Neuralgia is one of the common symptoms in neurosurgery, which refers to pain felt without external stimulation, also known as spontaneous pain, often manifesting as pins and needles-like pain, electric shock-like pain, burning pain, touch pain, paralysis, etc. The pain is often distributed along the nerve course, and can be transient or persistent, with a variety of manifestations. Neuralgia can be classified according to its etiology: those with unknown etiology are called primary neuralgia, and those with clear etiology are called secondary (or symptomatic) neuralgia; pain can also be classified according to its location: central neuralgia and peripheral neuralgia.
I. Central neuralgia
It includes: spinal cord pain, thalamic pain (common in cerebrovascular disease and tumor), pontine medullary pain (seen in cerebrovascular disease, tumor, multiple sclerosis, etc.), and cortical pain (seen in tumor and vascular disease, etc.). Among them, spinal cord pain is also divided into posterior horn pain (mostly seen in trauma, tumor, spinal cord cavitation, etc.), posterior cord pain (seen in multiple sclerosis, spinal cord tuberculosis, etc.), and spinal cord thalamic tract pain (mostly seen in spinal cord cavitation).
Case 1: Patient Li ×××, female, 63 years old, was admitted to the hospital with “right C-P angle hemangiopericytoma combined with Chiari’s malformation and cervical medullary cavity more than 3 months after surgery”. The main problems: severe burning pain in the left quadrant, true bulbar palsy (dysphagia), and cerebrospinal fluid incisional leakage. The patient was discharged after 2 weeks of treatment with Chinese herbal medicine (Semen, Poria, Atractylodes, Paeonia lactiflora, Yannis, Tianma, Gynostemma, Radix et Rhizoma, etc.), the pain improved by 30% and was pain tolerant.
Case 2: Patient Lu××, female, 69 years old, was operated in a local hospital in April 2013 for right basal ganglia cerebral hemorrhage, and gradually recovered after the operation, but there was unfavorable movement of the left limb and gradually developed obvious pain that could not be touched, resulting in daily activities and sleep were greatly affected. The patient was more irritable and had obvious psychiatric symptoms, and the family was suffering. It is characterized by shoulder pain on the affected side, limited movement (especially intense when moving the affected shoulder passively), hand pain on the affected side (flexion of the affected fingers can cause or aggravate the pain), swelling of the hand, increase in skin temperature, and atrophy of the hand muscles after the swelling subsides, until contracture and deformity. Treatment of Western medicine is mainly a small amount of steroid drugs for a short period of time to relieve pain, can not further improve the symptoms, the overall efficacy is poor. According to Chinese medicine, the pathogenesis of the disease is “deficiency at the root and symptoms at the end”, in which the “root” is qi deficiency and blood deficiency caused by the dysfunction of the internal organs, and the “symptoms” are qi stagnation and blood stasis, and ying and guardianship disorders caused by unfavorable pulse pathways. It belongs to the evidence of Qi deficiency, Blood stasis and blockage. The treatment is mainly based on the principle of benefiting Qi, invigorating blood, and relieving pain, and focusing on both the symptoms and the root cause. The medicine used is angelica, henbane, yu zhu, stretching grass, mulberry branch, cow knee, yan hu su, whole scorpion, centipede, white peony, roasted licorice, etc. In addition, acupuncture was added, taking acupoints in front of the shoulder, behind the shoulder, shoulder k, arm, Quchi, Quze, Hand Sanli, Neiguan, Waiguan and Hegu. Effect: The first few days did not show any effect, and Mrs. Lu continued to be irritable, making it impossible for her patients in the same ward to sleep at night. After 7 days, the pain in her left arm decreased day by day, and the patients in the same room could feel her moaning less and less every day. On the 10th day, the old woman’s pain was significantly reduced, her left arm was fine for daily touching, her stiff joints could be loosened, and she was able to sleep normally. On the 14th day, Mrs. Lu herself was able to greet the medical staff happily. On the 15th day, she was successfully discharged from the hospital.
II. Peripheral neuralgia
1. Occipital neuralgia
Definition: paroxysmal or persistent pain within the distribution of the greater occipital nerve (posterior occipital region), or paroxysmal intensification on the basis of persistent pain.
