【摘要】：第一部分乙狀竇后入路三叉神經(jīng)根臨床解剖學(xué)觀察 目的 通過乙狀竇后入路，顯微鏡下觀察三叉神經(jīng)根及其周圍結(jié)構(gòu)，識別感覺主根、運動根，指導(dǎo)微血管減壓手術(shù)。 資料和方法 收集廣東省第二人民醫(yī)院神經(jīng)外科自2012年3月至2013年12月收治的行微血管減壓的患者共220例,其中120例原發(fā)性三叉神經(jīng)痛（TN）為實驗組，100例原發(fā)性面肌痙攣（HFS）為對照組。通過乙狀竇后入路進行手術(shù)，術(shù)中通過觀察，將血管與三叉神經(jīng)的關(guān)系分明顯壓迫型、接觸型及無壓迫型三類，將明顯壓迫型及接觸型均稱為有血管壓迫。術(shù)中在顯微鏡下將三叉神經(jīng)感覺主根分為8個區(qū)域：I為外側(cè)區(qū)，II外上區(qū)，III中上區(qū)，IV內(nèi)上區(qū)，V內(nèi)側(cè)區(qū)，VI內(nèi)下區(qū)，VII中下區(qū)，VIII外下區(qū)（見圖5）。探查并記錄血管與三叉神經(jīng)根的關(guān)系及類型，對比分析兩組病人之間有無差別，統(tǒng)計責(zé)任血管壓迫三叉神經(jīng)的方位。然后，從兩組病患中各選取20例，對三叉神經(jīng)腦干角、三叉神經(jīng)感覺主根及運動根進行詳細觀察及測量，對比兩組病人三叉神經(jīng)腦干角有無差別，同時得出感覺主根長、寬、厚度等詳細數(shù)據(jù)，并記錄運動根與感覺主根的位置關(guān)系。最后記錄影響手術(shù)視野暴露的結(jié)構(gòu)，橋前池、巖骨、巖上靜脈。所有患者均行頭部磁共振血管增強成像（MRA）檢查，排除橋小腦角繼發(fā)性病變，同時排除既往曾行伽馬刀、三叉神經(jīng)根選擇性切斷術(shù)等三叉神經(jīng)手術(shù)的病患。 結(jié)果 1、術(shù)中血管壓迫三叉神經(jīng)，三叉神經(jīng)痛組血管壓迫率（81.7%）明顯高于面肌痙攣組血管壓迫率（8%）。 2、三叉神經(jīng)痛組有血管壓迫的98例（81.7%），其中5例為2支動脈血管壓迫，1例為3支動脈血管壓迫，3例為動靜脈聯(lián)合壓迫，單純靜脈壓迫2例，總計記錄責(zé)任血管108條。責(zé)任血管中，小腦上動脈為主要責(zé)任血管，有82例（75.9%），且以上方壓迫多見；其次為小腦前下動脈，13例（12.0%），主要從下方推移壓迫三叉神經(jīng)；椎基底動脈壓迫7例（6.5%），多從內(nèi)側(cè)壓迫三叉神經(jīng)根；巖靜脈壓迫4例（3.7%），多從三叉神經(jīng)根的外側(cè)壓迫三叉神經(jīng)。其他責(zé)任血管有橋動脈及其他細小分支動脈2例（1.9%）。 3、兩組病患三叉神經(jīng)腦干角沒有差別，角度變化范圍均為10-80°，且多數(shù)為30-50°。 4、兩組病患三叉神經(jīng)感覺主根的長度、寬度、厚度無差別，其長度為12.8±1.5mm，寬度3.5±0.6mm，厚度2.7±0.3mm； 5、在術(shù)中可記錄到獨立的三叉神經(jīng)運動根（或異行感覺根）根絲數(shù)目為3-14條，直徑為0.3-1mm，自橋腦單獨發(fā)出，發(fā)出點位于感覺主根內(nèi)側(cè)、內(nèi)上方及內(nèi)下方，與感覺主根伴行進入Meckel’s囊。運動根之根存在吻合，運動根與感覺根之間也存在吻合。 6、受解剖學(xué)及醫(yī)學(xué)倫理學(xué)限制，對感覺主根無法分出第1、2、3支，也無法辨別異行感覺根與運動根。 結(jié)論 1、血管壓迫是三叉神經(jīng)痛的病因之一；橋前池狹小、巖骨隆起制約對于三叉神經(jīng)根及Meckel’s囊的觀察。 2、根據(jù)運動根的形態(tài)、起源點、分布規(guī)律以及與感覺主根的關(guān)系，可以鏡下準確識別三叉神經(jīng)運動根，，并加以保護。 第二部分三叉神經(jīng)根電生理研究 目的 通過電生理監(jiān)測，辨別三叉神經(jīng)感覺纖維、運動纖維、異行感覺根，研究三叉神經(jīng)根有傳導(dǎo)功能的纖維的分布規(guī)律。 資料和方法 收集31例行乙狀竇后入路微血管減壓術(shù)的患者，其中18例為原發(fā)性三叉神經(jīng)痛患者（實驗組），13例為原發(fā)性面肌痙攣患者（對照組）。術(shù)中解剖分離三叉神經(jīng)顱內(nèi)段感覺主根、運動根(異行感覺根)；術(shù)中將感覺主根分為8個區(qū)域逐一給予0.2mA的電流刺激。其中I、II、VIII區(qū)為感覺主根的外側(cè)，III、VII區(qū)為中部，IV、V、VI為內(nèi)側(cè)。在外周眶上孔、眶下孔、頦孔記錄V1、V2、V3的復(fù)合神經(jīng)動作電位（CNAP），在咬肌和顳肌處記錄復(fù)合肌肉動作電位（CMAP）；以刺激時出現(xiàn)復(fù)合神經(jīng)動作電位（CNAP）的區(qū)域為感覺神經(jīng)纖維，以刺激時出現(xiàn)復(fù)合肌肉動作電位（CMAP）的區(qū)域為運動神經(jīng)纖維；對比兩組患者，神經(jīng)纖維分布有無差別；最后根據(jù)復(fù)合神經(jīng)動作電位及復(fù)合肌肉動作電位出現(xiàn)的頻率確定三叉神經(jīng)根有傳導(dǎo)功能的纖維（感覺纖維、運動纖維）的空間分布規(guī)律。 結(jié)果 1.刺激三叉神經(jīng)根，所有病例均可在外周眶上孔、眶下孔、頦孔處記錄到穩(wěn)定的復(fù)合神經(jīng)動作電位，在咬肌和顳肌處記錄到穩(wěn)定的復(fù)合肌肉動作電位； 2.刺激感覺主根時，主要記錄到的為復(fù)合神經(jīng)動作電位； 3.刺激運動根或感覺主根內(nèi)側(cè)時，可以記錄到咬肌和（或）顳肌的復(fù)合肌肉動作電位，同時伴有V1、V2、V3一支或多支的復(fù)合神經(jīng)動作電位；但刺激運動根產(chǎn)生的復(fù)合肌肉動作電位波幅（60-90uV）高于刺激感覺主根內(nèi)側(cè)產(chǎn)生的復(fù)合肌肉動作電位波幅（30-60uV）； 4.刺激異行感覺根時，外周記錄不到復(fù)合神經(jīng)動作電位及復(fù)合肌肉動作電位，但并非所有的病例均可發(fā)現(xiàn)異行感覺根的存在。 結(jié)論 1、運用復(fù)合神經(jīng)動作電位和復(fù)合肌肉動作電位能幫助識別三叉神經(jīng)的感覺主根、運動根及異行感覺根，避免運動根的損傷。 2、刺激運動根，電信號在半月節(jié)內(nèi)可泛化至外周感覺神經(jīng)根，結(jié)合臨床病例觀察推測，三叉神經(jīng)運動纖維參與了三叉神經(jīng)痛的發(fā)生與發(fā)展。
