I. General treatment
(A) Drug therapy
Most patients have taken carbamazepine. According to statistics, this drug can make 70% of patients completely stop pain and 20% of patients have relief during the period of taking the drug.
of patients can be relieved. However, when this drug is taken for a long time, most patients will develop drug tolerance, i.e., the drug dose becomes higher and higher, but the efficacy becomes worse and worse. Many patients experience intolerable drug side effects. It is wise to choose a radical pain treatment as early as possible.
1, carbamazepine (aminoglutethimide, tegretol, carbamazepine) initial dose of 100mg, 1 day 2 times, and then increase 100mg per day until the pain stops (the maximum amount should not exceed 1000mg / d); then gradually reduce, to determine the minimum effective amount, as a maintenance dose to take. This drug is contraindicated in pregnant women (see “epilepsy” for side effects).
2.Phenytoin sodium starts at 0.1g, 3 times/d; if it is not effective, the dose can be increased by 0.1g daily, (the maximum amount should not exceed 0.6g/d). If toxic symptoms (such as dizziness, unstable walking, nystagmus, etc.) arise, the dose should be reduced until the toxic reaction disappears. If it is still effective, this is the maintenance amount.
3, seven-leaved lotus (wild papaya) a herbal medicine belongs to the family Mouton family, made into injections and tablets. Injections of 4ml each time, 2-3 times a day, intramuscular injection, once the pain is reduced, switch to oral tablets, 3 tablets each time, 4 times a day, continuous intake. Sometimes combined with phenytoin sodium and carbamazepine can improve the efficacy.
4. Other phenobarbital and chlorpromazine can be used in combination to improve therapy.
(II) Chinese medicine treatment
According to Chinese medicine, trigeminal neuralgia belongs to the category of “headache”, “migraine” and “facial pain”. In ancient medical books, there are records of the names of “first wind,” “brain wind,” and “head wind,” such as “Su Wen・Wind Theory”: “The symptoms of first wind, head and face sweating and evil wind, when the first wind 1 day is very sick, headache can not be out inside.
Some patients with trigeminal neuralgia can receive certain therapeutic effects after taking traditional Chinese medicine, which can stop or reduce the pain attacks. Some clinicians have used internal Chinese medicine to treat trigeminal neuralgia and have achieved certain results. Traditional Chinese medicine advocates the identification and treatment of this disease, and gives targeted treatment according to different types.”
External attack of wind evil: the treatment is to invigorate blood circulation, remove blood stasis, dispel wind and relieve pain. It can be applied to add flavor Wu Zhuyu Tang (25g each of Dang Ginseng and Chuanxiong, 18g each of Wu Zhuyu, Angelica dahurica and Tianma, 12g each of Ginger, Peppermint and Fangfeng, 20g each of Danshen and Xiangxiang, 15g of Red Peony, 30g of Hooked Vine, and 3g of Hossein), or it can be applied to 10g of Baihuizi, 10g of Stiff Silkworm, 10g of Tianma, 10g of Fangfeng, 10g of Angelica dahurica, 10g of Hossein, 10g of Bile Nanxing, 10g of Di Long, 10g of Rhizoma Chuanxiong 10g, Scorpion 3g.
Liver fire type: Nourishing Yin and submerging Yang, lowering fire and quenching wind. We can use 5g of whole scorpion, 2 centipedes, 15g of each of silkworm, Di Long, Chuan Xiong, Niubizi, Sheng Di, Bai Shao, Bai Zhu, 10g of each of Chuan Wu, 10g of each of Angelica dahurica, Tian Ma and Semen Parviflora, 4g of fine spices, 20g of hooked vine and 30g of stone cassia (first decoction). It can also be used with 9g each of Baishenjian, Manchurian, Fried Myrrh, Gentiana, Tribulus terrestris, 12g each of Angelica dahurica, 15g each of Paeonia lactiflora and Radix et Rhizoma, 30g of Shijiazhuang (first decoction), 6g of Allium sativum, and 3g of Glycyrrhiza glabra.
