I. Applicable objects
First diagnosis of trigeminal neuralgia (ICD-10:G50.0) under stereotactic navigation with radiofrequency thermocoagulation of the hemimelia.
Second, the basis of diagnosis
According to the Clinical Diagnosis and Treatment Guide-Neurosurgery Sub-volume (edited by Chinese Medical Association, People’s Health Publishing House), Clinical Technical Operation Specification-Neurosurgery Sub-volume (edited by Chinese Medical Association, People’s Health Publishing House), Neurosurgery (People’s Health Publishing House)
1.Medical history
(1) The pain is limited to one side of the frontal area, face, upper and lower alveoli, etc. The pain is sudden and abrupt and lasts for a short period of time, about seconds or minutes, and the nature of the pain is cut-like, electric shock-like or tear-like severe pain.
(2) Pain manifestations are rare bilaterally and can be triggered by mechanical stimuli such as washing, brushing, eating, talking, etc.
(3) In the later stages of the disease, the pain may be persistent, and the patient may not be able to eat or even dare to speak because of the pain.
(4) The patient often needs to increase the dose of carbamazepine because the pain is aggravated by taking carbamazepine effectively.
2.Signs
There are trigger points on one side of the paranasal, upper lip, lower lip and cheek, and the signs of neurological examination are normal.
3.Auxiliary examinations
(1) Cranial CT/MRI to exclude secondary trigeminal neuralgia such as pontocerebellar horn tumor.
(2) Cranial 3D-TOF-MRA examination to understand whether there are vessels adjacent to trigeminal nerve roots.
4.Differential diagnosis
Pontocerebellar horn tumor detected by cranial CT/MRI is not included in this pathway, and is treated according to the surgical diagnosis of pontocerebellar horn tumor.
The basis for choosing treatment plan
1.Persons with clear diagnosis, old and frail, unable to tolerate general anesthesia surgery.
2.Ineffective drug treatment or cannot tolerate the side effects of drugs.
3.The doctor informed in detail that radiofrequency thermocoagulation can produce facial numbness and has a certain chance of recurrence, but still requested to perform radiofrequency surgery.
4, unresectable tumor or hemangioma, the patient’s quality of life is seriously affected by pain.
5, trigeminal nerve microvascular decompression, gamma knife or nerve block treatment is not effective or recurrence.
IV. Standard hospitalization day is 3 days
V. Entry pathway criteria
1. the first diagnosis must be in accordance with ICD-10:G50.0 trigeminal neuralgia disease code
2. the patient requires radiofrequency thermal coagulation and has no contraindications to surgery.
3, purely for trigeminal nerve branch 1 pain, radiofrequency thermal coagulation is prone to produce loss of corneal reflex, so it is not entered into the pathway.
4, the elderly and frail, can not tolerate general anesthesia surgery.
Six, preoperative preparation 1 day
1, the necessary examination items.
(1) Three major routine, blood type.
(2) Liver and kidney function, blood electrolytes, blood glucose.
(3) Coagulation function.
(4) Infectious disease screening (hepatitis B, AIDS, syphilis)
(5) Electrocardiogram, chest X-ray.
(6) Cranial MRI and 3D-TOF-MRA.
(7) Prophylactic antimicrobial drug selection and timing of use
1.Prophylactic selection of cephalosporin II or III antimicrobial agents.
2.Pre-operative prophylactic medication: one dose, 30 minutes before surgery.
3.No need to use antimicrobial drugs after surgery.
Eight, the day of surgery is the second day of hospital admission
1.Anesthesia: local anesthesia.
2.Surgical method: radiofrequency thermocoagulation of the trigeminal nerve hemianopia under stereotactic navigation.
3. Preoperative medication: atropine 0.5 mg intramuscularly and nitroglycerin for blood pressure control.
4.Preoperative preparation: install the stereotactic navigation head frame, send it to the CT room to locate the foramen ovale on the diseased side under spiral CT scan, and use the hemianopia as the target point to calculate the puncture angle and depth with the navigation system.
5. Intraoperative supplies: cardiac monitor, trigeminal nerve semilunar puncture needle, temperature-controlled radiofrequency instrument.
IX. Postoperative hospitalization and recovery for 1 day
After the operation, return to the ward, rest in bed for 1 to 2 hours, then eat and get out of bed, and observe whether there is blood oozing or hematoma formation at the puncture site.
X. Discharge criteria
Patients with trigeminal neuralgia significantly improved or disappeared, and there was no blood oozing or hematoma at the puncture site, they could be discharged.
XI. Variation and analysis of causes
1. In a few patients, a transient decrease in heart rate and blood pressure occurred during the intraoperative heating and destruction operation. It was considered that the decrease in heart rhythm was caused by the stimulation of the vagus nerve during the intraoperative radiofrequency needle puncture through the foramen ovale into the Meckel cavity.
2.Some patients showed numbness of the affected side after surgery, which was considered to be caused by sensory nerve injury, and the symptoms were relieved after 3-6 months of follow-up and had no effect on daily life.
3.A few patients showed weakness in mastication, which was considered to be caused by damage to the motor branch of trigeminal nerve, and they could recover on their own after 1-2 months of follow-up.
Very few patients with sluggish corneal reaction, considered to be caused by damage to the 1st branch of the trigeminal nerve, need to apply antibiotic eye ointment and topical eye drops to prevent corneal ulceration, and can gradually return to normal.
5, facial herpes zoster, consider viral infection caused by the antiviral treatment can be cured.
6, very few patients after surgery, the original pain does not necessarily disappear immediately, it may gradually reduce or disappear after a period of time.