Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Surgery, Hôpital du Sacré-Cœur de Montréal, University of Montréal, Montréal, Québec, Canada.
Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
World Neurosurg. 2024 Apr;184:e9-e16. doi: 10.1016/j.wneu.2023.08.126. Epub 2023 Sep 2.
Trigeminal neuralgia is a facial pain syndrome most commonly caused by a neurovascular compression (NVC) of the trigeminal nerve. Microvascular decompression (MVD) is the most durable surgical treatment; however, patients without an NVC are not candidates for this procedure. Alternative treatments such as percutaneous rhizotomy and radiosurgery are effective but with higher recurrence rates. Internal neurolysis (IN) is a less frequently used procedure that aims to provide long-term relief to patients without NVC.
We present the surgical techniques for IN developed at our institution. We also discuss the technical nuances related to nerve consistency and present a new classification based on these findings. We provide pain and numbness outcomes for our cohort of patients stratified by the extent of neurolysis and nerve consistency.
Patients with medically intractable trigeminal neuralgia eligible for posterior fossa exploration are eligible for MVD and possible IN. If no NVC or a mild NVC is encountered, IN is performed. We have divided the procedure into 4 main steps: opening the outer connective sheath, fascicular dissection, inside-out dissection and the fascicular irrigation technique. Trigeminal nerve consistency has been classified into 3 main types: type 1 is soft and friable; type 2 is intermediate consistency and ideal for neurolysis; and type 3 is firm and presents a more challenging dissection.
In the absence of microvascular compression, we advocate for a thorough neurolysis using the techniques described in our article.
三叉神经痛是一种面部疼痛综合征，最常见的原因是三叉神经的神经血管压迫（NVC）。微血管减压术（MVD）是最持久的手术治疗方法；然而，没有 NVC 的患者不适合这种手术。替代治疗方法，如经皮神经根切断术和放射外科，虽然有效，但复发率较高。神经内松解术（IN）是一种较少使用的手术方法，旨在为没有 NVC 的患者提供长期缓解。
我们介绍了我们机构开发的 IN 的手术技术。我们还讨论了与神经一致性相关的技术细节，并根据这些发现提出了一种新的分类。我们根据神经松解和神经一致性的程度，为我们的患者队列提供疼痛和麻木的结果。
对于适合后颅窝探查的药物难治性三叉神经痛患者，如果没有 NVC 或只有轻微的 NVC，可进行 MVD 和可能的 IN。如果遇到 NVC 或轻度 NVC，则进行 IN。我们将该手术分为 4 个主要步骤：打开外膜、束状解剖、内外解剖和束状冲洗技术。三叉神经的一致性已分为 3 种主要类型：1 型为柔软易碎型；2 型为中等一致性，是神经松解的理想类型；3 型为坚硬型，解剖更具挑战性。
在没有微血管压迫的情况下，我们主张使用我们文章中描述的技术进行彻底的神经松解。
