Treatment of Migraine by Micro-Nerve Decompression and its Prognosis Analysis
Jin Yongjian Feng Zengwei Li Dan Xiao Qing Wang Lin Chen Guoqiang Feng Zengwei, Department of Neurosurgery, Aviation General Hospital of China Medical University
[Abstract] Objective To investigate the relevant factors affecting the prognosis of patients with migraine treated by microvascular decompression after surgery. Methods From January 2006 to July 2010, 96 migraine patients treated with microvascular decompression in our hospital were followed up, and the relationship between the site and extent of pain attacks, intraoperative lesion characteristics and prognosis were retrospectively analyzed. The results showed that 73% of the patients were completely cured, 90.6% were effective (cured+effective), 7.3% were improved, and 2% were ineffective at 1-4 years of follow-up (mean follow-up: 2.4 months). Among them, the cure rate and total effective rate of auriculotemporal, orbitofrontal, posterior occipital and two or more compound regions were 58%, 83.3%, 88%, 62.5% and 90.3%, 91.7%, 96%, 81.3%, respectively. It was suggested that the radical effect of auriculotemporal and compound regions was lower than that of other regions. In addition, intraoperative decompression was found to be more effective in cases where the nerve was more significantly stuck by the blood vessel. Conclusion Microvascular decompression surgery is an effective surgical treatment for migraine, and the pain site, pain range and different lesion characteristics are closely related to its prognosis.
Keywords】migraine; microscopic nerve decompression (MVD); follow-up; prognosis
Microscopic nerve decompression for migraines
and its prognostic analysis JING yong-jian, FENG zeng-wei,LI dan,XIAO qing, WANG
Department of Neurosurgery, Yuquan Hospital, Tsingtao
Department of Neurosurgery,Yuquan Hospital,Tsingtao University,Beijing 100049,China
[Abstract] Objective To explore the microscopic vascular
To explore the microscopic vascular decompression surgery affect prognosis in patients with migraine of related factors.
Methods follow-up from January 2006 to July 2010 in
Our hospital accept microscopic vascular decompression treatment of 96 cases of
migraine patients were retrospectively analyzed attack, pain, scope and part
Results 1 to 4 years of follow-up (average follow-up of 2.4 months), and the prognosis related.
The temporal and physical characteristics of the patients were analyzed.
the temporal ears, orbital frontal, after pillow and two or more
more than two composite regional cure rate and the total effective rate were
58%, 83.3%, 88%, 62.5% and 90.3%, 91.7%, 96%, 81.3%.Point out the temporal ears and composite region of the effect than other areas. In addition, intraoperative found the temporal ears and composite region of the effect than other areas.
addition, intraoperative found the oppressed nerve by vascular more apparent
Conclusion Microscopic vascular decompression surgery method for
the treatment of migraine an effective
Microscopic vascular decompression surgery method for the treatment of migraine an effective surgical methods, and painful place, pain in the range and different lesions characteristics
Microscopic vascular decompression surgery method for the treatment of migraine an effective surgical methods, and painful place, pain in the range and different lesions characteristics is closely related with its prognosis.
[Key words】migraine;
Microscopic vascular
decompression; Follow-up; Prognosis
Migraine is a common vascular headache, and the recurrent severe headaches seriously affect the quality of patients’ daily life. Since the first report of microvascula decompression (MVD) in China in the 1980s, this surgical method has become another effective treatment for intractable migraine in China. The procedure is now another effective treatment for intractable migraine in China. From January 2006 to June 2010, we treated 96 migraine patients with MVD and followed up all of them for more than 1 year. We retrospectively analyzed the correlation between the characteristics of different regions, scopes and types of lesions and their prognosis, with the aim of improving the long-term efficacy of MVD for migraine.
Data and methods
1. General data: The group consisted of 96 migraine patients who received MVD treatment in our hospital from January 2006 to July 2010. Among them, 33 cases were male and 63 cases were female; age ranged from 16 to 64 years old, with an average of 37.3 years. The history of headache was 2~16 years, and the frequency of headache attacks was 8~24 times/year, with conservative drug treatment for more than 6 months.
2. Clinical manifestations: (1) Aura symptoms: such as flashing light in front of the eyes, black haze, etc. 48 cases. (2) Pain site: 31 cases of pain in the auriculotemporal region, 24 cases of pain in the orbitofrontal region, 25 cases of pain in the posterior occipital region, and 16 cases of widespread pain in the compound region (3 cases in the temporo-occipital region, 6 cases in the frontotemporal region, 5 cases in the frontal-occipital region, and 2 cases in the frontotemporo-occipital region). (3) Nature of pain: pulsating throbbing pain in 68 cases, other 28 cases (pins and needles and burning-like pain in 24 cases, swelling pain in 20 cases, and other 6 cases. (4) Concomitant symptoms: 17 cases with nausea, vomiting, dizziness, 3 cases with severe depression, and the rest with no obvious complications.
