伽玛刀放射治疗原发性三叉神经痛的长期随访分析

doi:10.3877/cma.j.issn.2095-123X.2020.05.003

目的

总结分析伽玛刀（GKS）治疗原发性三叉神经痛（PTN）的手术经验。

方法

回顾性分析山东大学第二医院神经外科自2016年5月至2019年12月经GKS治疗的53例PTN患者的临床资料，评估疗效、安全性及影响预后的因素。

结果

伽玛刀术后疼痛缓解的起效时间约为35（7.5，85）d，疼痛缓解率为90.57%。伽玛刀治疗术后BNI分级比术前BNI分级明显改善，其差异具有统计学意义（Z=-5.961，P<0.001）。并发症发生率为18.87%，主要为面部麻木及眼干。单因素分析显示病程的长短和既往手术治疗影响术后PTN的改善，而多因素分析仅病程影响GKS的预后。

结论

GKS治疗PTN疗效显著、定位精准、并发症少，是PTN患者的主要治疗方式，对于确诊的PTN患者应建议其早期首选GKS治疗，如果GKS治疗后效果欠佳可再次GKS治疗或结合其他治疗方式综合治疗。

关键词: 三叉神经痛, 颅神经, 伽玛刀

Objective

To summarize and analyze the experience of Gamma Knife Surgery (GKS) in the treatment of primary trigeminal neuralgia (PTN).

Methods

Fifty-three patients with PTN, admitted by the Department of Neurosurgery of the Second Hospital of Shandong University from May 2016 to December 2019, were analyzed retrospectively to evaluate the efficacy, safety and the prognosis influential factors.

Results

The pain relief time after GKS is 35 (7.5, 85) d, and the pain relief rate after GKS is 90.57%. Compared with the preoperative BNI grading, The BNI grading after GKS was significantly improved, and the difference between them was statistically significant (Z=-5.961, P<0.001). The complication rate of GKS was 18.87%, which were mainly facial numbness and dry eyes. Univariate analysis showed that PTN duration and previous surgery affected the remission of PTN after GKS, while multivariate analysis showed the only factor that affected the prognosis of GKS was PTN duration.

Conclusion

GKS is the main treatment for patients with PTN due to its remarkable curative effect, precise positioning and few complications. For patients with confirmed PTN, GKS should be recommended in the early stage of the disease. If the outcome of GKS is not satisfactory, GKS can be repeated or combined with other treatments.

Key words: Trigeminal neuralgia, Cranial nerve, Gamma knife surgery

图1 伽玛刀治疗计划：伽玛刀治疗靶点选择三叉神经根部脑池段，边缘剂量40 Gy，等剂量线50%

表1 术前与术后BNI分级的改变

BNI分级	术前	术后
1级	0	22
2级	1	12
3级	2	14
4级	25	3
5级	25	2
Z值	-5.961
P值	<0.001

表1 术前与术后BNI分级的改变

BNI分级	术前	术后
1级	0	22
2级	1	12
3级	2	14
4级	25	3
5级	25	2
Z值	-5.961
P值	<0.001

表2 影响术后BNI评分的单因素分析

因素		例数	0个等级	1个等级	2个等级	3个等级	4个等级	P值
性别								0.583
	男	19	1	3	5	5	5
	女	34	2	8	10	11	3
年龄								0.722
	<70岁	24	1	5	7	9	2
	≥70岁	29	2	6	8	7	6
侧别								0.945
	左侧	24	2	5	6	7	4
	右侧	29	1	6	9	9	4
病程								0.015
	<4年	31	1	3	9	10	8
	≥4年	22	2	8	6	6	0
既往手术治疗								0.028
	无	21	0	4	6	4	7
	有	32	3	7	9	12	1
血管压迫								0.991
	无	23	1	5	6	7	4
	有	30	2	6	9	9	4
中心剂量								0.311
	<80 Gy	2	0	0	2	0	0
	≥80 Gy	51	3	11	13	16	8

表2 影响术后BNI评分的单因素分析

因素		例数	0个等级	1个等级	2个等级	3个等级	4个等级	P值
性别								0.583
	男	19	1	3	5	5	5
	女	34	2	8	10	11	3
年龄								0.722
	<70岁	24	1	5	7	9	2
	≥70岁	29	2	6	8	7	6
侧别								0.945
	左侧	24	2	5	6	7	4
	右侧	29	1	6	9	9	4
病程								0.015
	<4年	31	1	3	9	10	8
	≥4年	22	2	8	6	6	0
既往手术治疗								0.028
	无	21	0	4	6	4	7
	有	32	3	7	9	12	1
血管压迫								0.991
	无	23	1	5	6	7	4
	有	30	2	6	9	9	4
中心剂量								0.311
	<80 Gy	2	0	0	2	0	0
	≥80 Gy	51	3	11	13	16	8

