Because the etiology and pathology of trigeminal neuralgia are not clear, the purpose of treatment should be long-term analgesia. There are still various methods to relieve pain. It can be roughly divided into non-invasive treatment and invasive treatment. Non-invasive treatment methods include drug treatment, acupuncture treatment of traditional Chinese medicine, physical therapy and so on. It is suitable for patients with short course of disease and mild pain. It can also be used as an auxiliary treatment for invasive treatment. Invasive treatment methods include surgical treatment, injection treatment and radiofrequency thermocoagulation.
I. General therapy
drug therapy
1. carbamazepine is used twice a day at first, and then it can be used three times a day. 0.2~0.6g daily, taken in 2 ~ 3 times, with the maximum daily dose of 1.2g, and the analgesic effect can be achieved after taking the medicine for 24 ~ 48h.
2. Phenytoin sodium, alias Darren, is white powder, odorless and slightly bitter. Soluble in water, almost insoluble in ether or chloroform, easily deliquescent in air.
(2) Chinese medicine treatment
Traditional Chinese medicine believes that trigeminal neuralgia belongs to the category of headache, migraine and facial pain. In ancient medical books, there are names such as "the first wind", "the brain wind" and "the first wind", such as On Su Wenfeng: "The first wind is like sweating, and the first wind 1 day is very sick, so you can't go out with a headache." Some patients with trigeminal neuralgia can receive a certain therapeutic effect after taking traditional Chinese medicine, which can stop or alleviate the pain attack. Some clinicians treated trigeminal neuralgia by oral administration of traditional Chinese medicine, and achieved certain results. Traditional Chinese medicine advocates treating this disease according to syndrome differentiation and giving targeted treatment according to different types.
For exogenous wind evil type, it advocates promoting blood circulation to remove blood stasis, expelling wind and relieving pain. Modified Evodia rutaecarpa decoction (Codonopsis pilosula and Ligusticum chuanxiong each 25g, Evodia rutaecarpa, Radix Angelicae Dahuricae and Rhizoma Gastrodiae each 18g, Zingiberis Rhizoma, Herba Menthae, Radix Saposhnikoviae each 12g, Radix Salviae Miltiorrhizae and Rhizoma Cyperi each 20g, Radix Paeoniae Rubra 15g, Ramulus Uncariae cum Uncis 30g and Asari 3g) or Rhizoma Typhonii/kloc can be used. Angelica dahurica10g, Asari10g, Arisaema cum bile10g, earthworm10g, Ligusticum chuanxiong10g, and Scorpio 3g.
For those with hyperactive liver fire, nourish yin and subdue yang to reduce fire and extinguish wind. 5 grams of scorpion, 2 centipedes, 65438 05 grams of Bombyx Batryticatus, Lumbricus, Ligusticum Chuanxiong, Achyranthes bidentata, Radix Rehmanniae, Radix Paeoniae Alba and Atractylodis Rhizoma, 65438 00 grams of prepared Radix Aconiti, 65438 00 grams of Radix Angelicae Dahuricae, Rhizoma Gastrodiae, Rhizoma Pinelliae Preparata, 4 grams of Asari, 20 grams of Uncaria and 30 grams of Concha Haliotidis (first decocted). 9 g of Bombyx Batryticatus, 9 g of Vitex negundo, 9 g of Myrrha Preparata, 9 g of Radix Gentianae and 9 g of Tribulus terrestris, 0/2 g of Radix Angelicae Dahuricae, 0/5 g of Radix Paeoniae Alba and Radix Rehmanniae, 30 g of Concha Haliotidis, 6 g of Scorpio and 3 g of Radix Glycyrrhizae can also be used.
(3) Acupuncture treatment
1. Common acupuncture therapy Acupuncture treatment is convenient, safe, fast and has few side effects in clinical application. Main acupoints: Fengchi, Yifeng, Xiaguan, Shousanli and Hegu. Matching points: 65438+ 0 pain plus Sun, Yang Bai, Bamboo Fishing and Touwei. The second and third pain patients are added with sun, four whites, Shimonoseki, audition, underground warehouse, pulp bearing and incense welcoming. Repeated stimulation of needle retention can also be used for electroacupuncture treatment with electrical stimulation therapy machine.