3. Treatment methods
(1) Indications for surgery: Patients with intractable migraine with fixed headache areas and stereotypic attacks who have failed to respond to drug therapy or have serious side effects from long-term medication, and patients with positive 2% lidocaine nerve block test (temporary relief or disappearance of pain) and excluding intracranial occupying lesions.
(2) Surgical method [2-3]: The surgery is performed under local anesthesia, according to the pain activation points (supraorbital notch, auriculotemporal nerve point, occipital greater nerve out of the tendon membrane), microscopically searching for vascular and nerve compression sites along the vessels and nerves, freeing the vessels and nerves, wrapping the nerves with absorbable medical film to prevent postoperative adhesions, cutting or cauterizing the responsible vessels if necessary, loosening the muscle or fascia compression of the vessels and nerves, and finding enlarged lymph nodes and scarring. If necessary, cut or cauterize the responsible blood vessel, release the muscle or fascia from compression of the vascular nerve, and remove the enlarged lymph nodes and scar adhesions. For patients with compound regional pain, surgery is first performed on the site with the most prominent pain, and then the other site is operated on 1 week later.
4. Criteria for judging the efficacy: cure: headache disappears without recurrence after more than one year of follow-up; efficacy: headache relieved by more than 90% after more than one year of follow-up, and no effect on life and work; improvement: headache relieved after more than one year of follow-up, but it has some effect on life and work, and medication is needed for pain. Invalid: no significant improvement in pain. Total effective rate: the total effective rate was cured + significant effect (%).
5. Follow-up mode and content: Telephone and outpatient follow-up were used. (1) Postoperative pain changes, such as whether the pain disappeared, the degree of pain, the frequency of pain, the range of pain, etc. (2) Whether the pain affected the daily life and work, and whether the pain needed to be controlled by medication, etc.
Results
1. Intraoperative exploration data: 96 patients underwent surgery at 116 sites. Among them, 31 cases of auriculotemporal nerve decompression, 24 cases of supraorbital nerve decompression, 25 cases of microscopic decompression of the greater occipital nerve, and 16 cases of combined nerve decompression of 2 or more sites were performed. A total of 58 cases of nerve compression due to vascular abnormalities (nerve compression caused by dilatation, displacement, tortuosity and entanglement of vessels) were found intraoperatively (Figure 1-3), 28 cases of nerve compression caused by the coexistence of vascular abnormalities and other lesions (scar, tumor), and 10 cases of no vascular compression were found.
2. Postoperative follow-up results: All patients were followed up from 1 to 4 years after surgery, with an average follow-up of 24.6 months. There were 70 cases of complete cure, accounting for 73% (70/96), 87 cases of total effectiveness, accounting for 90.6% (87/96), 7 cases of improvement, accounting for 7.3% (7/96), and 2 cases of ineffectiveness, accounting for 2% (2/96). The cure rate and total effective rate of auriculotemporal, orbitofrontal, posterior occipital and compound areas were 58% (18/31), 83.3% (20/24), 88% (22/25), 62.5% (10/16) and 90.3% (28/31), 91.7% (22/24), 96% (24/25), 81.3% (13/16), respectively.
The following are some examples of the results.
DISCUSSION
Migraine is a common condition, and according to epidemiological surveys [4], the prevalence of migraine in adults ranges from 7.7 to 18.7%, and severe migraine has become a chronic disease that seriously affects the life and work of patients. The symptom onset of migraine is divided into remission phase, aura phase and headache attack phase. It is generally believed [5-6] that the development of migraine from remission phase to headache symptom attack is related to the following mechanisms (1) neural hyperexcitability in remission phase: the excitability of neurons in the cerebral cortex, especially in the occipital region, is increased in remission phase, and headache can be triggered if stimulated by various internal and external factors in this phase. (2) Cortical blood flow “diffusion inhibition” during the aura period: The recurrent aura symptoms such as flickering and bright light around dark spots before migraine attacks are related to cortical blood flow “diffusion inhibition”. (3) Mechanism of migraine attack: The mechanism of migraine attack is not completely clear so far, but scholars from various countries have put forward various hypotheses including the vascular neurological theory and the trigeminal vascular reflex theory. The activation of the peripheral and central regions of the trigeminal nerve causes migraine, and the stimulation of the central nerve such as the brainstem by dopamine and other neuromediators in the gray matter around the brainstem aqueduct causes nausea and vomiting. Currently, the medications used to treat migraine include prophylactic medications during the aura phase and symptomatic medications during the headache attack. The main effect of medication for aura is to reduce the excitability of the brain and stop the trigger of aura. Most patients can stop the acute attack of migraine through preventive medication, but there are still a few patients with intractable migraine that cannot be effectively controlled and lead to migraine attack. Analgesic drugs are still the first choice for migraine attacks, but for severe intractable migraine, they can only reduce headache symptoms and the number of attacks, but not the root cause of migraine. The search for effective treatment during migraine attacks is the key to the treatment of migraine, and the peripheral nerve region of the head is becoming an important target for surgical treatment of migraine.