表3 伽玛刀放射治疗原发性三叉神经痛患者预后影响因素的多因素分析

变量		偏回归系数	标准误	OR值	Wald值	95%CI	P值
病程
	<4年	1.492	0.550	4.446	7.093	1.513~13.065	0.007
	≥4年			1
既往手术治疗
	无	0.707	0.536	2.028	1.719	0.709~5.800	0.187
	有			1
BNI改变阈值
	0个等级	-1.997	0.6394	0.136	9.757	0.039~0.475	0.002
	1个等级	-0.049	0.4333	0.952	0.013	0.407~2.225	0.909
	2个等级	1.330	0.4651	3.782	8.181	1.520~9.411	0.004
	3个等级	3.075	0.6014	21.64	26.133	6.658~70.337	0.000

表3 伽玛刀放射治疗原发性三叉神经痛患者预后影响因素的多因素分析

变量		偏回归系数	标准误	OR值	Wald值	95%CI	P值
病程
	<4年	1.492	0.550	4.446	7.093	1.513~13.065	0.007
	≥4年			1
既往手术治疗
	无	0.707	0.536	2.028	1.719	0.709~5.800	0.187
	有			1
BNI改变阈值
	0个等级	-1.997	0.6394	0.136	9.757	0.039~0.475	0.002
	1个等级	-0.049	0.4333	0.952	0.013	0.407~2.225	0.909
	2个等级	1.330	0.4651	3.782	8.181	1.520~9.411	0.004
	3个等级	3.075	0.6014	21.64	26.133	6.658~70.337	0.000

[1]	Jannetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia[J]. J Neurosurg, 1967, 26(1): Suppl: 159-162.
[2]	Rogers CL, Shetter AG, Fiedler JA, et al. Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of the Barrow neurological institute[J]. Int J Radiat Oncol Biol Phys, 2000, 47(4): 1013-1019.
[3]	Kondziolka D, Lacomis D, Niranjan A, et al. Histological effects of trigeminal nerve radiosurgery in a primate model: implications for trigeminal neuralgia radiosurgery[J]. Neurosurgery, 2000, 46(4): 971-976; discussion 976-977.
[4]	Kondziolka D, Lunsford LD, Flickinger JC, et al. Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional study using the gamma unit[J]. J Neurosurg, 1996, 84(6): 940-945.
[5]	Park SH, Hwang SK, Kang DH, et al. The retrogasserian zone versus dorsal root entry zone: comparison of two targeting techniques of gamma knife radiosurgery for trigeminal neuralgia[J]. Acta Neurochir (Wien), 2010, 152(7): 1165-1170.
[6]	Xu Z, Schlesinger D, Moldovan K, et al. Impact of target location on the response of trigeminal neuralgia to stereotactic radiosurgery[J]. J Neurosurg, 2014, 120(3): 716-724.
[7]	Flickinger JC, Pollock BE, Kondziolka D, et al. Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study[J]. Int J Radiat Oncol Biol Phys, 2001, 51(2): 449-454.
[8]	Zhao H, Shen Y, Yao D, et al. Outcomes of two-isocenter gamma knife radiosurgery for patients with typical trigeminal neuralgia: pain response and quality of life[J]. World Neurosurg, 2018, 109: e531-e538.
[9]	Tuleasca C, Régis J, Sahgal A, et al. Stereotactic radiosurgery for trigeminal neuralgia: a systematic review[J]. J Neurosurg, 2018, 130(3): 733-757.
[10]	Tuleasca C, Carron R, Resseguier N, et al. Multiple sclerosis-related trigeminal neuralgia: a prospective series of 43 patients treated with gamma knife surgery with more than one year of follow-up[J]. Stereotact Funct Neurosurg, 2014, 92(4): 203-210.
[11]	Maesawa S, Salame C, Flickinger JC, et al. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia[J]. J Neurosurg, 2001, 94(1): 14-20.
[12]	Regis J, Tuleasca C, Resseguier N, et al. Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study[J]. J Neurosurg, 2016, 124(4): 1079-1087.
[13]	Mousavi SH, Niranjan A, Huang MJ, et al. Early radiosurgery provides superior pain relief for trigeminal neuralgia patients[J]. Neurology, 2015, 85(24): 2159-2165.
[14]	Lee CC, Chen CJ, Chong ST, et al. Early stereotactic radiosurgery for medically refractory trigeminal neuralgia[J]. World Neurosurg, 2018, 112: e569-e575.
[15]	Fountas KN, Smith JR, Lee GP, et al. Gamma knife stereotactic radiosurgical treatment of idiopathic trigeminal neuralgia: long-term outcome and complications[J]. Neurosurg Focus, 2007, 23(6): E8.
[16]	Martinez Moreno NE, Gutierrez-Sarraga J, Rey-Portoles G, et al. Long-term outcomes in the treatment of classical trigeminal neuralgia by gamma knife radiosurgery: a retrospective study in patients with minimum 2-year follow-up[J]. Neurosurgery, 2016, 79(6): 879-888.