Self-treatment
(1) Patients should pay attention to maintaining optimism, avoiding strain, keeping warm, avoiding local freezing and dampness, not using too cold or too hot water to wash the face, strengthening nutrition, choosing soft and easy-to-chew food for diet, and not using stimulating food to avoid triggering painful attacks.
(2) prescription therapy
(1) 30-50 grams of lotus of seven leaves, decocted in water, 1 dose daily, is effective for trigeminal neuralgia. There are now tablets and injections of lotus of seven leaves, which are used clinically for trigeminal neuralgia treatment.
② 10 grams of dried gooseberry, 5 grams each of tooth soap and pseudostemma, and 2.5 grams of green daisy, grinded together and inhaled into the ipsilateral nostril at any time to treat trigeminal neuralgia. Hooked vine 15 grams (later down), dahurica dahurica, Xia Gu Cao 10 grams each, Tian Ma 5 grams, 1 dose daily, water decoction in 2 doses, 3 to 5 doses in a row, has the effect of stopping trigeminal neuralgia.
(3) Pinching and acupuncture therapy: If the first branch of trigeminal nerve is painful, press and pinch the sun, head dimension and catarrh; if the second branch is painful, press and pinch the shimonoseki; if the third branch is painful, press and pinch the cheek carriage, hearing palace and digong. If all three branches are painful, add with the valley and the foot three li with strong stimulation.
Combing therapy: It is more effective for the first branch of pain. The operation method is: use a wooden comb, comb your hair in the morning after waking up, after lunch break and at night before going to bed, from the forehead to the occiput via the top of the head, 20-30 times per minute at first, and gradually increase the speed later. Combing force should be even, appropriate, in order not to scratch the scalp as degree. Each comb 5 to 10 minutes. This persists for more than a month, the pain can be greatly reduced; adhere to 2 to 3 months can generally be cured.
(C) acupuncture treatment
1, ordinary acupuncture therapy: acupuncture treatment in the clinical application of convenient, safe and fast, with few side effects.
Main acupoints: Fengchi, Cataract, Shimonoseki, Hand Sanli, Hegu.
Supporting points: Sun, Yangbai, Zanzhu, and Touwei for branch 1 pain. For the 2nd and 3rd branch pain, add Sun, Sibai, Shimonoseki, Hearing, Dicang, Chengjue, Yingxiang. Perform heavy stimulation method and keep the needles, can add electric needles.
2.Acupuncture of the peripheral branches of the trigeminal nerve
Needle prick the supraorbital foramen, infraorbital foramen, posterior superior alveolar foramen and chin foramen, and directly prick the peripheral branch of trigeminal nerve, waiting for the pain and numbness response in the distribution area of the ipsilateral branch, and obtain rapid analgesic effect. The needling technique held is a strong stimulation by lifting and twisting, regardless of yin and yang, and the patient is in the prone position for the first time, and the technique should be light so as not to cause dizziness or fear of needles.
3, the use of bee acupuncture therapy: bee sting needles contain bee needle liquid, the nervous system has a significant effect. The combination of acupuncture principles to take points treatment, often received good results.
The trigeminal nerve peripheral branch closure therapy
Trigeminal nerve peripheral branch closure is a common method for clinical treatment of trigeminal neuralgia. The injection sites are mainly the bone holes through which the trigeminal nerve branches pass, such as the supraorbital hole, infraorbital hole, inferior alveolar hole, chin hole and pterygopalatine hole. The drugs used include anhydrous ethanol, phenol solution, doxorubicin, streptomycin, etc. The range of pain relief with trigeminal peripheral branch closure treatment is limited, and its effectiveness is also closely related to the operator’s skill level and the extent of the patient’s condition; therefore, most patients relapse within six months to two years.
The peri-trigeminal nerve branch block is divided into: supraorbital nerve block, infraorbital nerve block, posterior superior alveolar nerve block, maxillary nerve block, chin nerve block, inferior alveolar nerve block and mandibular nerve block according to the injection site.
III. Semilunar ganglion block therapy
The treatment of trigeminal neuralgia with semilunar ganglion block has been widely used both at home and abroad, and this injection therapy has been proved to be effective for many years. However, because the injection technique is difficult to master, mainly because the accuracy of the puncture operation is difficult to grasp, the treatment effect varies greatly with each person’s technique.
