神经导航系统下射频治疗原发性三叉神经痛的解剖及临床学研究
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摘要
国际疼痛研究学会将原发性三叉神经痛(trigeminal neuralgia)定义为一种“局限于三叉神经分布区的突发性,反复发作的,短暂的,阵发性剧痛”,该病的发病率为每年3-5/1000,00人,其发病机制尚不十分明确。三叉神经痛多于中年后发病,平均发病年龄在67岁左右,男性多于女性,疼痛常位于单侧,右侧多见,双侧者少见。疼痛发作部位以三叉神经Ⅱ、Ⅲ支分布区最为常见,第Ⅰ支发病者少见。
原发性三叉神经痛的诊断主要依靠典型的临床表现,而无客观的实验室及病理学方面的改变,各种影像学检查也无明显的与发病有关的器质性病变,临床上也不表现阳性的神经系统体征。
原发性三叉神经痛的治疗方法有多种。抗惊厥药卡马西平为首选的保守治疗药物,但长期服用卡马西平会出现耐药及难以忍受的副作用,其他用于治疗神经性疼痛的抗惊厥药也各有其相应的副作用,所以许多病人最后不得不选择外科治疗方法。
治疗原发性三叉神经痛的手术方法较多,包括乙醇、丁醇三叉神经节阻滞术,微血管减压术,周围神经切断术,经皮微球囊三叉神经节压迫术,三叉神经分支或三叉神经节射频热凝术,立体定向γ刀放射治疗术等。各种术式均有一定疗效,也各有其优缺点。
射频热凝术治疗三叉神经痛的作用原理是三叉神经细小、无髓鞘的痛觉纤维A_δ和C纤维较传导触觉的A_α、A_β纤维耐受的温度低,利用射频产生的热效应对疼痛神经进行热凝达到治疗效果,而触觉和运动纤维功能得以保留。
尽管经皮穿刺射频治疗三叉神经痛在某种程度上会影响三叉神经的功能,但因为该手术方式相对简单、安全,且重复治疗往往有效而易于为患者接受,同时由于射频热凝治疗三叉神经痛可选择性治疗三叉神经某一分支而使其并发症相应减少,所以该方法成为许多神经外科医生的首选。
卵圆孔的精确定位是决定射频热凝治疗三叉神经痛成功的关键。最初,有学者在X线透视辅助下定位卵圆孔,因为不能持续照射,卵圆孔定位往往不够精确,相应的并发症也屡见报道。随后CT及立体定向下定位卵圆孔大大提高了穿刺的准确性,从而减少了相关并发症的发生。
作为一种简单、快捷的定位工具,神经导航技术的出现拓宽了立体定向神经外科的治疗领域,大大促进了神经外科的发展。它是经典立体定向技术、计算机医学影像技术、人工智能技术与微侵袭技术相结合的产物,在虚拟的数字化三维影像与实际神经外科解剖结构之间建立起动态的联系,已逐渐成为微侵袭神经外科手术的重要组成部分。理论上,神经导航系统辅助下可实现靶点的可视化及实时监控手术径路,为精确定位卵圆孔提供了可能。
但在临床实践中,神经导航技术是否能精确地反映特定个体的解剖学特征,其性能稳定性如何也一直困扰着神经外科医生。
该研究从解剖学入手,对25例50侧成人尸头进行相关解剖,对卵圆孔及相关参数分别进行实际标本、CT工作站影像、导航系统观察、测量,评估神经导航系统反应个体解剖的精确性及稳定性,同时选择21例原发性三叉神经痛患者,在导航辅助下行射频热凝治疗,探讨神经导航系统在原发性三叉神经痛射频热凝治疗中的作用,以期为临床射频治疗三叉神经痛提供理论指导。
在基础方面,选取福尔马林浸泡成人尸头25例(50侧)去掉颅顶骨,清除脑组织,暴露颅底,充分显示卵圆孔。对25例尸头标本行螺旋CT扫描获取影像资料,将影像资料导入导航工作站进行颅底重建。对25例尸头分别进行实际标本、CT影像及导航系统下观察卵圆孔大小、形态、对称性,并分别测量卵圆孔的相关参数,包括卵圆孔长径、宽径、不同手术入路穿刺针进针深度,将影像测量、导航测量结果分别与实际测量结果进行配对资料检验,评估三种测量方法的等效性及稳定性。结果显示:卵圆孔形态大小个体差异较大,CT影像、神经导航系统能客观显示卵圆孔的个体解剖特征;CT影像测量、导航测量卵圆孔相关参数与实际测量结果无统计学差异(P＞0.2);CT影像测量测得数据的变异系数较小。
在临床方面,选取21例确诊为原发性三叉神经痛患者,术前行颅脑薄层CT扫描获取影像资料,并将影像资料输入神经导航系统,将卵圆孔等重要结构标记后行三维重建,在神经导航下行卵圆孔穿刺后行射频热凝治疗。在治疗后1小时,治疗后第7日,第3个月,第7个月记录疼痛强度评分(Numerical ratingscale,NRS),生活质量评分,计算NRS差值,观察并记录并发症。结果显示:导航下术中卵圆孔穿刺成功率达100%,治疗后1小时,7天,3个月,7个月NRS值较术前明显降低,治疗后生活质量较术前有较大提高,无严重并发症发生。
结论:1)卵圆孔形态、大小个体差异较大,术前行CT扫描可确定卵圆孔形态、大小,估计卵圆孔穿刺难易程度。2)神经导航系统能精确反应卵圆孔的个体解剖特征,且能精确测量卵圆孔的各项径值及射频穿刺针进针深度。3)在能够精确、客观定位解剖结构时,CT影像测量数据稳定性较强。4)神经导航系统在三叉神经痛的射频热凝治疗中的应用使卵圆孔定位更精确,穿刺成功率更高,疗效好,尤其是可避免严重并发症的发生。