[Abstract]:Part one clinical anatomic observation of trigeminal nerve root after retrosigmoid approach
objective
Through the retrosigmoid approach, the trigeminal nerve root and its surrounding structures were observed under microscope, and the sensory root and motor root were identified to guide microvascular decompression operation.
Information and methods
220 cases of microvascular decompression were collected from the Department of Neurosurgery of Guangdong No.2 People's Hospital from March 2012 to December 2013. 120 cases of primary trigeminal neuralgia (TN) were used as the experimental group and 100 cases of primary hemifacial spasm (HFS) as the control group. The operation was carried out through the retrosigmoid sinus approach, and the vessels and trigeminal nerve were observed during the operation. The relationship clearly showed three types of compression type, contact type and no oppression type. The obvious compression type and contact type were all called vascular compression. Under the microscope, the main root of trigeminal nerve was divided into 8 regions: I in the lateral region, II upper region, upper III, IV upper region, V inside region, VI inner subregion, VII middle and lower region, VIII outer and lower region (see Figure 5). The relationship between the blood vessels and the trigeminal nerve root was recorded and the difference between the two groups was compared, and the position of the trigeminal nerve was compressed by the statistical responsible blood vessels. Then, 20 cases were selected from two groups of patients. The trigeminal brainstem angle, the trigeminal sensory root and the motor root were observed and measured in detail, and the trigeminal nerves were compared to the two groups of the trigeminal gods. At the same time, the length, width, thickness and other detailed data of the sensory root were obtained, and the relationship between the moving root and the position of the sensory root was recorded. Finally, the structure of the surgical field, the anterior pontine, the rock bone, and the upper rock vein were recorded. All the patients were examined by head magnetic resonance blood Guan Zengqiang imaging (MRA), and the secondary venereal disease in the cerebellopontine angle was excluded. Meanwhile, patients with trigeminal neurosurgery who had undergone gamma knife surgery and trigeminal selective rhizotomy were excluded.