2. Acupuncture the peripheral branch of trigeminal nerve, acupuncture the supraorbital foramen, suborbital foramen, posterior superior alveolar foramen and mental foramen, and directly acupuncture the peripheral branch of trigeminal nerve until the pain and swelling reaction in the distribution area of ipsilateral branches appear, so as to obtain rapid analgesic effect. The acupuncture techniques used are lifting, inserting, twisting and turning to stimulate strongly, regardless of yin and yang. It is advisable for beginners to lie prone, and the techniques should be light to avoid dizziness or fear.
Second, trigeminal peripheral branch block therapy
Blocking the peripheral branches of trigeminal nerve is a common method in clinical treatment of trigeminal neuralgia. The injection site is mainly the bone hole through which the trigeminal nerve branches pass, such as supraorbital hole, infraorbital hole, inferior alveolar hole, mental hole and pterygopalatine hole. The drugs used are anhydrous ethanol, phenol solution, adriamycin and streptomycin. The range of relieving pain by blocking the peripheral branch of trigeminal nerve is limited, and its effect is closely related to the technical level of the operator and the degree of the patient's illness. Therefore, most patients relapse within six months to two years.
Peripheral branch block of trigeminal nerve can be divided into supraorbital nerve block, infraorbital nerve block, posterior superior alveolar nerve block, maxillary nerve block, mental nerve block, inferior alveolar nerve block and mandibular nerve block according to the injection site.
Third, semilunar ganglion block therapy
abstract
Semilunar ganglion block has been widely used in the treatment of trigeminal neuralgia at home and abroad. Over the years, this injection therapy has been proved to be effective, and it can really cure trigeminal neuralgia permanently. However, the injection technology is difficult to master, mainly because the accuracy of puncture operation is difficult to grasp. Therefore, the therapeutic effect varies greatly because of the different skills of each person. Puncture the semilunar ganglion in the cranial cavity through the foramen ovale and inject glycerol, anhydrous ethanol, phenol solution, adriamycin and other nerve injury drugs. Blocking the second, third or even all three branches of trigeminal nerve can achieve long-term blocking effect. Can be used for treating intractable trigeminal neuralgia, maxillofacial cancer pain and post-herpetic pain.
Indications for treatment: 1. This injection therapy is suitable for all severe and intractable patients with trigeminal neuralgia, especially the elderly, the weak and the disabled who have contraindications for craniotomy. 2. Trigeminal neuralgia involves the second and third branches at the same time, 1, two branches or all three branches, and it is invalid to be blocked by the surrounding branches. 3. Refractory trigeminal neuralgia after facial herpes zoster.
Complications Semilunar ganglion block may cause some complications, which are mostly caused by inaccurate puncture direction (unarmed puncture without instrument positioning) or too deep needle penetration, which damages nearby blood vessels, cranial nerves and tissues, or large dose of ethanol (medical high-purity glycerol used in our hospital) flowing into subarachnoid space. The incidence of complications is very low. The complications of semilunar ganglion block can be largely avoided through hard work.
The main complications are: sensory loss or abnormal block range; Vertigo syndrome; Chewing difficulty; Brain nerve injury; Unilateral keratitis, corneal ulcer, etc.
The relationship between injection therapy and craniotomy can complement each other. Surgical treatment of trigeminal neuralgia is rare in recent years. For patients who are suitable for craniotomy, injection therapy should be carried out first, and for patients who fail craniotomy, or whose surgical treatment effect is not good, or who relapse after operation, injection therapy can also receive good results.
Fourthly, radiofrequency thermocoagulation therapy.
abstract
Radio frequency thermocoagulation therapy is to use high temperature to act on ganglia, nerve trunk and nerve root, so as to coagulate and denature their protein, thus blocking the conduction of nerve impulses. At present, radiofrequency thermocoagulation is widely used in clinic. The therapeutic effect of thermocoagulation is good, but there are many complications. So far, no death cases have been reported. Although the recurrence rate is high, it can be repeated because of its convenient operation, and finally achieve the purpose of analgesia.