Primary trigeminal neuralgia(TN) is defined by the International Association for the Study of Pain(IASP) as "a sudden,severe,brief stabbing,recurrent pain localization in the distribution of one or more branches of the fifth cranial nerve." The incidence rate of the disease is 3 to 5 per 100,000 per year.The pathogenesy of it is unknown.TN usually falls ill after the middle age.The median age at diagnosis is about 67 years.The incidence rate of female is higher than that of male.The pain ususlly located in the single lateral,the right is more than the left,and the bilaterality pain is little.The pain usually appears on the branchⅡ,Ⅲof the trigeminal nerve, and little on the branchⅠ.
The diagnosis of TN depends strictly on clinical criteria.There are no objective laboratory or pathological tests,no apparent structural disease or functional disease by various kinds of imaging examination and it show no present neurologic sign.
There are many kinds of treatment methods for the primary trigeminal neuralgia. The anticonvulsant drug carbamazepine is considered the drug of first choice. However,carbamazepine's effective may taper,and side effects are major problem. Several other drugs,usually other anticonvulsants used for neuropathic pain,are also some what side effects.Many patients who eventually become refractory to medication are candidates for one of several surgical options.
The surgery methods include ethanol or butanol injection trigeminal ganglion, microvascular decompression(MVD),peripheral neurotomy,percutaneous microballoon compression(PMC),percutaneous radiofrequency thermocoagulation (PRFT) and stereotactic radiosurgery Gamma knife.Every method show some effects and related shortcomings.
The mechanism of percutaneous radiofrequency thermocoagulation of the trigeminal ganglion is that the action potentials of small nociceptive fibers(A-delter and C fibers) are blocked at lower temperature than those of the larger tactile fibers(A-alpha and A-beta fibers)during surgical procedure,through the procedure the nociceptive fibers were damaged and tactual fibers were retained.