Result
1, intraoperative vascular compression of trigeminal nerve, trigeminal neuralgia group vascular compression rate (81.7%) was significantly higher than that of hemifacial spasm group vascular compression rate (8%).
2, there were 98 cases of vascular compression in the trigeminal neuralgia group (81.7%), of which 5 cases were compressed by 2 arteries, 1 cases were oppressed by 3 arteries, 3 cases were combined with arteriovenous compression, 2 with pure vein compression, and 108 vessels of responsible vessels. In the responsible vessels, the superior cerebellar artery was mainly responsible for vessels, 82 cases (75.9%), and oppressive above. The second was the inferior cerebellar inferior artery, 13 cases (12%), which mainly oppressed the trigeminal nerve from the lower part; the vertebral basilar artery oppressed 7 cases (6.5%), oppressed the trigeminal nerve root mostly from the medial, 4 cases (3.7%) oppressed the vein, and more from the lateral of the trigeminal nerve root. The other vessels had the bridge artery and the other small branch arteries in 2 cases (1.9%).
3, there was no difference in the trigeminal nerve stem angle between the two groups, the angle variation range was 10-80 degrees, and most of them were 30-50 degrees.
The length, width and thickness of the sensory root of the 4 trigeminal nerve in two groups were not different, the length was 12.8 + 1.5mm, the width was 3.5 + 0.6mm, and the thickness was 2.7 + 0.3mm.
5, the number of the independent trigeminal motor root (or the sensory root) of the trigeminal nerve (or the sensory root) was 3-14, and the diameter was 0.3-1MM. It was produced separately from the bridge brain. The emit point was located inside the sensory root, above and below the inner part of the sensory root. The root of the motor root was in anastomosis with the root of the sensory root. There was a kiss between the root and the sensory root, and there was a kiss between the moving root and the sensory root. Close.
6, restricted by anatomy and medical ethics, it is impossible to distinguish the 1,2,3 branch from the sensory main root, nor can it distinguish the root and the moving root of the diverting sensation.
conclusion
1, vascular compression is one of the causes of trigeminal neuralgia. The anterior bridging pool is small and the bony bone protuberance restricts the observation of the trigeminal nerve root and the Meckel 's capsule.
2, according to the morphology, origin, distribution and the relationship with the sensory root, we can accurately identify the motor roots of trigeminal nerve and protect them.
The electrophysiological study of the second part of the trigeminal nerve root
objective
By electrophysiological monitoring, the trigeminal sensory fibers, motor fibers and abnormal sensory roots were distinguished, and the distribution of fibers with conduction function in trigeminal nerve roots was studied.
Information and methods
31 patients with posterior sigmoid microvascular decompression were collected, of which 18 were patients with primary trigeminal neuralgia (experimental group), 13 were patients with primary hemifacial spasm (control group). Intraoperative anatomical separation of the sensory main root of the trigeminal nerve and the moving root (sensory root) was dissected during the operation, and the sensory root was divided into 8 regions to give 0.2mA one by one. Current stimulation. The I, II, and VIII areas are the lateral of the sensory root, and the III, VII region is the middle, IV, V, VI are inside. In the peripheral orbital foramen, the suborbital hole, and the mental pore record the V1, V2, V3 compound nerve action potential (CNAP) and the region of the compound nerve action potential at the masseter and temporal muscles. Sensory nerve fibers, the region of the complex muscle action potential (CMAP) that appears as a motor nerve fiber at the time of stimulation; compared to the two groups of patients, the distribution of nerve fibers is different; finally, according to the frequency of the compound nerve action potential and the frequency of the complex muscle action potential, the fibers of the trigeminal root have the conduction function (sensory fiber, sports fiber). The spatial distribution of dimensions.
Result
1. stimulation of the trigeminal nerve root, all cases were able to record a stable compound nerve action potential at the peripheral orbital foramen, suborbital foramen and mental hole, and a stable complex muscle action potential was recorded at the masseter and temporalis muscles.
2. when stimulating the sensory root, the compound nerve action potential was recorded.
3. the compound muscle action potential of the masseter and / or temporal muscle can be recorded at the medial part of the motor root or the sensory root of the sensory root, with the combined action potential of one or more branches of V1, V2, V3, but the amplitude (60-90uV) of the compound muscle action potential (60-90uV) produced by the stimulation of the motor root is higher than that of the compound muscle action potential produced on the inside of the sensory primary root. Amplitude (30-60uV);
4. when the sensory roots were stimulated, the peripheral nerve action potential and the complex muscle action potential were not recorded in the peripheral blood, but not all the cases could find the existence of the sensory root of the alien line.
conclusion
1, using the combined action potential and the complex muscle action potential can help to identify the sensory root of the trigeminal nerve, the moving root and the sensory root of the different lines, and avoid the injury of the motor root.
2, stimulates the movement root, the electrical signal can be generalized to the peripheral sensory nerve root in the semilunar node. Combined with clinical case observation, it is conjectured that trigeminal motor fibers participate in the occurrence and development of trigeminal neuralgia.
【學(xué)位授予單位】：南華大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R322.85

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