三叉神经痛和带状疱疹后三叉神经痛是安全有效的,但治疗后疱疹后三叉神经痛失眠的发生率较高,而原发性三叉神经痛的抑郁发生率较高。     

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.     

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.     

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.     

显微血管减压术对面肌痉挛患者生活质量的影响

目的:研究显微血管减压术对面肌痉挛(HFS Hemifacial Spasm)患者生活质量的影响。方法:对2014年至2016年底在哈医大一院神经外科四科接受显微血管减压手术(MVD Mcrovascular Decompression)治疗的40名面肌痉挛患者进行生活质量量表(QOL Quality of Life)评分,对患者的疗效及治疗前后生活质量的变化情况进行统计学分析。结果:治疗后,MVD的明显缓解率为95%,手术前后不同生活质量项目评分的差异具有统计学意义(P<0.05),术前QOL量表评分总值为21.83±2.01,术后总值为2.15±0.8,术后QOL量表评分总值较术前显著降低(P<0.05)。结论:显微血管减压手术对面肌痉挛患者的症状缓解效果显著,同时可以明显改善患者的生活质量,特别是对患者内心窘迫的改善最为明显。     

Results of treatment of trigeminal neuralgia by microvascular decompression of the Vth nerve at its root entry zone.

Eighty five patients suffering from trigeminal neuralgia resistant to medical therapy underwent surgical treatment for relief of pain at the Department of Neurosurgery University Alexander Hospital Sofia from 1981 until 1997. Microvascular decompression at the root entry zone of the V(th) nerve has been performed using the technique of Jannetta. The operative exploration of the parapontine root entry zone disclosed neurovascular conflicts in 87.1% of the cases. They represented displacement and/or distortion, sometimes pressure grooves, discoloration, altered vascularity of the V(th) nerve. The analysis of early postoperative results have shown an excellent outcome in 90.6% of the cases, good in 3.5% and poor in 2.4% with mortality of 3.5% early in these series when no postoperative monitoring was available. The follow up study one year after surgery revealed 90.2% excellent and 3.7% good results and poor outcome and recurrences in 6.1% of the cases. Patients with long lasting trigeminal neuralgia, previous destructive procedures, venous compression, lack of convincible evidences for neurovascular conflicts had less favorable outcome or recurrences. In the last years partial sensory rhizotomy was performed in cases when no neurovascular conflicts were found out. Patients with unquestionable arterial compression leading to displacement associated with distortion and pressure grooves had excellent outcomes. Early recurrences were associated with missed pathology at the entry zones. During reexplorations for late recurrences new arterial compression was found in less than half of the cases.     

Electrical stimulation of the trigeminal tract in chronic, intractable facial neuralgia

In this paper the treatment of patients with chronic, intractable trigeminal neuralgia by invasive electrical stimulation of the Gasserion ganglion is reviewed. Two different surgical techniques are employed in this treatment. Most frequently, a method similar to the traditional technique for percutaneous glycerol and radiofrequency trigeminal rhizolysis is used: a small percutaneous stimulation electrode is advanced under fluoroscopic control through a thin needle via the foramen ovale to the Gasserian cistern. Some neurosurgeons use an open surgical technique by which the Gasserian ganglion is approached subtemporally and extradurally, and the bipolar pad electrode is sutured to the dura. When percutaneous test stimulation is successful (at least 50% pain relief) the electrode is internalized and connected to a subcutaneous pulse generator or RF-receiver. Data from 8 clinical studies, including 267 patients have been reviewed. Of all 233 patients with medication-resistant atypical trigeminal neuralgia 48% had at least 50% long term pain relief. The result of test stimulation is a good predictor of the long term effect, because 83% of all patients with successful test stimulation had at least 50% long term relief, and 70% had at least 75% long term relief. Patients generally preferred this invasive method over TENS. The success rate in patients with postherpetic trigeminal neuralgia was very low (less than 10%). It is suggested that the likelihood of pain relief by electrical stimulation is inversely related to the degree of sensory loss. It is concluded that invasive stimulation of the Gasserian ganglion is a promising treatment modality for patients with chronic, intractable, atypical trigeminal neuralgia.     

Contralateral injections of botulinum A toxin for the treatment of hemifacial spasm to achieve increased facial symmetry.

Six patients noted facial asymmetry after botulinum toxin injection for hemifacial spasm. Each patient was injected on the side contralateral to the spasms with 10 to 15 IU over the zygomatic major and minor muscles. Each patient noted improvement in facial symmetry in the resting position and dynamic facial movements. Five of the six patients desired this approach with subsequent injections. This injection method variation proved helpful in the managing of hemifacial weakness created by botulinum A toxin for this condition.