Although percutaneous radiofrequency thermocoagulation of the trigeminal ganglion may affect the function of the trigeminal nerve to some extent,it is accepted by many patients because of its safety and simplicity.Moreover,the surgery is highly selective for the trigeminal ganglion damage leading to a low complication rate. Therefore,some neurosurgeons regard it as the first choice for most patients with intractable TN.
Correct puncture of the oval foramen is one of the most important step in PRFT. Conventionally,PRFT is guided by intermittent fluoroscopy,which cannot be used to achieve precise location of the oval foramen consistently.Complications reported by many authors.Later computed tomography(CT) fluoroscopy-guided oval foramen puncture,and stereotactic radiofrequency thermocoagulation have been used to improve the accuracy of puncture and minimize the complications.
As a simply and rapid localization tool,neuronavigation technique broadens the field of stereotactic neurosurgery,and prompts the development of neurosurgery greatly.It can provide us a real-time link between digitized neuroradiological images and anatomic structures.Theoretically,neuronavigation system can make the target points be viewable and monitor the trail of the surgery,so it provide us the possibility of precise localization of oval foramen.
But if the neuronavigation system can precisely reflect the individual detail anatomical characteristics and if the system show its satisfactory stability,these problems puzzled the neurosurgeons constantly.
This study began with the anatomy research,evaluated the precision and stability of neuronavigation system in reflecting the individual detail anatomical characteristics. Meanwhile,the study selected 21 primary trigeminal neuralgia cases who candicated for percutaneous radiofrequency thermocoagulation under neuronavigation, investigated the effects of navigation in the treatment of primary trigeminal neuralgia, provided theoretically basis for treating trigeminal neuralgia with radiofrequency thermocoagulation.
In the anatomy parts,25 adults'(50 sides) cadaveric head were dissected and exposed the skull base and had continuous thin-slice CT scans.CT images were then transferred to the computer workstation via an optical disk,labeled the important structure such as foramen ovale of skull base and reconstructed.The cadaveric head were registered by Z-touch laser scanning.Observed the shape,size and position of foramen ovale,measured the diameters of foramen ovale and the depth of needle in trigeminal ganglion blocking with different surgery methods through neuronavigation system,CT images and standard scientific calipers respectively,evaluated the equivalence and stability of the three measurement methods.The results shew that foramen ovale is much varied in different individual on cadaveric heads,CT images and neuronavigation system.Neuronavigation system and CT images can reflect the individual detail anatomical characteristics of oval foramen.Compared with the values measured on cadaveric heads,the values of oval foramen parameters measured both on CT images and on neuronavigation shew no statistic difference(p＞0.2).The coefficient of variation of CT image measurement was smaller than the other two methods.
In the clinical parts,21 patients with trigeminal neuralgia had continuous and thin-slice CT scans before surgery.The CT datas were transported to the neuronavigation system,the important structure such as foramen ovale of skull base were labeled and reconstructed and radiofrequency thermocoagulation was then performed on the patients.Routine monitoring during surgery included electrocardiography,heart rate,mean arterial blood pressure and pulse oximetry.All hemodynamic changes were monitored continuously and recorded throughout the surgical procedure.The results shew that neuronavigation assistance ensured precise puncture of oval foramen and successful targeting of oval foramen in all patients,the accuracy rate of puncturing is 100%.The value of numerical rating scales (NRS),decreased significantly from 8.7 to 2.5,1.7,2.0,2.2 at 1 hour,7 days,3 months,7 months after operation respectively.Also,the value of quality of life declined markedly.Serious complication wasn't observed.
