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.     

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。     

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.     

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。     

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。     

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.     

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.     

A method for bulbospinal trigeminal nucleotomy in the treatment of facial deafferentation pain

Many types of facial pain are difficult to treat, such as postherpetic, posttraumatic, or pain following denervation procedures used in the treatment of trigeminal neuralgia (anesthesia dolorosa), all of which involve deafferentation of the spinal trigeminal nucleus.     

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。     

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%).     

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.     

BK(Ca) channel agonist NS1619 and Kv channel antagonist 4-AP on the facial mechanical pain threshold in a rat model of chronic constriction injury of the infraorbital nerve

Trigeminal neuralgia is a paroxysmal disorder with severely disabling facial pain and thus continues to be a real therapeutic challenge. At present there are few effective drugs for treatment of this pain. The present study was aimed to explore the involvement of BK(Ca) channels and Kv channels in the mechanical allodynia in a rat model of trigeminal neuropathic pain. Here the effectiveness of drug target injection at the trigeminal ganglion through the infraorbital foramen was first evaluated by immunofluorescence and animal behavior test. Trigeminal neuropathic pain model was established by chronic constriction injury of the infraorbital nerve (ION-CCI) in rats. BK(Ca) channel agonist and Kv channel antagonist were administered into the trigeminal ganglion in ION-CCI rats and sham rats by the above target injection method, and the facial mechanical pain threshold was measured. The results showed that the drug could accurately reach the trigeminal ganglion by target injection which was more effective than that by the normal injection around infraorbital foramen. Rats suffered significant mechanical allodynia in the whisker pad of the operated side from 6 d to 42 d after ION-CCI. BK(Ca) channel agonist NS1619 significantly and dose-dependently attenuated the facial mechanical allodynia and increased the facial mechanical pain threshold in ION-CCI rats 15 d after operation. Kv antagonist 4-AP was able to reduce the threshold in ION-CCI rats when facial mechanical threshold was partly recovered and relatively stable on the 35th day after operation. These results suggest that BK(Ca) channel agonist NS1619 and Kv channel antagonist 4-AP can significantly affect the rats' facial mechanical pain threshold after ION-CCI. Activation of BK(Ca) channels may be related to the depression of the primary afferent neurons in trigeminal neuropathic pain pathways. Activation of Kv channels may exert a tonic inhibition on the trigeminal neuropathic pain.     

Atypical Facial Pain in the Elderly1

Atypical facial pain describes a chronic pain state but does not imply an etiology. One-hundred and two patients with atypical facial pain were evaluated. Patients were separated into two groups; 40 patients over age 60 and 62 patients under age 60. Comparisons between the two groups for sex, diagnostic classifications, location of symptoms, specific symptoms, and treatment results were performed. Medical/dental disorders (20%), psychiatric disorders (50%) and combinations of both (15%) were causes of atypical facial pain. Fifteen percent of patients had an indeterminate cause. Psychiatric treatment was effective in reducing psychopathology and pain when a psychiatric diagnosis was present. Burning of the oral mucosa as a specific symptom occurred more frequently in the elderly. No differences were noted between the two age groups in relation to sex, diagnostic classification, or treatment results. No particular psychiatric, medical or dental disorder predominated as a specific cause of atypical facial pain.     

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。     

Radiofrequency thermocoagulation of Gasserian ganglion and its rootlets for trigeminal neuralgia.

Thirty-nine patients with trigeminal neuralgia, not controlled by medical treatment, were treated by radio-frequency thermocoagulation of the Gasserian ganglion and its posterior rootlets. Thirty-six received satisfactory pain relief. In 30 patients touch sensation in the treated territory was preserved. The corneal reflex was affected in only six patients, two of whom subsequently developed keratitis. There were no other complications apart from a minor unpleasant sensation in eight patients. By selectively destroying pain fibres this technique offers the scope of preserving touch sensation in the treated area. Moreover, the zone of analgesia can be restricted to the affected region by sensory mapping through electrode stimulation before thermocoagulation. Its simplicity, low morbidity, associated short hospital stay, and the increased ability to preserve touch sensation, especially of the cornea, seem to make it preferable to other forms of surgical management for trigeminal neuralgia.     

