姚秀霞

（河北省滄州市中心醫(yī)院，河北滄州061001）

[摘要]三叉神經(jīng)痛是一種影響三叉神經(jīng)支配區(qū)域的疼痛綜合征，該病已成為涉及顱神經(jīng)最常見的神經(jīng)疾病。本文綜述當(dāng)前針對該病外科治療最新方法，為神經(jīng)外科醫(yī)生提供參考。

[關(guān)鍵詞]三叉神經(jīng)痛；微血管減壓術(shù)；立體定向放射手術(shù)

中圖分類號：R651文獻(xiàn)標(biāo)識碼：B文章編號：2095-5200（2014）04-015-04

DOI：10.11876/mimt201404005

Advances of surgical treatments for trigeminal neuralgiaYAO Xiu-xia.（Cangzhou Central Hospital of Hebei Province,Cangzhou 061001,China）1概述

三叉神經(jīng)痛（TN）是涉及顱神經(jīng)最常見疾病之一，通常為單側(cè)、嚴(yán)重、短暫、針刺樣、反復(fù)發(fā)作于第五顱神經(jīng)的一個(gè)或幾個(gè)分支分布區(qū)域的疼痛[1]。三叉神經(jīng)痛可以是原發(fā)的，例如先天性的；也可以為繼發(fā)的，由創(chuàng)傷或中樞神經(jīng)系統(tǒng)損傷導(dǎo)致[2]。按照國際頭痛協(xié)會(huì)[3]的數(shù)據(jù)，60%的患者主訴為口角至下頜角處刺痛，為三叉神經(jīng)分支下頜神經(jīng)痛；30%的患者表現(xiàn)為三叉神經(jīng)分支上頜神經(jīng)分布區(qū)疼痛；只有不到5%的患者疼痛涉及眼神經(jīng)分布區(qū)[4]。

近期提出的點(diǎn)火假說（ignitionhypothesis）認(rèn)為，三叉神經(jīng)痛由三叉神經(jīng)根或神經(jīng)節(jié)處的特異的三叉神經(jīng)傳入神經(jīng)元病變導(dǎo)致，損傷使得軸突和軸突切斷的胞體更易于興奮，而高興奮性傳入神經(jīng)因同步放電活動(dòng)導(dǎo)致疼痛發(fā)作[5]。導(dǎo)致這種疾病進(jìn)程的具體原因尚不清楚[6]。

本文列舉了當(dāng)前臨床應(yīng)用的外科治療三叉神經(jīng)痛方法，結(jié)合文獻(xiàn)對其進(jìn)展綜述如下。

2治療方法

2.1微血管減壓術(shù)

微血管減壓術(shù)（microvasculardecompression，MVD）的目標(biāo)是將神經(jīng)根從壓迫血管下解放出來，從而永久治愈疼痛并遺留較少甚至無感覺缺失。微血管壓迫是術(shù)前選擇患者、確定手術(shù)方案和預(yù)測預(yù)后的重要癥狀。Ni等[7]建議使用MRI系統(tǒng)行增強(qiáng)三維快速擾相梯度回波磁共振成像和三維磁共振血管造影來術(shù)前檢測三叉神經(jīng)根進(jìn)入?yún)^(qū)（trigeminalrootentryzone,TREZ）神經(jīng)和血管結(jié)構(gòu)的關(guān)系。93%的患者術(shù)中所見與影像學(xué)結(jié)果是一致的。Leal等提出患者術(shù)前需常規(guī)行雙側(cè)三叉神經(jīng)3D-TOF核磁共振體層血管造影，明確三叉神經(jīng)根與周圍血管關(guān)系，其敏感性為80%-95%[8]，并提到應(yīng)用彌散張量成像可顯示神經(jīng)的受壓程度[9]。

Kondo[10]在他連續(xù)的研究中建議首選MVD，大部分患者（87%-98%）術(shù)后即刻疼痛得到緩解。1-2年疼痛的完全緩解率為75%-80%。8-10年后，疼痛的緩解率降為58%-64%，只有4%-12%的患者有輕微的復(fù)發(fā)。曾經(jīng)認(rèn)為高齡為MVD的禁忌癥，近期臨床試驗(yàn)證明，不同年齡組MVD并發(fā)癥的發(fā)生率無統(tǒng)計(jì)學(xué)意義，故不應(yīng)將高齡作為MVD禁忌[11]。隨著內(nèi)鏡手術(shù)的興起，內(nèi)鏡下血管減壓術(shù)也被報(bào)道為一種有效治療三叉神經(jīng)痛的選擇，57%的患者疼痛完全緩解或得到較好控制，且無手術(shù)并發(fā)癥出現(xiàn)[12]。