Etiology: neuritis, upper respiratory tract infection, influenza, malaria, rheumatism, diabetes, thyroid disease, alcohol, lead poisoning, occipital and cervical trauma, cervical spondylosis, rheumatoid spondylitis or metastatic cancer, skull base recess, foramen magnum stenosis, atlanto-occipital fusion, atlanto-axial dislocation, upper cervical vertebral body separation insufficiency, cerebellar submandibular herniation, intravertebral tumor, tumor in the foramen magnum area, adhesive spinal arachnoiditis, spinal cord cavitation, suboccipital joint ligament injury, anterior and posterior atlantoaxial arch fracture, atlantoaxial subluxation, cervical muscle injury, etc.
Clinical manifestations: pins and needles, knife-like or burning pain in the posterior occipital region or in the collar on one or both sides, the patient does not dare to turn his head when it hurts, and the head and neck are sometimes in a straightened state. Examination: pressure pain at the outlet of the great nerve, hyperalgesia or hyperalgesia in the distribution area of the great occipital nerve (C2-3), i.e., below the ear collar line to the hairline.
Treatment: Chinese medicine, local closure.
2.Intercostal neuralgia
Definition: Frequent pain occurring in one or several intercostal areas with episodes of exacerbation.
Etiology: primary intercostal neuralgia is extremely rare; secondary cases are mostly related to viral infection, toxin stimulation, mechanical injury and foreign body compression, etc. It can be caused by infectious and toxic radiculitis, pleurisy, chronic pneumonia, aortic aneurysm, mitral stenosis, thoracic organ lesion, thoracic spinal tuberculosis, tumor, ankylosing spondylitis, spinal cord tumor, spinal cord inflammation, rib aneurysm, rib fracture, bone scab, herpes zoster, etc.
Clinical manifestations: The pain mostly occurs in one of the nerves on one side, and its pain is mostly stabbing or burning in nature and distributed along the intercostal nerves. At the onset of the disease, the pain radiates in a semi-circular pattern from posterior to anterior along the corresponding intercostal space, and the pain is stabbing or burning-like. The pain increases with coughing, deep breathing, or sneezing. Patients with intercostal neuralgia due to herpes zoster may see skin lesions within the painful area with piles of clustered rashes with normal skin between the rashes or, in severe cases, oozing or redness. Most patients with shingles recover with treatment, but some patients develop pain in the damaged skin area after the herpes has healed, which lasts for more than 3 months and is called postherpetic neuralgia.
Treatment: Choose a treatment plan for the cause.
3.Sciatic neuralgia
Definition: The sciatic nerve is the largest peripheral nerve in the human body. It starts from the spinal cord in the lumbosacral region, passes through the pelvis, and passes through the foramen magnum to reach the buttocks, and then descends along the back of the thigh to the foot. Pain occurs at the site where the sciatic nerve passes through, and the pain attacks may radiate along the buttocks, posterior femur, lateral calf, and dorsum of the foot, with varying degrees of sensory impairment, decreased muscle strength in the lower extremities, and decreased or absent Achilles tendon reflexes, and the pain increases when the sciatic nerve is pulled, so the patient’s affected lower extremity is often flexed to relieve the pain.
Etiology: The most common is lumbar disc herniation. Others, such as spinal tuberculosis, arachnoiditis, and intravertebral metastatic cancer. In addition, sacral arthritis and pelvic cavity tumor compression nerve can also cause sciatica.
Treatment: B vitamins, Chinese herbal medicine to relax the tendons and activate blood, as well as acupuncture and physiotherapy can be used for treatment.
4.Trigeminal neuralgia
Definition: Recurrent paroxysmal severe neuralgia in the distribution area of the trigeminal nerve in the face. It is sometimes called “face pain” and is easily confused with toothache.
Causes: Commonly caused by inflammatory infiltration, atherosclerotic compression, tumor of the pontocerebellar angle, nasopharyngeal carcinoma, trigeminal ganglion tumor, chordoma, multiple sclerosis, etc.