Conclusions:1) The foramen ovale is much varied in different individual.CT images on skull base before operation can reflect the shape and size of foramen oval and evaluate the difficult degree of puncturing foramen ovale.2) Neuronavigation system can show the individual anatomy characteristics of oval foramen objectively, measure the diameters of foramen ovale of cranial base and the depth of needle in trigeminal ganglion blocking precisely.3) When the anatomic structure is located precisely and objectively,the datas measured on CT images are more stable than that of the other two methods.4) Neuronavigation-guided radiofrequency thermocoagulation is very useful in puncturing the oval foramen and minimizing serious complications for primary trigeminal neuralgia.
原发性三叉神经痛的诊断主要依靠典型的临床表现,而无客观的实验室及病理学方面的改变,各种影像学检查也无明显的与发病有关的器质性病变,临床上也不表现阳性的神经系统体征。
原发性三叉神经痛的治疗方法有多种。抗惊厥药卡马西平为首选的保守治疗药物,但长期服用卡马西平会出现耐药及难以忍受的副作用,其他用于治疗神经性疼痛的抗惊厥药也各有其相应的副作用,所以许多病人最后不得不选择外科治疗方法。
治疗原发性三叉神经痛的手术方法较多,包括乙醇、丁醇三叉神经节阻滞术,微血管减压术,周围神经切断术,经皮微球囊三叉神经节压迫术,三叉神经分支或三叉神经节射频热凝术,立体定向γ刀放射治疗术等。各种术式均有一定疗效,也各有其优缺点。
射频热凝术治疗三叉神经痛的作用原理是三叉神经细小、无髓鞘的痛觉纤维A_δ和C纤维较传导触觉的A_α、A_β纤维耐受的温度低,利用射频产生的热效应对疼痛神经进行热凝达到治疗效果,而触觉和运动纤维功能得以保留。
尽管经皮穿刺射频治疗三叉神经痛在某种程度上会影响三叉神经的功能,但因为该手术方式相对简单、安全,且重复治疗往往有效而易于为患者接受,同时由于射频热凝治疗三叉神经痛可选择性治疗三叉神经某一分支而使其并发症相应减少,所以该方法成为许多神经外科医生的首选。
卵圆孔的精确定位是决定射频热凝治疗三叉神经痛成功的关键。最初,有学者在X线透视辅助下定位卵圆孔,因为不能持续照射,卵圆孔定位往往不够精确,相应的并发症也屡见报道。随后CT及立体定向下定位卵圆孔大大提高了穿刺的准确性,从而减少了相关并发症的发生。
作为一种简单、快捷的定位工具,神经导航技术的出现拓宽了立体定向神经外科的治疗领域,大大促进了神经外科的发展。它是经典立体定向技术、计算机医学影像技术、人工智能技术与微侵袭技术相结合的产物,在虚拟的数字化三维影像与实际神经外科解剖结构之间建立起动态的联系,已逐渐成为微侵袭神经外科手术的重要组成部分。理论上,神经导航系统辅助下可实现靶点的可视化及实时监控手术径路,为精确定位卵圆孔提供了可能。
但在临床实践中,神经导航技术是否能精确地反映特定个体的解剖学特征,其性能稳定性如何也一直困扰着神经外科医生。
该研究从解剖学入手,对25例50侧成人尸头进行相关解剖,对卵圆孔及相关参数分别进行实际标本、CT工作站影像、导航系统观察、测量,评估神经导航系统反应个体解剖的精确性及稳定性,同时选择21例原发性三叉神经痛患者,在导航辅助下行射频热凝治疗,探讨神经导航系统在原发性三叉神经痛射频热凝治疗中的作用,以期为临床射频治疗三叉神经痛提供理论指导。
在基础方面,选取福尔马林浸泡成人尸头25例(50侧)去掉颅顶骨,清除脑组织,暴露颅底,充分显示卵圆孔。对25例尸头标本行螺旋CT扫描获取影像资料,将影像资料导入导航工作站进行颅底重建。对25例尸头分别进行实际标本、CT影像及导航系统下观察卵圆孔大小、形态、对称性,并分别测量卵圆孔的相关参数,包括卵圆孔长径、宽径、不同手术入路穿刺针进针深度,将影像测量、导航测量结果分别与实际测量结果进行配对资料检验,评估三种测量方法的等效性及稳定性。结果显示:卵圆孔形态大小个体差异较大,CT影像、神经导航系统能客观显示卵圆孔的个体解剖特征;CT影像测量、导航测量卵圆孔相关参数与实际测量结果无统计学差异(P＞0.2);CT影像测量测得数据的变异系数较小。
在临床方面,选取21例确诊为原发性三叉神经痛患者,术前行颅脑薄层CT扫描获取影像资料,并将影像资料输入神经导航系统,将卵圆孔等重要结构标记后行三维重建,在神经导航下行卵圆孔穿刺后行射频热凝治疗。在治疗后1小时,治疗后第7日,第3个月,第7个月记录疼痛强度评分(Numerical ratingscale,NRS),生活质量评分,计算NRS差值,观察并记录并发症。结果显示:导航下术中卵圆孔穿刺成功率达100%,治疗后1小时,7天,3个月,7个月NRS值较术前明显降低,治疗后生活质量较术前有较大提高,无严重并发症发生。
结论:1)卵圆孔形态、大小个体差异较大,术前行CT扫描可确定卵圆孔形态、大小,估计卵圆孔穿刺难易程度。2)神经导航系统能精确反应卵圆孔的个体解剖特征,且能精确测量卵圆孔的各项径值及射频穿刺针进针深度。3)在能够精确、客观定位解剖结构时,CT影像测量数据稳定性较强。4)神经导航系统在三叉神经痛的射频热凝治疗中的应用使卵圆孔定位更精确,穿刺成功率更高,疗效好,尤其是可避免严重并发症的发生。