The semilunar ganglion in the cranial cavity is punctured through the oval hole, and nerve-destroying drugs such as glycerin, anhydrous ethanol, phenol solution, doxorubicin, and adriamycin are injected to block the 2nd, 3rd, or even all three branches of the trigeminal nerve, and a prolonged blocking effect can be obtained. It is used for the treatment of intractable trigeminal neuralgia, maxillofacial cancer pain and postherpetic pain of herpes zoster.
Indications.
1.This injection therapy is suitable for all patients with more serious and stubborn trigeminal neuralgia, especially for old, weak and chronically ill patients with contraindications to open surgery.
2.Trigeminal neuralgia involving both the 2nd and 3rd branches, the 1st and 2nd branches or all the 3 branches, and the peripheral branch block is ineffective.
3, Stubborn trigeminal neuralgia after facial herpes zoster.
Complications: Some of the possible complications caused by semilunar ganglion block are mostly due to damage to nearby blood vessels, cerebral nerves and tissues caused by inappropriate direction of puncture (uninstrumented freehand puncture) or too deep needle entry, or damage caused by a large dose of ethanol and flowing into the subarachnoid space.
The incidence of complications is very low. Most of the complications of the semilunar ganglion block can be avoided with effort.
The main complications are: loss or abnormal sensation within the block area; vertigo syndrome; difficulty in mastication; cerebral nerve damage; ipsilateral keratitis and corneal ulceration.
The relationship between injection therapy and craniotomy is complementary to each other. Surgical treatment of trigeminal neuralgia has been rare in recent years. Patients who are suitable for craniotomy should be treated with injection therapy first. For those who have failed to perform craniotomy, or those who have poor surgical results, or those who have relapsed after surgery, injection therapy can also receive very good results.
Four, radiofrequency thermal coagulation therapy
Radiofrequency thermal coagulation therapy is the use of high temperature on the ganglion, nerve trunk and nerve roots and other parts, so that the protein coagulation denaturation, thereby blocking the conduction of nerve impulses.
Currently, radiofrequency thermocoagulation is more widely used in the clinic, and the therapeutic effect of thermocoagulation is good, but there are more complications, and no cases of death have been reported. Although the recurrence rate is high, due to the ease of operation, it can be repeatedly performed for the ultimate purpose of analgesia.
Adverse reactions and complications
1. Pain during operation: This method needs to obtain the cooperation of the patient. It should be made clear before treatment that such treatment under local anesthesia is painful, and the patient’s understanding and cooperation must be obtained, and attention should be paid to slow heating from 60℃, which can reduce the pain caused by sudden high temperature.
2, intracranial hemorrhage: the medial aspect of the semilunar ganglion is adjacent to the cavernous sinus and the internal carotid artery, so inadvertent puncture or entering the foramen ovale too deeply can easily damage and bleed, and in serious cases, intracranial hematoma can be formed.
3, brain nerve damage: such as facial light paralysis, etc.
4, intracranial infection: strict aseptic operation can prevent secondary intracranial infection. Special attention should be paid to prevent repeated punctures of the buccal mucosa by the puncture needle to bring bacteria from the oral cavity into the skull.
5. Herpes zoster: It can appear in the affected area several days after surgery, and its mechanism is not clear. Local nail violet or cortisone ointment can be applied and heal in a few days.
6, keratitis: one of the more serious complications of hemianoplasty is the loss of corneal reflexes, which can cause paralytic keratitis in severe cases, and can eventually lead to blindness. During the operation, it is important to control the heating temperature and time, and to check the change of corneal reflex at any time.
In cases where loss of corneal reflex has occurred, the patient should be instructed to wear glasses and use eye ointment to protect the cornea and prevent keratitis. Some corneal reflex loss takes several months to gradually recover.
7, facial sensory disorders: most patients can have different degrees of facial sensory disorders after treatment. In the 315 cases summarized by Menzel, about 93.1% of patients had varying degrees of numbness or burning sensation in the face after treatment.
Therefore, before treatment, patients and their families have the right to inform the treating physician about the possible side effects of treatment.