Neuropathic orofacial pain: Cannabinoids as a therapeutic avenue

Neuropathic orofacial pain (NOP) exists in several forms including pathologies such as burning mouth syndrome (BMS), persistent idiopathic facial pain (PIFP), trigeminal neuralgia (TN) and postherpetic neuralgia (PHN). BMS and PIFP are classically diagnosed by excluding other facial pain syndromes. TN and PHN are most often diagnosed based on a typical history and presenting pain characteristics. The pathophysiology of some of these conditions is still unclear and hence treatment options tend to vary and include a wide variety of treatments including cognitive behaviour therapy, anti-depressants, anti-convulsants and opioids; however such treatments often have limited efficacy with a great amount of inter-patient variability and poorly tolerated side effects. Analgesia is one the principal therapeutic targets of the cannabinoid system and many studies have demonstrated the efficacy of cannabinoid compounds in the treatment of neuropathic pain. This review will investigate the potential use of cannabinoids in the treatment of symptoms associated with NOP.     

Trigeminal neuralgia: a retrospective study of 188 Thai cases

doi: 10.1111/j.1741‐2358.2011.00530.x Trigeminal neuralgia: a retrospective study of 188 Thai cases Objective: To describe the clinical characteristics and treatment of trigeminal neuralgia (TN) in a group of Thai patients. Materials and methods: Records of 188 patients with TN were reviewed retrospectively for patient demographics, the characteristics of the pain and treatment modalities. Results: Of the 188 patients, 37.2% were men and 62.8% were women. The peak incidence (46.8%) was in the age range of 50–69 years. Pain occurred on the right side of the face more often than on the left (1.8:1). The mandibular division of the trigeminal nerve was the most frequently affected (30.3%), followed by the combined maxillary and mandibular divisions (29.3%) and the maxillary division alone (25%). The majority described their attack as a sharp pain (77.6%), and the most common primary locations were at previous extraction sites (40.5%). The most common triggers were chewing (61.2%) and speaking (47.3%). Carbamazepine was the most common prescribed drug (76.1%) for the initial treatment. Combination drug therapy was introduced when the monotherapy failed to control the pain. Surgical intervention was the alternative choice of treatment in refractory cases. Conclusion: TN affected women more than men, and this disorder occurred most frequently in patients aged 50 years and older. The mandibular division of the trigeminal nerve was most commonly involved.     

三叉神经痛的临床治疗进展

三叉神经痛是一种常见的面部疼痛性疾病,目前对其病因的认识并不明确。普遍认为压迫可导致三叉神经痛,致病原因包括血管因素和非血管因素,其次创伤也可导致三叉神经痛,常见于口腔外科手术后。三叉神经痛的治疗方法较多,首选药物治疗,包括全身用药和局部用药,药物治疗初期效果明显,但很难治愈三叉神经痛,而且需要长期服药,副作用较大,当药物治疗无效或者患者难以耐受其副作用时,可采用外科疗法进行辅助治疗。三叉神经痛的外科疗法主要包括无创的微血管减压术及有创的射频热凝术、球囊压迫术和甘油毁损术。近年来采用放射外科对三叉神经痛进行治疗,取得了确切效果。此外,还有一些关于其他治疗方法的文献报道,均有一定效果。本文对三叉神经痛病因的认识及临床治疗进展作一回顾性综述。     

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.     

Oral health status and temporomandibular disorders in multiple sclerosis patients

Multiple sclerosis (MS) is an inflammatory disease of unknown etiology involving the central nervous system. Certain clinical manifestations affect the oro-facial region. Three in particular should be of interest to the dentist: trigeminal neuralgia, sensory neuropathy of the trigeminal nerve and facial palsy. The aim of this study was to determine the oral health status, the frequency of subjective symptoms and temporomandibular disorders (TMD) subtype according to Research diagnostic criteria for temporomandibular disorders (RDC/TMD) among MS patients. Examinees in this study were 50 patients suffering from MS, who were at least once treated during their disease in the Clinic Hospital Center, Rijeka, Clinic for Neurology. All examinees had to meet the diagnostic criteria for clinically and laboratory confirmed MS, according to Poser. The results show the difference in mean DMFT (decayed, missing, filled teeth) between MS and the control group. The number of decayed and missing teeth was higher, but the number of filled teeth was significantly lower in MS group. Eighty-two per cent of the subjects with MS had a least one symptom of dysfunction compared with 24% of the subjects in the healthy control group. In the present study, pain, the pain during mouth opening, the difficulty with mouth opening and temporomandibular joint (TMJ) sounds were more commonly reported in the MS group than in the control group. This study shows a statistically significant excess of dental caries and temporomandibular disorders among MS patients compared with the control group. These results suggest that MS is a possible etiological factor in temporomandibular disorders.