Onset characteristics: The onset of pain is often unpredictable, with sudden onset of lightning-like, brief and severe pain. Patients often describe it as a burning, stabbing, cutting or tearing pain. The patient often presses the affected side of the face with the palm of the hand or a towel or rubs the painful side of the face to relieve the pain. Due to frequent rubbing, the facial skin becomes rough and sometimes eyebrows may fall off. Sometimes the attack is accompanied by constant chewing action, and in severe cases, it is often accompanied by reflexive twitching of the facial muscles, with the corners of the mouth pulled to one side, also known as “painful twitching”. Sometimes it is accompanied by facial redness, increased skin temperature, conjunctival congestion, tearing, increased saliva production, nasal mucosa congestion, runny nose, etc. Some patients even roll around in bed in pain. The pain can stop abruptly after each attack from a few seconds to a few minutes, and during the interval as normal, a few may still have a burning sensation. The attacks are usually milder or stop at night, but in severe cases, they can also occur frequently overnight and cannot sleep or wake up in pain after sleeping. Most of the pain is gradually aggravated and the attacks become more frequent, even one attack in a few minutes or even all day long. The course of the disease can be cyclical, with each attack lasting weeks or months, and the remission period can vary from days to years. The period of remission may vary from several days to several years. The period of attack seems to be related to the climate, with spring and winter being more prone to attack. The pain can be triggered by actions such as washing the face, brushing the teeth, or eating. Patients are often afraid to brush their teeth, eat, or even drink or speak, which can trigger the onset of trigeminal neuralgia, thus affecting normal life and work, and is known as the “number one pain in the world”.
Treatment: 1.
1, Western medicine: commonly used drugs are neurotrophic drugs, carbamazepine or gabapentin, drug treatment is not effective, but also surgical treatment, commonly used surgery for radiofrequency destruction, microvascular decompression, gamma knife. The advantages of microvascular decompression: obvious pain relief, non-destructive, less side effects, and very low recurrence rate, which is the safest and most effective method of treating trigeminal neuralgia recognized internationally. However, the procedure can have many complications: brainstem infarction, ipsilateral hearing loss or disappearance, facial palsy, facial numbness, cerebellar contusion, intracranial hemorrhage, cerebrospinal fluid leakage and subcutaneous effusion, intracranial infection, etc. The incidence is 3.1-13.3% and the morbidity and mortality rate is 0.1-1%. Although the disease brings great pain to patients, it is not fatal, so patients and their families have high requirements for the efficacy and safety of surgery, and it is difficult to accept postoperative complications, so many patients are afraid of surgery, reject surgery, and refuse surgery.
2.In Chinese medicine, this disease belongs to the category of “migraine”, “head wind”, “facial pain” and other diseases. Pathogenesis: The head is “the meeting of all yang” and “the house of clear yang”, the three yang veins of hands and feet all meet here, the essence of qi and blood of the five viscera and six bowels are all injected into the head, external evil, internal injury or internal and external combined evil, causing the dysfunction of the viscera and bowels, paralysis of the meridians and collaterals, qi and blood reversing upward to offend the head and face and cause pain. Causes: The main cause is wind and blood stasis. The wind evil causes the blood to be closed and depressed, the meridians are paralyzed and obstructed, and the pain is caused by lack of circulation. Treatment: dispel wind, remove blood stasis and open the channels.
Case 3: Patient Wei ××, female, 81 years old, underwent radiofrequency disruption for right facial trigeminal neuralgia in a hospital in Shanghai 3 years ago, and the pain disappeared 2 years after the operation. After 1 week of taking Chinese medicine, the pain was relieved and the patient could speak and eat normally, and after 1 week of taking Chinese medicine, the pain was further relieved, the patient was in good spirits and spoke and ate freely.
Case 4: Meng ××, male, 76 years old, right facial trigeminal neuralgia for more than 30 years, too painful to speak, long-term use of carbamazepine, no significant effect, due to the age of reluctance to open surgery, taking Chinese medicine for 5 days, the pain began to relieve, 12 days after the pain relief of 70%, renewed Chinese medicine 7 days after the pain relief of 80%, has been able to speak normally, eating, drinking water still have a little pain, and then more than 1 month after the pain completely disappeared The pain did not recur even after stopping the Chinese medicine and continuing to take carbamazepine for more than 2 months.
Trigeminal neuralgia patients precautions: life, diet should be regular, to ensure sufficient sleep and rest, avoid overwork. Keep your mood relaxed, avoid impulsiveness, anger and depression. Establish confidence in the treatment of the disease and actively cooperate with the doctor. Take part in sports, exercise and strengthen your body. Move gently and slowly, avoid all pain-inducing factors as much as possible, such as washing face, brushing teeth, etc., and try to avoid stimulating the trigger point. Pay attention to keep warm on cold days and avoid direct stimulation of the face by cold wind. Eat softer food. For patients whose pain is induced by chewing, eat a liquid diet and never eat fried items, irritating food, seafood products and hot food. Adhere to the treatment and do not stop the medicine at will in order to cure.
