当前位置:首页 > 文献频道 > 临床内科学 > 文献详细

《神经外科学》

面肌痉挛显微血管减压术中对静脉压迫的处理 (附29例分析)

发表时间:2011-06-29  浏览次数:471次

  作者:于炎冰 徐晓利 作者单位:卫生部北京中日友好医院神经外科, 北京 100029

  【摘要】 目的 探讨特发性面肌痉挛显微血管减压术中对静脉压迫的处理。 方法 回顾性分析2001年3月~2006年3月采用显微血管减压术治疗的422例面肌痉挛病例,29例 (6.9%) 术中探查发现面、听神经出 (进) 脑干区有静脉通过,其中8例 (1.9%) 确认为责任动脉压迫之外并存静脉压迫。责任静脉处理方法:电凝后切断7例,将静脉充分游离后以Teflon棉垫开1例。另外21例 (5.0%) 由于静脉不是责任血管,未予处理。 结果 29例病人术后即刻有效率100%,治愈28例 (96.6%),另1例即刻未治愈而于术后3周延迟治愈。平均随访44个月,无复发病例。与静脉处理有关的术后并发症:轻-中度面瘫、听力下降伴耳鸣2例,随访期间均好转,暂时性单纯耳鸣1例,一过性轻度面瘫1例。 结论 特发性面肌痉挛显微血管减压术中,对与面神经出脑干区责任动脉压迫并存的静脉性压迫应电凝后切断,方能彻底减压;但术后面、听神经并发症的发生率增加。静脉性压迫均合并动脉性压迫,且为次要压迫因素时,静脉不会单独对面神经出脑干区构成压迫;在面、听神经出 (进) 脑干区之间通过的静脉不是责任血管,可不予处理。

  【关键词】 显微血管减压术 面部单侧痉挛 静脉性压迫

  Management of venous compression in microvascular decompression

  for idiopathic hemifacial spasm: analysis of 29 cases

  YU Yanbing, ZHANG Li, XU Xiaoli, et al

  Department of Neurosurgery, China-Japan Friendship Hospital, Ministry of Public Health, Beijing 100029, China

  Abstract: Objective To study the management of venous compression in microvascular decompression for idiopathic hemifacial spasm. Methods Clinical data of 422 patients who underwent microvascular decompression operations for idiopathic hemifacial spasm performed from March 2001 to March 2006 were retrospectively analyzed. The veins passing through nerve exit or entry zone (REZ) of facial and vestibulocochlear nerves were found in 29 (6.9%) cases. The veins were believed to be offending vessels accompanied by arterial compression in 8 cases (1.9%), among them 7 veins were coagulated and cut, 1 was taken away from REZ by a Teflon prothesis. The other 21 veins were believed not to be offending vessels and not treated. Results In the 29 cases, the immediate efficacy rate was 100%, cure rate was 96.6% (28 cases), and the spasm disappeared 3 week later after surgery in 1 case not recovered right after the operation. The cure rate was 100% during the follow-up period with mean duration of 44 months. There was no recurrence. The postoperative complications in the 8 patients with venous management included transient mild to moderate facial palsy, decreased hearing ability and tinnitus which improved during the follow-up in 2 cases, transient tinnitus in 1, and transient mild facial palsy in 1. Conclusion When the venous compression is observed during microvascular decompression for idiopathic hemifacial spasm, the offending veins should be coagulated and cut to achieve decompression, but this procedure is always difficult and dangerous, which could result in higher postoperative complication rate of facial and vestibulocochlear nerves. There is always an arterial compression besides the venous compression and the later is always the less important one. It is impossible to find a venous compression without arterial compression in hemifacial spasm. If the veins passing between REZ of facial and vestibulocochlear nerves are not offending vessels, the treatment can be neglected.

  Key words: microvascular decompression; hemifacial spasm; venous compression

  显微血管减压术 (MVD) 是治疗特发性偏侧面肌痉挛 (HFS) 的有效手术方法。长期的临床实践表明:动脉性血管压迫是大多数HFS的根本病因。2001年3月~2006年3月,我们采用MVD治疗422例HFS,术中发现静脉通过面、听神经出 (进) 脑干区 (REZ) 29例,现对该29例进行分析,以探讨静脉性压迫的处理方法。

  1 对象与方法

  1.1 一般资料 男性11例,女性18例;年龄28~67岁,平均44岁。左侧17例,右侧12例。病程1~18年,平均5.3年。术前均经头颅影像学检查除外继发性病因。

  1.2 手术方法 常规病侧枕下乙状窦后锁孔入路探查桥小脑角 (CPA),8例 (1.9%) 确认为除责任动脉压迫面神经REZ之外并存静脉性压迫;责任动脉:小脑后下动脉主干3例,椎动脉及小脑后下动脉主干共同压迫2例,小脑前下动脉主干2例,小脑前下动脉分支1例;责任静脉处理方法:电凝后切断7例,将静脉充分游离后以Teflon棉垫开1例。另外21例 (5.0%) 静脉在面、听神经REZ之间通过且更靠近听神经REZ,认为不是责任血管,未予处理。术中未发现静脉单独对面神经REZ构成压迫的情况。