V. Peripheral nerve avulsion
Some experts believe that the arteries supplying the trigeminal nerve become sclerotic and ischemic, resulting in degeneration of the nerve fibers due to disturbance of nutrient metabolism. The compression of blood vessels by the proliferation of peripheral nerve tissue at the distal end of the nerve further reduces the blood supply and aggravates the degeneration of the nerve, resulting in the demyelination of nerve fibers and the phenomenon of “short-circuiting and crosstalk”.
For this reason, peripheral nerve avulsion surgery has emerged in clinical practice. When performing this surgery, as much of the nerve should be avulsed proximally as possible to prevent recurrence of trigeminal neuralgia after surgery. Since this method is stretched and ineffective in the treatment of multi-branch pain or deep pain trigeminal neuralgia, it is not used much.
VI. Balloon compression method of the semilunar ganglion
The balloon compression method is an international technique that has been used for the treatment of trigeminal neuralgia since the eighties. The patient is under general anesthesia, tracheal intubation and controlled breathing. The duration of anesthesia varies from 20 to 160 minutes, depending on the proficiency of the puncture operator.
Therefore, it is required that the anesthesia be terminated at any time and the patient be awake as soon as possible. Semilunar ganglion puncture is performed under an x-ray screen. A 14-gauge puncture needle with a needle core is punctured through the facial skin. The puncture needle is stopped at the foramen ovale and the core is withdrawn, and the Fogarty balloon is placed into the semilunar ganglion via the puncture needle.
The catheter connector outside the balloon was connected with a syringe and 1 to 2 ml of fluid was injected to distend the balloon to form a pear-shaped capsule of approximately 1 × 1.5 cm (as seen on the x-ray screen) and maintained for several minutes. At the end of compression the fluid is withdrawn and the distended balloon is recovered. The balloon is withdrawn with the puncture needle and the puncture site is compressed to stop bleeding. The entire operation is performed under an x-ray screen. The success rate of the operation is about 90%, but the recurrence after six months is effective to be treated again, and the long-term effect is to be observed.
VII. Trigeminal nerve root microvascular decompression
Since Dandy
Since Dandy first put forward the argument that vascular compression of the trigeminal nerve root can cause trigeminal neuralgia in 1934, some clinical data have also shown that vascular compression of the trigeminal nerve is one of the causes of trigeminal neuralgia. Many scholars have therefore used neurovascular decompression to treat trigeminal neuralgia.
(I) Commonly used methods
The following craniotomies are commonly used in the treatment of trigeminal neuralgia: transcranial middle fossa trigeminal sensory root dissection, trigeminal spinal bundle dissection, trigeminal root decompression and posterior cranial fossa trigeminal root microvascular decompression.
(B) Surgical operation technique
After routine disinfection, 2% lidocaine is used for infiltration anesthesia or general anesthesia in the postauricular marker line. An incision is made along the marker line, and a bone window of approximately 2 cm in diameter is drilled with a cranial drill immediately behind the posterior border of the sigmoid sinus (the bone debris is collected and set aside).
The cerebellum was gently retracted posteriorly and superiorly under the operating microscope, and a miniature cerebral pressure plate with a 2- to 3-mm wide band suction tube was placed to reach the root of the trigeminal nerve, and the vascular compression and other lesions were explored distally from the nerve out of the cerebral bridge.
A small autologous muscle piece is placed between the nerve and the vessel. The nerve that is compressed by the vessel is wrapped around and separated from the vessel. At this point, the patient is asked to hit the trigger point with his own hand and perform certain movements that normally trigger pain, and if there is no pain, decompression is achieved. The incision is closed with layer-by-layer sutures.
(C) Factors affecting the subjective satisfaction of surgical results
Although the long-term efficacy of trigeminal neuralgia treatment with microvascular decompression is reported differently, it can still be applied as a feasible method. In the past, long-term outcome follow-ups have mostly focused on objective factors, but lacked understanding of patients’ subjective satisfaction with the treatment outcome, which is also important for judging the overall effect of trigeminal nerve decompression. Some factors that affect subjective satisfaction include.