The trigeminal vascular reflex theory explains the neuromediator-induced headache attack mechanism, but this hypothesis cannot explain the unilateral onset of migraine or the regional nature of the pain site. In fact, most migraine patients do not start with hemiplegic pain, but start from one of the supraorbital nerve, auriculotemporal nerve or occipital nerve, and gradually spread to hemiplegic or bilateral pain. With the development of neuroanatomy and micro-neurosurgery, it was gradually recognized that most migraine attacks are closely related to structural and/or functional abnormalities of local blood vessels and nerves, and the theory of neurovascular compression was proposed in the 1990s [2], which suggested that most migraine attacks are closely related to the compression of local nerves in the scalp by abnormal blood vessels or pulsatile stimulation. This compression does not directly cause a headache attack, but when the concentration of neurotransmitters in the blood vessels changes and the hemodynamics of the vessel walls change, the nerves in abnormal contact are stimulated and cause a headache attack. The nerve compression theory not only explains that pain has an excitation site and pain is regional in nature, but also provides a theoretical basis for the treatment of migraine by MVD.
Migraine can be divided into auriculotemporal migraine, orbitofrontal migraine, and posterior occipital migraine according to the site of pain triggering. Traditional surgical treatments include [7-10]: (i) removal of the frenulum muscle through an eyelid incision to relieve the compression of the supraorbital nerve and the supraorbital nerve. (ii) Excision of the zygomaticotemporal branch of the trigeminal nerve to prevent compression of the nerve by the temporalis muscle. (iii) Excision of part of the semispinalis muscle to prevent compression of the greater occipital nerve and other treatments, etc. However, the mechanism of this surgical method is not clear and it is more traumatic and has more side effects, and its effect is not sure. In 1992, Ren Yanwu [11] and others treated 70 migraine patients with MVD, and the cure rate reached 85% and the efficiency rate reached 95%. In 2008, Wang Bin [12] and others treated 35 migraine patients with MVD, and the effective rate was 97%. The cure rate of this group was 73% and the total effective rate was 90.6%, which was lower than that reported by Ren Yanwu et al. The author thought that it might be related to the different selection of cases and follow-up time. It is generally believed that the abnormal vascular nerve contact includes [11,13]: ① direct compression of the nerve by the abnormal tortuous vessel. (ii) Winding of dilated tortuous vessels compressing the nerve. (iii) Scar tissue and tumor pushing the vessel and compressing the nerve. In our group, we found 86 cases of direct compression of the nerve by such abnormal-shaped vessels, accounting for 90% of all cases. Zhang Jizhi [14] et al. found that the MMP-9 values in migraine patients were higher than normal and decreased significantly at 7 days after surgery, suggesting that the release of the abnormal blood vessel compression on the nerve may have prevented the prograde and retrograde diffusion of vascular inflammatory mediators in the nerve and inhibited the pain attack.