2.2射頻神經(jīng)節(jié)消融術(shù)

射頻神經(jīng)節(jié)消融術(shù)本質(zhì)是一種選擇性損傷部分受影響神經(jīng)節(jié)或半月神經(jīng)節(jié)后根。熱凝可導(dǎo)致選擇性薄髓鞘和無髓鞘的痛覺傳導(dǎo)纖維損毀[13]。Scrivani等[14]報(bào)道了一個(gè)包括215位患者的回顧性研究，絕大部分的患者（92%）疼痛立即緩解。在平均隨訪時(shí)間32個(gè)月中，27%的患者出現(xiàn)復(fù)發(fā)。He等[15]改良了暴露卵圓孔的方法，患者采取健側(cè)臥位，AP位暴露蝶鞍并使其位于視野中央，使蝶鞍向頭側(cè)偏移，暴露中顱窩弓的骨性標(biāo)記，兩段中顱窩弓的交界處即卵圓孔，穿刺準(zhǔn)確率達(dá)100%，且無穿刺相關(guān)并發(fā)癥。Karol等[16]應(yīng)用陣列電極，面部被分為34個(gè)感覺區(qū)，消融范圍是傳統(tǒng)射頻消融術(shù)的1/3，將損傷控制在疼痛的病變區(qū)域，降低了病變支以外區(qū)域麻木的發(fā)生率。

2.3甘油神經(jīng)節(jié)消融術(shù)

此方法由Hakansson[17]在一次偶然中發(fā)現(xiàn)的，在實(shí)施γ照射的立體定位時(shí)，甘油與鉭粉的混合物不只使三叉神經(jīng)池顯影，同時(shí)也消除了三叉神經(jīng)痛患者的疼痛。盡管疼痛緩解都是即刻的，部分患者7天就會(huì)復(fù)發(fā)。作者[18]同時(shí)提出起始80%的患者疼痛能夠緩解，但遠(yuǎn)期效果高度變化。術(shù)后12月時(shí)，復(fù)發(fā)率波動(dòng)在10%-53%。這個(gè)術(shù)式一般容易承受，且死亡率極低。Goodwin等將甘油神經(jīng)節(jié)消融術(shù)應(yīng)用于微血管減壓術(shù)并未發(fā)現(xiàn)神經(jīng)血管結(jié)構(gòu)異常的患者中，患者術(shù)后疼痛均較術(shù)前明顯改善，在1至3個(gè)月的隨訪中，14位患者中的10位疼痛較前降低50%-80%。故認(rèn)為甘油神經(jīng)節(jié)消融術(shù)可作為微血管減壓術(shù)的備選手段[19]。

2.4球囊壓迫法

有學(xué)者提出壓迫神經(jīng)節(jié)與神經(jīng)根減壓產(chǎn)生的結(jié)果相同。此術(shù)在常規(guī)麻醉下進(jìn)行。在熒光對比下，將探針插入卵圓孔，但不越過卵圓孔。沿著探針將Fogarty導(dǎo)管送入至其尖端位于Meckel腔內(nèi)，向球囊內(nèi)緩慢充入0.5-1.0mL對比劑直至充滿整個(gè)腔隙，確保達(dá)到充分壓迫。患者只需要制動(dòng)1晚[20]。Kauzounias等[21]研究了經(jīng)皮球囊壓迫術(shù)治療三叉神經(jīng)痛的影響因素。他們總結(jié)出球囊形狀作為參數(shù)對結(jié)果有重要影響，而球囊的容量應(yīng)適應(yīng)此參數(shù)。穩(wěn)定的橢圓球囊應(yīng)在此術(shù)式中棄用。壓迫60秒與更長時(shí)間對結(jié)果影響并無差別。之前的手術(shù)次數(shù)與疼痛緩解程度并無關(guān)聯(lián)，但會(huì)增加并發(fā)癥發(fā)生幾率。患有多發(fā)性硬化的患者通過此術(shù)式獲益與經(jīng)典三叉神經(jīng)痛患者相同。術(shù)后第1年6%-14%的病例復(fù)發(fā)。在Abdennebi[22]的系列研究中，平均隨訪4.3年后，1/3的患者需再手術(shù)。Lichtor和Mullan[23]得到了稍好的結(jié)果，20%的病例在隨訪5年后復(fù)發(fā)，少數(shù)隨訪達(dá)10年的患者中，有28%復(fù)發(fā)。最近關(guān)于100位球囊壓迫術(shù)后病例的分析提出，球囊壓迫法手術(shù)成功率為90%，中位疼痛緩解時(shí)間為28個(gè)月[24]。