III. Headache
1. Mechanism of occurrence.
(1) Stimulation or pulling of the meninges, stimulation or squeezing and pulling of the brain nerve with pain sensation (V.IX.X) and cervical nerve.
(2) Vascular factors: constriction and dilation of intracranial and extracranial blood vessels and traction or stretching of blood vessels due to various causes.
(3) Contraction of the muscles of the head and neck.
(4) head and facial pain caused by lesions of the five senses and cervical spine.
(5) Biochemical factors and endocrine disorders.
(6) Nerve dysfunction.
2.Common causes of headache.
(1) Systemic diseases: acute infections, cardiovascular diseases, poisoning, etc.
(2) Extracranial lesions: headache caused by cranial bone diseases (skull base concavity, cranial tumor), cervical spondylosis and other neck diseases, neuralgia (trigeminal neuralgia, glossopharyngeal nerve and occipital neuralgia), eye, ear, nose and dental diseases.
(3) Intracranial lesions: infections (meningitis, meningoencephalitis, encephalitis, brain abscess), vascular lesions (cerebral hemorrhage, cerebral thrombosis, cerebral embolism, hypertensive encephalopathy, cerebral blood supply deficiency, cerebrovascular malformation), occupational lesions (intracranial tumors, parasitic diseases), craniocerebral trauma (concussion, cerebral contusion, subdural hematoma, intracranial hematoma, sequelae of traumatic brain injury), others (migraine, cluster headache, headache type epilepsy).
(4) Neurological disorders: neurasthenia and hysterical headache.
3.Concomitant symptoms of headache
(1) With violent vomiting: increased intracranial pressure.
(2) With vertigo: cerebellar tumor, inadequate blood supply of vertebrobasilar artery.
(3) with fever: systemic infectious disease or intracranial infection.
(4) Chronic progressive headache with psychiatric symptoms: intracranial tumor.
(5) Chronic headache with sudden exacerbation of consciousness: brain herniation.
(6) Visual impairment: glaucoma or brain tumor.
(7) with meningeal irritation: meningitis.
(8) with seizures: cerebrovascular malformation, intracerebral parasitic disease or tumor.
(9) with neurological disorders: neurofunctional headache.
(4) Intractable headache needs to be alerted to brain tumor
There is no record of brain tumor in ancient Chinese medical texts, but some similar symptoms are mentioned in diseases such as “headache”, “real headache” and “head wind”. For example, “Ling Shu? The true headache is very painful, the brain is painful, and the hands and feet are cold to the joints, and death is not treated. In Zhongzangjing: If the head and eyes have been in pain for a long time and the vision is unclear at the end, the person will die.
Chinese medicine etiology and pathogenesis of brain tumor: if the external sensation of six evil spirits, the balance of qi, blood, yin and yang of the body is lost, resulting in clear yang not ascending, turbid yin not descending, so that qi and blood are depressed in the brain, which becomes accumulation over time. If you are depressed and angry, the flow of qi is not smooth, and there is no way to move blood, resulting in stagnation of blood and stagnation of stagnation of dampness into phlegm due to stagnation of qi and stoppage of fluid; qi depression turns into fire over time, burning fluid into phlegm, and phlegm and stasis intermingle, accumulating in the clear orifices.
Treatment of brain tumor: Western medicine is surgery + radiotherapy + chemotherapy; Chinese medicine is herbal medicine + acupuncture + moxibustion + cupping, etc. For example, patient Xu××, male, 58 years old, left occipital astrocytoma grade II postoperative, took Chinese medicine for 1 year and then the tumor foci shrank significantly.
Combination of Chinese and Western medicine has better advantages and development prospects: for patients who undergo surgery, long-term use of Chinese medicine to support and cultivate the root after surgery is expected to improve postoperative complications and prevent or delay tumor recurrence and metastasis. For radiotherapy patients, Chinese medicine can reduce the adverse effects of radiotherapy and improve the therapeutic effect. For patients who are not suitable for surgery or radiotherapy: TCM treatment according to the principles of clearing heat and detoxification, activating blood circulation and blood stasis, resolving phlegm and quenching wind, and softening hardness and dispersing nodules can often achieve the purpose of reducing symptoms, improving the quality of survival and prolonging life, and may even shrink the tumor.
Summary: There are many different kinds of neuralgia, so clinical attention should be paid to identify them; the combination of Chinese and Western medicine has obvious advantages in treating neuralgia.