Although the effectiveness of MVD in the treatment of migraine has been widely reported in the literature, there are few studies on the long-term postoperative efficacy in patients with different areas and lesion characteristics. The present study data suggest that the efficacy of surgery is closely related to the following factors: (1) pain site: the auriculotemporal nerve innervation area has poor radical effect. The cure rate of the auriculotemporal nerve was 58%, which was significantly lower than the decompression surgery of the superior orbital nerve and occipital nerve innervation area. The auriculotemporal nerve is located at the root of the auriculotemporal nerve (above the parotid gland), and there are more bifurcations of the superficial temporal artery in this area, which may lead to incomplete decompression. In two patients with recurrence after treatment, we found residual superficial temporal artery branches that had not been treated during the exploration. (2) Vascular lesions: abnormal vascular dilatation and nerve compression changes are mostly concentrated in the auriculotemporal nerve innervation area, and the decompression effect is the most significant. In our group, 12 of the 18 cases of vasodilatation were in the auriculotemporal nerve innervation area, and after surgical excision of these lesions, all of them were cured in the long-term follow-up. The mechanism of the vasodilatation in this area is still unclear, but it may be related to the vascular properties of the superficial temporal artery itself, as well as the long-term vascular inflammatory response and the release of neuromediators. These patients often complain of vasodilatation and pulsatile pain during painful episodes, and the author believes that this clinical presentation is particularly important for preoperative assessment of prognosis. In addition, although the effect of radical treatment in the auriculotemporal innervation area is lower than that in other areas, it can effectively relieve the number of pain attacks and the degree of pain, so decompression surgery is still an effective treatment method for patients with intractable migraine. (3) Pain range: decompression is poor in patients with bilateral or widespread pain. The data of this group shows that the cure rate and overall efficiency of postoperative decompression in patients with bilateral or widespread pain are lower than those of decompression in other areas. In these patients, it is often necessary to perform nerve trunk block tests on different areas of pain excitation points and decompress the most effective pain activation point during preoperative evaluation, in order to achieve pain relief. (4) Type of neurovascular compression: The cure rate of cases with dilated or thick trunk vessels compressing the nerve was 89.3% (50/56), which was significantly better than the cure rate of 40% (12/30) for cases with compression by other small branches, while there was no correlation between other factors such as adhesions and inflammatory scars and prognosis. It was suggested that the vascular decompression effect was more pronounced in cases with severe nerve compression, suggesting that the abnormal neurovascular contact mechanism is an important factor in causing pain.
In conclusion, this study analyzed the correlation between the prognosis of migraine treated with MVD and the area and extent of pain attacks as well as the characteristics of vascular lesions. The key to improve the cure rate of MVD is to carefully assess the characteristics of each patient before surgery, to strictly control the indications for surgery, and to carefully investigate the abnormal neurovascular contacts that need to be decompressed during surgery and to completely release the nerve compression sites. Since microscopic neurological decompression has the advantages of low trauma, low risk, high efficacy, short hospitalization time and low cost, it is expected to be an effective surgical treatment for intractable migraine that is ineffective to pharmacological treatment in the future, therefore, it is necessary to further investigate its pathogenesis and decompression treatment mechanism.
References
(1)
Duan Meicai. Surgical treatment of migraine in 56 cases. Chinese Journal of Neurosurgery, 1988, 1: 55.
(2)
Wang L., ed. Neurosurgery. Wuhan: Hubei Science and Technology Press, 1998: 155.
(3)
Duan Guosheng, ed. Neurosurgery: The Complete Collection of Surgery. Beijing: People’s Military Medical Publishing House, 1994.
(4)
Wu Jiang, ed. Neurology. Beijing: People’s Health Publishing House, 2005: 284.
(5)
Pietrobon D, Striessnic J. Neurobiology of migraine. Nat Rev
Neurosci, 2003,4:386-398.
(6)
Welch KMA. Contemporary concepts of migraine pathogenesis. Neurology, 2003, 61(Suppl 4):S2-S8.
(7)
Guyuron B, Varghai A, Michelow BJ, et a1. Corrugator supercilii
muscle resection and migraine headaches.Plast Reconstr Surg, 2000, 106: 429-434.
(8)
Guyuron B, Tucker T, Davis J. Surgical treatment of
(8) Guyuron B, Tucker T, Davis J. Surgical treatment of migraine headaches.Plast Reeonstr Surg, 2002, 109: 2183-2189.
(9)
Franz D, Klaus B. Surgical treatment of
Surgical treatment of migraine headaches by corrugator muscle resection.Plast Reconstr Surg, 2004, 114: 652-657.
(10) Guyuron B, Kriegler js, Davis J, et a1. Comprehensive surgical treatment of migraine headaches.
Plast Reconstr Surg, 2005, 115: 1-9.
(11) Ren Yanwu, Zhao Yadu, et al. A discussion on the etiology and surgical treatment of migraine headache. Chinese Journal of Neurosurgery, 1992,8: 271-272.
(12) Wang B, Ma Y, Zou JJ, et al. Clinical experience of 35 cases of vascular migraine treated by microvascular decompression. Chinese Journal of Neurosurgery 2008, 24: 853.
(13) Zhao YH, Li P, Chen END, et al. Pathological observation and pathogenesis of migraine pain paralysis point. Journal of Pain, 1995, 3: 99-101.
(14) Zhang JZ, Deng DF, Wang MCH, et al. Chinese modern drug applications. 2010, 4: 57-58.