2.5立體定向放射外科

LarsLeksell發(fā)明了放射外科手術(shù)工具“γ刀”治療功能性腦疾患，作為開顱手術(shù)之外的選擇。這個(gè)方法是現(xiàn)存治療的一種有價(jià)值的補(bǔ)充，對患者創(chuàng)傷小且安全。Han等[25]研究了γ刀放射治療62例典型三叉神經(jīng)痛患者的遠(yuǎn)期療效。他們發(fā)現(xiàn)實(shí)際未復(fù)發(fā)率在術(shù)后第1-5年分別為84.8%、76.1%、69.6%、63.0%和45.8%。Park等[26]比較了γ刀作為第一和第二治療處理難治性原發(fā)性三叉神經(jīng)痛。在放射劑量、起始起效時(shí)間、復(fù)發(fā)或疼痛緩解率上，作為第一治療或第二治療原發(fā)性三叉神經(jīng)痛并無顯著差異。術(shù)后新發(fā)病灶的出現(xiàn)率在二組中一致，但總的面部感覺改變在第二治療組更嚴(yán)重。英國國家立體定向放射外科中心報(bào)道70例TNγ刀術(shù)后第6、12、24月時(shí)療效，疼痛控制極好占39%、36%、64%，較好為71%、57%、53%；約一半患者術(shù)后復(fù)發(fā)，不需藥物控制；60%患者第2次治療后疼痛緩解；術(shù)后感覺缺失出現(xiàn)于31%患者[27]。

2.6周圍神經(jīng)切斷術(shù)

這是個(gè)安全、簡單的術(shù)式，特別是對于老年人，優(yōu)先選擇注射治療。神經(jīng)切斷術(shù)通過在眉弓處切口（眶上神經(jīng)）或口腔內(nèi)切口（眶下神經(jīng)、齒槽神經(jīng)和舌神經(jīng)）施行。所有分支在放大下被分開并抽出。相關(guān)的孔用骨蠟、木條或硅膠塞封堵。燒灼剩余神經(jīng)。盡管如此，再發(fā)時(shí)仍能找到剩余神經(jīng)，可用相同的方法處理來緩解患者疼痛。Danish等[28]發(fā)現(xiàn)在平均7年的隨訪中，78%接受過神經(jīng)切斷術(shù)的患者出現(xiàn)再發(fā)。一半的患者在1月內(nèi)就出現(xiàn)第一次復(fù)發(fā)。在他們的系列研究中，神經(jīng)切斷術(shù)（也包括酒精阻斷）與射頻消融術(shù)相比獲益更少。

2.7冷凍療法

冷凍療法是一種暴露三叉神經(jīng)三支主要分支并通過直接應(yīng)用冷凍探針冰凍的手術(shù)技術(shù)，探針尖端溫度為從-50℃至-70℃。患者需要接受靜脈使用鎮(zhèn)靜藥或常規(guī)麻醉。盡管此術(shù)式易于被患者接受，但結(jié)果并不盡如人意。145例進(jìn)行過1-11次冷凍治療（56%有多于1次的治療）的患者，手術(shù)效果持續(xù)6個(gè)月的僅有一半，到術(shù)后12個(gè)月時(shí)，僅剩28%的患者疼痛完全緩解。幾乎2/3的患者需要再回到以前的藥物治療。盡管針對一條神經(jīng)效果會(huì)有所改善，但就疼痛緩解這方面來說，冷凍治療不管靶點(diǎn)是神經(jīng)節(jié)還是神經(jīng)根效果均不理想[29]。

2.8酒精阻斷

周圍神經(jīng)和神經(jīng)節(jié)酒精阻斷從上世紀(jì)初就開始應(yīng)用，但由于其療效不確切和并發(fā)癥眾多而應(yīng)用甚少。酒精注射必須直接注入神經(jīng)。注射過程非常痛苦，且易造成局部水腫[20]。在一個(gè)對45位患者的回顧性分析中，所有患者均接受過一或多次酒精阻斷，84%的患者均在平均8年的隨訪中疼痛復(fù)發(fā)。一半的患者甚至在術(shù)后1月內(nèi)復(fù)發(fā)。Kyung[30]對98例患者行酒精阻滯，此方法對疼痛的緩解率在第1、2、3年和第7年分別為90.4%，69.0%，53.5%和33.0%。其并發(fā)癥和緩解時(shí)間較其它消融方式并無特殊，故認(rèn)為一次或反復(fù)注射無水酒精是治療三叉神經(jīng)痛的合適方法。