Adverse reactions and complications
1. Pain during operation. This method requires the cooperation of patients. Before treatment, it should be clear that it is painful to carry out this treatment under local anesthesia, and the patient's understanding and cooperation must be obtained. Slow heating from 60℃ can alleviate the pain caused by sudden high temperature.
2. Intracranial hemorrhage The medial semilunar ganglion is adjacent to cavernous sinus and internal carotid artery. Careless or too deep puncture into the foramen ovale is easy to cause bleeding, and in severe cases, it can form intracranial hematoma. (Instrument positioning puncture can be completely avoided)
3. Facial paralysis and other brain nerve injuries.
4. Strict aseptic operation of intracranial infection can prevent secondary intracranial infection. Special attention should be paid to prevent the puncture needle from penetrating the oral mucosa and bringing bacteria in the oral cavity into the skull during repeated puncture.
5. Herpes zoster can appear in the affected area several days after operation, and its mechanism is still unclear. Topical application of nail violet or cortisone ointment will heal in a few days.
6. A serious complication of semilunar ganglion thermocoagulation in the treatment of keratitis is the disappearance of corneal reflex, which can cause paralytic keratitis and eventually lead to blindness. During the operation, we should pay attention to controlling the heating temperature and time, and check the changes of corneal reflection at any time. Those who have lost corneal reflex should be instructed to wear glasses and use eye ointment to protect the cornea and prevent keratitis. Some corneal reflexes take several months to gradually recover after they disappear.
7. Facial sensory impairment Most patients may experience facial sensory impairment to varying degrees after treatment. In the 3 15 cases summarized by Menzel, about 93. 1% of the patients had numbness or burning sensation in different degrees after treatment.
Therefore, before treatment, patients and their families have the right to know the possible side effects of treatment from the attending doctor.
Five, peripheral nerve avulsion injury
Some experts believe that arteriosclerosis and ischemia supplying trigeminal nerve lead to disorder and degeneration of nerve fiber nutrition and metabolism. The compression of blood vessels by the proliferation of fibrous tissue around the distal nerve further reduces blood supply, aggravates neurodegeneration, leads to demyelination of nerve fibers, and produces the phenomenon of "short circuit in series". Therefore, peripheral nerve avulsion has occurred in clinic, and it should be avulsed near the heart as much as possible to prevent the recurrence of trigeminal neuralgia after operation. This method is not widely used because of its poor therapeutic effect on multi-branch pain or deep pain of trigeminal neuralgia.
Six, semilunar ganglion balloon compression method
Balloon compression is a technique used to treat trigeminal neuralgia since 1980s. The patient received general anesthesia, tracheal intubation and controlled breathing. Due to the different proficiency of puncture operators, the anesthesia time is 20 minutes to 160 minutes. Therefore, anesthesia is required to be terminated at any time, and patients should be awake as soon as possible. Semilunar ganglion puncture was performed under X-ray. Puncture 14 puncture needle through facial skin. The puncture needle was stopped at the foramen ovale, the needle core was pulled out, and the Fogarty balloon was placed in the semilunar ganglion through the puncture needle. Connect the catheter connector outside the balloon with a syringe, inject 1 ~ 2ml liquid to inflate the balloon, and form a pear-shaped balloon (as seen on the X-ray film) of about 1× 1.5cm, and keep it for several minutes. After compression, the liquid is pumped out and the inflated balloon is restored. Pull out the balloon together with the puncture needle, and press the puncture point to stop bleeding. The whole operation was performed under the X-ray screen. The success rate of operation is about 90%, but it is effective to treat recurrence again after half a year, and the long-term effect remains to be seen.
Seven, trigeminal nerve root microvascular decompression
Since Dandy 1934 first put forward the argument that trigeminal nerve root vascular compression can cause trigeminal neuralgia, some clinical data also show that trigeminal nerve vascular compression is one of the causes of trigeminal neuralgia. Therefore, many scholars use neurovascular decompression to treat trigeminal neuralgia.
(a) General methodology
At present, the commonly used craniotomy for trigeminal neuralgia includes: transection of sensory root of trigeminal nerve in middle cranial fossa, transection of spinal tract of trigeminal nerve, decompression of trigeminal nerve root and microvascular decompression of trigeminal nerve root in posterior cranial fossa.