1. trigeminal neuralgia is a disorder that causes great pain to patients, and various treatment methods do not have very satisfactory results. Thus, it was found during the follow-up that although objectively the pain did not disappear completely after the surgery, leaving mild pain or pain recurrence, but the pain level was mild, and the condition that the pain could not be controlled by drugs before the surgery was changed, or accompanied by mild complications, subjectively the patients were still satisfied with the results of this surgery. For this objective and subjective inconsistency, it is understandable that patients self-compared the kind of unbearable pain before surgery with the situation after surgery and arrived at the right choice, which also enhanced confidence in the use of manifest microvascular decompression for trigeminal neuralgia. The high satisfaction rate of patients in the follow-up indicated that this procedure is still a better method for trigeminal neuralgia treatment.
2.
The early cure rate after surgery is not reliable. During the follow-up, it was found that most of those who did not have pain relief or complete relief after surgery expressed dissatisfaction. These patients were all cases in the early stage of carrying out apparent microvascular decompression surgery. In recent years, due to the emphasis on the identification of the involved vessels, especially those cases where the small unnamed artery crosses the trigeminal nerve or contacts at the brainstem, or where multiple invading vessels exist or the arterial ring is hidden, the vein is cut by compression electrocoagulation, and the thickened arachnoid membrane around the nerve is also completely cut to straighten the trigeminal nerve root, and satisfactory results are obtained.
3. After microvascular decompression surgery, patients will not be satisfied if complications such as facial sensory impairment or hearing impairment remain despite pain relief. Performing vascular decompression not only to relieve pain, but also must pay attention to the preservation of nerve function, which is an important point that is different from other surgical methods for trigeminal neuralgia.
Eight, gamma knife treatment of trigeminal neuralgia
Gamma knife was introduced more than 30 years ago, has become the most important tool in the field of stereotactic radiosurgery. The principle of gamma knife analgesia is to focus gamma rays on the pre-selected pain-related brain nuclei or nociceptive conduction pathways, a high-dose irradiation to destroy the nociceptive conduction pathways, blocking the conduction of nociception and achieve the analgesic effect. The application of gamma knife treatment of trigeminal neuralgia has also achieved certain efficacy.
Gamma knife treatment is to calculate the three-dimensional coordinates of the trigeminal nerve root through imaging positioning, and then focus the gamma rays on the target point, the treatment physician can block the nociceptive conduction through the control of the dose size. The treatment process is simple, less painful and easily accepted by patients. However, a treatment is expensive, around $20,000. According to the industry experts engaged in gamma knife work, the success rate of gamma knife treatment of trigeminal neuralgia is about 60%, and there is a possibility of recurrence. Many of the patients who come to our hospital for treatment have been treated with gamma knife and not cured, of which the Singaporean patient Du is one of the examples.
According to the current experience, the conditions suitable for gamma knife treatment are.
① other treatments have not been effective in persistent post-herpetic trigeminal neuralgia
② diagnosed as secondary trigeminal neuralgia, there is a small intracranial tumor or vascular malformation by imaging, the primary lesion can be treated with gamma knife. Usually the pain will be relieved with the improvement of the primary lesion.
Prevention
1, the diet should be regular, it is appropriate to choose soft, easy to chew food, chewing induced pain patients, then to eat a liquid diet, do not eat fried things, irritating food, seafood products and hot food; diet should be nutritious, usually should eat more vitamin-rich and detoxifying food; eat more fresh fruits, vegetables and legumes, less fatty meat and more lean meat, food to light is appropriate.
2.Eating and gargling, talking, brushing teeth, washing face should be gentle, should not eat irritating food, so as not to induce plate machine point and cause trigeminal neuralgia.
3, pay attention to the head and face warmth, avoid local freezing, moisture, do not use too cold, too hot water to wash the face; usually should maintain emotional stability, should not be excited, often listen to soft music, calm mood, maintain adequate sleep.
4, keep a happy spirit, avoid mental stimulation; try to avoid touching the “trigger point”; regular living, indoor environment should be quiet, neat, fresh air. Appropriate participation in sports, exercise, enhance physical fitness.