[1]	陆月合, 高晓燕. 新生儿感染性脑损伤的早期诊断[J]. 中华妇幼临床医学杂志(电子版), 2021, 17(04): 380-386.
[2]	石爽, 杨瑞, 吴越, 夏海坚, 孙晓川, 钟东. 经颅神经内镜下幕下小脑上旁正中入路切除松果体区肿瘤[J]. 中华神经创伤外科电子杂志, 2022, 08(01): 61-64.
[3]	任鸿翔, 张黎, 申宇晓, 任贵玲, 于炎冰. 桥小脑角区肿瘤继发颅神经疾患的临床特点及疗效研究[J]. 中华神经创伤外科电子杂志, 2021, 07(03): 177-181.
[4]	樊晓彤, 闫峰, 王亚明. 立体定向机器人辅助经皮穿刺半月神经节球囊扩张压迫术[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(03): 191-192.
[5]	中国医师协会功能神经外科专家委员会, 世界华人神经外科协会功能神经外科专家委员会, 中国研究型医院学会神经外科学专业委员会, 中华医学会神经外科分会功能神经外科学组. 经皮球囊压迫术治疗三叉神经痛中国专家共识[J]. 中华脑科疾病与康复杂志(电子版), 2022, 12(05): 260-268.
[6]	李岩峰, 马逸. 经皮穿刺球囊压迫术治疗三叉神经痛在中国的现状与展望[J]. 中华脑科疾病与康复杂志(电子版), 2022, 12(04): 193-195.
[7]	种玉龙, 徐武, 王晶, 姜成荣, 梁维邦. 头颅CTA检查在微血管减压术前安全性评估中的临床意义[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(05): 282-284.
[8]	姜成荣, 徐武, 种玉龙, 王晶, 周璐, 梁维邦. 三叉神经痛显微血管减压术中岩静脉的分型及处理策略[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(04): 200-203.
[9]	徐武, 姜成荣, 梁维邦. 卵圆孔形态和外口面积对半月神经节球囊压迫术的影响[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(04): 196-199.
[10]	黄华, 石鑫, 姜磊, 冯兆海, 王西宪, 郝玉军. C-臂引导下球囊压迫术治疗三叉神经痛对患者焦虑抑郁的影响[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(02): 79-82.
[11]	陈聪, 王昊, 杜垣锋, 王家栋, 江力, 王鼎, 沈永锋, 俞文华. 基于人工神经网络的多数据分析预测三叉神经痛患者MVD术后长期疗效[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(02): 68-73.
[12]	乔育, 李加龙, 孙帅, 于蓬勃, 马胜利, 张陇平, 王晓峰. 显微血管减压神经移位技术治疗三叉神经痛术中静脉压迫4例报道[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(01): 61-62.
[13]	蒋亦林, 伍刚, 刘波, 沈洁, 刘如恩. 继发性三叉神经痛诊疗策略[J]. 中华临床医师杂志(电子版), 2022, 16(07): 643-646.
[14]	王宇博, 杨铭. 芒针治疗三叉神经痛验案[J]. 中华针灸电子杂志, 2021, 10(03): 106-107.
[15]	史鹏飞, 王常伟, 郭亚洲, 刘霄, 李锴, 刘禹, 何兵, 赵余涛, 刘德中. 经皮穿刺球囊压迫与显微血管减压术治疗老年人三叉神经痛的疗效及安全性[J]. 中华脑血管病杂志(电子版), 2022, 16(04): 258-262.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Long-term follow-up analysis of gamma knife surgery for primary trigeminal neuralgia Wang

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Long-term follow-up analysis of gamma knife surgery for primary trigeminal neuralgia Wang