Primary trigeminal neuralgia(TN) is defined by the International Association for the Study of Pain(IASP) as "a sudden,severe,brief stabbing,recurrent pain localization in the distribution of one or more branches of the fifth cranial nerve." The incidence rate of the disease is 3 to 5 per 100,000 per year.The pathogenesy of it is unknown.TN usually falls ill after the middle age.The median age at diagnosis is about 67 years.The incidence rate of female is higher than that of male.The pain ususlly located in the single lateral,the right is more than the left,and the bilaterality pain is little.The pain usually appears on the branchⅡ,Ⅲof the trigeminal nerve, and little on the branchⅠ.
The diagnosis of TN depends strictly on clinical criteria.There are no objective laboratory or pathological tests,no apparent structural disease or functional disease by various kinds of imaging examination and it show no present neurologic sign.
There are many kinds of treatment methods for the primary trigeminal neuralgia. The anticonvulsant drug carbamazepine is considered the drug of first choice. However,carbamazepine's effective may taper,and side effects are major problem. Several other drugs,usually other anticonvulsants used for neuropathic pain,are also some what side effects.Many patients who eventually become refractory to medication are candidates for one of several surgical options.
The surgery methods include ethanol or butanol injection trigeminal ganglion, microvascular decompression(MVD),peripheral neurotomy,percutaneous microballoon compression(PMC),percutaneous radiofrequency thermocoagulation (PRFT) and stereotactic radiosurgery Gamma knife.Every method show some effects and related shortcomings.
The mechanism of percutaneous radiofrequency thermocoagulation of the trigeminal ganglion is that the action potentials of small nociceptive fibers(A-delter and C fibers) are blocked at lower temperature than those of the larger tactile fibers(A-alpha and A-beta fibers)during surgical procedure,through the procedure the nociceptive fibers were damaged and tactual fibers were retained.
Although percutaneous radiofrequency thermocoagulation of the trigeminal ganglion may affect the function of the trigeminal nerve to some extent,it is accepted by many patients because of its safety and simplicity.Moreover,the surgery is highly selective for the trigeminal ganglion damage leading to a low complication rate. Therefore,some neurosurgeons regard it as the first choice for most patients with intractable TN.