針對三叉神經(jīng)痛的其余外科療法還有激光局部照射、激光穿刺和電針刺療法等，但由于其僅作為輔助治療應(yīng)用，在此不贅述。

上述外科治療三叉神經(jīng)痛的常見并發(fā)癥見表1。

表1三叉神經(jīng)痛外科治療相關(guān)的并發(fā)癥

術(shù)式 報(bào)道的并發(fā)癥

微血管減壓術(shù) 小腦損傷、VIII顱神經(jīng)損傷、腦脊液漏

射頻神經(jīng)節(jié)消融術(shù) 感覺遲鈍、角膜麻木、腦膜炎、頸內(nèi)動(dòng)脈海綿竇瘺、顱內(nèi)出血、顱神經(jīng)損傷

甘油神經(jīng)節(jié)消融術(shù) 腦膜炎、感覺遲鈍、顱神經(jīng)麻痹、局部血腫、口唇皰疹激活、持續(xù)性咬肌無力、角膜炎

球囊壓迫法 感覺遲鈍、咬肌無力

立體定向放射外科 面部感覺異常

周圍神經(jīng)切斷術(shù) 眼部異常、感覺遲鈍

冷凍療法 術(shù)后局部感染、明顯感覺遲鈍

酒精阻斷 感覺遲鈍、面神經(jīng)麻痹、失明、皮膚壞死、死骨產(chǎn)生、復(fù)視

激光局部照射、激光穿刺 未有報(bào)道

電針刺療法 未有報(bào)道

3小結(jié)

在外科治療三叉神經(jīng)痛方面，Barker等[31]進(jìn)行了一項(xiàng)回顧性研究，對1185位接受三叉神經(jīng)根微血管減壓術(shù)的三叉神經(jīng)痛患者，評估此術(shù)的遠(yuǎn)期療效。他們總結(jié)，微血管減壓術(shù)是一個(gè)安全有效地治療三叉神經(jīng)痛的方法，有較好的遠(yuǎn)期療效。Lopez等[32]進(jìn)行了一項(xiàng)神經(jīng)外科消融手術(shù)治療三叉神經(jīng)痛的系統(tǒng)性回顧分析。涉及經(jīng)皮半月神經(jīng)節(jié)后根射頻消融書、甘油消融術(shù)、氣囊壓迫半月神經(jīng)節(jié)立體定向放射外科的臨床隨機(jī)對照研究均被納入。他們總結(jié)出射頻消融術(shù)比甘油消融和立體定向放射外科能提供更高的完全疼痛緩解率，但它被證明有數(shù)量最多的并發(fā)癥。

對有經(jīng)皮介入術(shù)式失敗病史的患者，微血管減壓術(shù)會(huì)是有效的方法。放射外科可被用于那些對其他手術(shù)方式不敏感的患者。對于微血管減壓術(shù)復(fù)發(fā)的患者，建議再行探查或神經(jīng)切斷[33]。對治療不典型三叉神經(jīng)痛患者，復(fù)合療法被證明是有效的。Nguyen等[34]描述了順利治療非典型V2支三叉神經(jīng)痛的案例，同時(shí)應(yīng)用脈沖射頻消融治療、蝶腭骨阻斷和少量美沙酮進(jìn)行治療。

總結(jié)如下，對藥物治療無效的三叉神經(jīng)痛的患者可考慮手術(shù)治療。半月神經(jīng)節(jié)經(jīng)皮術(shù)式、γ刀和微血管減壓術(shù)可作為候選術(shù)式。微血管減壓術(shù)選擇可優(yōu)于其他術(shù)式，因其能提供最久的無痛持續(xù)時(shí)間[35]。

4展望

外科治療是治療三叉神經(jīng)痛的一個(gè)重要手段，且占據(jù)舉足輕重的地位，作為神經(jīng)外科醫(yī)生要學(xué)會(huì)合理應(yīng)用不同術(shù)式。注重個(gè)體化治療理念，針對每位患者的自身情況，分析其適應(yīng)癥和可能出現(xiàn)的并發(fā)癥，選擇其最適合手術(shù)方式，從而在保證醫(yī)療安全前提下，使療效最大化。隨著神經(jīng)內(nèi)鏡技術(shù)出現(xiàn)，新的微創(chuàng)治療方式可以用于三叉神經(jīng)痛，這種方式帶來的損傷更小，療效與傳統(tǒng)MVD相當(dāng)，并發(fā)癥也相應(yīng)減少，將成為未來治療經(jīng)典三叉神經(jīng)痛的首要方法。

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