(2) Surgical technique
After routine disinfection, 2% lidocaine was used as ear tag for in-line infiltration anesthesia or general anesthesia. Cut along the marking line, and drill a bone window with a diameter of about 2cm near the posterior edge of sigmoid sinus with a skull drill (collect bone chips for later use). Under the operating microscope, the cerebellum was gently pulled back and forth, and the miniature brain pressure plate with 2 ~ 3 mm broadband suction tube was placed in the root of trigeminal nerve, and the vascular compression and other diseases were explored from the nerve outlet to the distal end. Put a small piece of autologous muscle between the nerve and the blood vessel. Wrap the nerve packet compressed by blood vessels and separate it from blood vessels. At this point, the patient is required to tap the trigger point by hand and do some actions that are easy to induce pain. If there is no pain, he has achieved the purpose of decompression. Close the incision layer by layer.
(3) Factors that affect the subjective satisfaction of surgical results.
Microvascular decompression can still be used as a feasible method to treat trigeminal neuralgia, although the long-term effect is different. In the past, the long-term follow-up of curative effect mostly focused on objective factors, lacking patients' subjective satisfaction with the therapeutic effect, which is also very important for judging the decompression effect of trigeminal microvasculature as a whole. Some factors that affect subjective satisfaction include:
1, trigeminal neuralgia is a disease that brings great pain to patients, but all kinds of treatment methods have no very ideal effect. Therefore, in the follow-up, it was found that although the postoperative pain did not completely disappear, leaving slight pain or pain recurrence, the degree of pain was light, which changed the situation that drugs could not control the pain before operation or accompanied with mild complications, but the patient was still subjectively satisfied with the surgical effect. It is understandable for patients to compare the unbearable pain before operation with the situation after operation and get the right choice, which also strengthens their confidence in using microvascular decompression to treat trigeminal neuralgia. The high satisfaction of patients in follow-up shows that this operation is still a good method to treat trigeminal neuralgia.
2. The early postoperative cure rate is unreliable. During the follow-up, it was found that most patients with postoperative pain did not relieve or did not completely relieve were dissatisfied. These patients are all early cases of microvascular decompression. In recent years, due to the attention paid to the identification of the involved blood vessels, especially when the innominate arteriole intersects with the trigeminal nerve or touches the brain stem, or there are many cases where blood vessels or arterial rings are concealed, the method of compressing electrocoagulation to cut off the vein and completely cut off the thickened arachnoid membrane around the nerve to straighten the trigeminal nerve root has achieved satisfactory results.
3. After microvascular decompression, although the pain is relieved, patients will not be satisfied if there are still complications such as facial sensory impairment or hearing impairment. Vascular decompression is not only to relieve pain, but also to preserve nerve function, which is different from other surgical methods for trigeminal neuralgia.
Eight, gamma knife treatment of trigeminal neuralgia
For more than 30 years, gamma knife has become the most important means in stereotactic radiosurgery. The principle of gamma knife analgesia is to focus gamma rays on pre-selected pain-related brain nuclei or pain conduction pathways, and large-dose irradiation destroys the pain conduction pathways and blocks the pain conduction, thus achieving the effect of analgesia. The application of gamma knife in the treatment of trigeminal neuralgia has also achieved certain results.
Gamma knife therapy is to calculate the three-dimensional coordinates of trigeminal nerve root through imaging and positioning, and then focus the focused gamma rays on the target. Therapists can block the conduction of pain by controlling the dose. The treatment process is simple, the patient has little pain and is easy to accept. But the cost of a treatment is very expensive, about 20 thousand yuan. According to experts engaged in gamma knife work, the success rate of gamma knife in the treatment of trigeminal neuralgia is about 60%, and there is a possibility of recurrence. Many patients who came to our hospital for treatment did not recover after gamma knife treatment, such as Du Mou, a Singaporean patient.
According to the current experience, the conditions suitable for gamma knife treatment are:
① Refractory trigeminal neuralgia after herpes zoster that is ineffective in other treatments.
② The diagnosis was secondary trigeminal neuralgia. After imaging examination, there are small tumors or vascular malformations in the brain, and the primary lesions can be treated with gamma knife. Generally, with the improvement of the primary disease, the pain will also be alleviated.