Correct puncture of the oval foramen is one of the most important step in PRFT. Conventionally,PRFT is guided by intermittent fluoroscopy,which cannot be used to achieve precise location of the oval foramen consistently.Complications reported by many authors.Later computed tomography(CT) fluoroscopy-guided oval foramen puncture,and stereotactic radiofrequency thermocoagulation have been used to improve the accuracy of puncture and minimize the complications.
As a simply and rapid localization tool,neuronavigation technique broadens the field of stereotactic neurosurgery,and prompts the development of neurosurgery greatly.It can provide us a real-time link between digitized neuroradiological images and anatomic structures.Theoretically,neuronavigation system can make the target points be viewable and monitor the trail of the surgery,so it provide us the possibility of precise localization of oval foramen.
But if the neuronavigation system can precisely reflect the individual detail anatomical characteristics and if the system show its satisfactory stability,these problems puzzled the neurosurgeons constantly.
This study began with the anatomy research,evaluated the precision and stability of neuronavigation system in reflecting the individual detail anatomical characteristics. Meanwhile,the study selected 21 primary trigeminal neuralgia cases who candicated for percutaneous radiofrequency thermocoagulation under neuronavigation, investigated the effects of navigation in the treatment of primary trigeminal neuralgia, provided theoretically basis for treating trigeminal neuralgia with radiofrequency thermocoagulation.
In the anatomy parts,25 adults'(50 sides) cadaveric head were dissected and exposed the skull base and had continuous thin-slice CT scans.CT images were then transferred to the computer workstation via an optical disk,labeled the important structure such as foramen ovale of skull base and reconstructed.The cadaveric head were registered by Z-touch laser scanning.Observed the shape,size and position of foramen ovale,measured the diameters of foramen ovale and the depth of needle in trigeminal ganglion blocking with different surgery methods through neuronavigation system,CT images and standard scientific calipers respectively,evaluated the equivalence and stability of the three measurement methods.The results shew that foramen ovale is much varied in different individual on cadaveric heads,CT images and neuronavigation system.Neuronavigation system and CT images can reflect the individual detail anatomical characteristics of oval foramen.Compared with the values measured on cadaveric heads,the values of oval foramen parameters measured both on CT images and on neuronavigation shew no statistic difference(p＞0.2).The coefficient of variation of CT image measurement was smaller than the other two methods.
In the clinical parts,21 patients with trigeminal neuralgia had continuous and thin-slice CT scans before surgery.The CT datas were transported to the neuronavigation system,the important structure such as foramen ovale of skull base were labeled and reconstructed and radiofrequency thermocoagulation was then performed on the patients.Routine monitoring during surgery included electrocardiography,heart rate,mean arterial blood pressure and pulse oximetry.All hemodynamic changes were monitored continuously and recorded throughout the surgical procedure.The results shew that neuronavigation assistance ensured precise puncture of oval foramen and successful targeting of oval foramen in all patients,the accuracy rate of puncturing is 100%.The value of numerical rating scales (NRS),decreased significantly from 8.7 to 2.5,1.7,2.0,2.2 at 1 hour,7 days,3 months,7 months after operation respectively.Also,the value of quality of life declined markedly.Serious complication wasn't observed.
Conclusions:1) The foramen ovale is much varied in different individual.CT images on skull base before operation can reflect the shape and size of foramen oval and evaluate the difficult degree of puncturing foramen ovale.2) Neuronavigation system can show the individual anatomy characteristics of oval foramen objectively, measure the diameters of foramen ovale of cranial base and the depth of needle in trigeminal ganglion blocking precisely.3) When the anatomic structure is located precisely and objectively,the datas measured on CT images are more stable than that of the other two methods.4) Neuronavigation-guided radiofrequency thermocoagulation is very useful in puncturing the oval foramen and minimizing serious complications for primary trigeminal neuralgia.
引文
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