  2 结 果

  29例病人术后即刻有效率100%,治愈率96.6% (28例),1例术后痉挛好转但未完全消失者于术后3周延迟治愈。平均随访44个月,治愈率100%,无复发病例。8例处理静脉病人术后并发症:轻-中度面瘫、听力下降伴耳鸣2例,暂时性单纯耳鸣1例,一过性轻度面瘫1例;处理静脉组术后面、听神经并发症发生率高达50%。21例未处理静脉病人术后并发症:暂时性单纯耳鸣1例;发生率仅为4.8%,与处理静脉组比较,差异显著 (P < 0.001)。

  3 讨 论

  特发性HFS的病因目前已确认是由于CPA部位的面神经REZ受责任血管压迫而发生脱髓鞘病变,传入与传出神经纤维之间冲动发生短路所致。MVD是目前已知惟一可治愈HFS的方法,特别是其具有完全保留血管和神经功能的特性,因此成为最有效的首选治疗方法。常见的责任血管主要有小脑前下动脉主干和 (或) 分支、小脑后下动脉主干和 (或) 分支、椎动脉[1,2]。理论上而言,任何通过面神经REZ的血管均为责任血管,包括动脉及静脉。不同于原发性三叉神经痛的是,有关HFS 静脉性血管压迫的报告甚少。Kondo[3]报道1 000余例HFS,未发现静脉单独构成压迫的现象;而Chung等[2]的资料显示:静脉性压迫的发生率为0.2%。Levy等[4]对<18岁的HFS病人行MVD,发现责任血管主要是静脉或静脉与小脑前下动脉分支共同构成压迫。Li[5]报道545例HFS MVD,术中发现2例静脉性压迫,其中延迟治愈1例,无效1例。

  本组发现29例静脉通过面、听神经REZ,其中8例静脉通过面神经REZ而确认为静脉性压迫,占全组422例的1.9%;予电凝后切断静脉7例,将静脉充分游离后以Teflon棉垫开1例。另外21例静脉在面、听神经REZ之间通过且更靠近听神经REZ,认为不是责任血管,未予处理。术中未发现静脉单独对面神经REZ构成压迫的情况。该29例病人术后均获满意疗效。根据本组经验,我们认为:通过面神经REZ的静脉是责任血管,必须加以处理。首先应尝试将静脉充分游离后以Teflon棉垫开,但此处静脉多为脑桥背外侧引流静脉,多不易与REZ分离,或游离后局部空间狭小,Teflon棉置入困难,应电凝后切断方能彻底减压[6];不可单纯烧灼闭塞,因其有很大的再通可能。在面、听神经REZ之间通过的静脉多更靠近或通过听神经REZ,不是责任血管,可不予处理。我们认为:静脉性压迫均合并动脉性压迫,且为次要压迫因素;静脉不会单独对面神经REZ构成压迫。

  即使对于有HFS MVD手术经验的神经外科医师而言,在面、听神经REZ附近进行针对责任静脉的显微操作往往也是困难和危险的。此处的脑桥背外侧引流静脉很难与REZ分离,游离、电凝责任静脉有时会骚扰到REZ,从而增加术后面、听神经并发症的发生率。本组处理静脉病人的术后面、听神经并发症发生率显著性高于未处理静脉者。所幸在随访期间,面、听神经功能均有恢复。极个别情况下,通过面神经REZ的责任静脉异常粗大,此时应放弃针对该静脉的任何操作,以免引起难以控制的出血或脑干梗死。

  【参考文献】

  [1] ABDEEN K, KATO Y, KIYA N, et al. Neuroendoscopy in microvascular decompression for trigeminal neuralgia and hemifacial spasm: technical note [J]. Neurol Res, 2000, 22(5): 522-526.

  [2] CHUNG S S, CHANG J W, KIM S H, et al. Microvascular decompression of the facial nerve for the treatment of hemifacial spasm: preoperative magnetic resonance imaging related to clinical outcomes [J]. Acta Neurochir(Wien), 2000, 142 (8): 901-907.

  [3] KONDO A. Follow-up results of microvascular decompression in trigeminal neuralgia and hemifacial spasm [J]. Neurosurgery, 1997, 40(1): 46-52.

  [4] LEVY E I, RESNICK D K, JANNETTA P J, et al. Pediatric hemifacial spasm: the efficacy of microvascular decompression [J]. Pediatr Neurosurg, 1997, 27(5): 238-241.

  [5] LI C S. Varied patterns of postoperative course of disappearance of hemifacial spasm after microvascular decompression [J]. Acta Neurochir (Wien), 2005, 147(6): 617-620.

  [6] BADR-EL-DINE M, EL-GAREM H F, TALAAT A M, et al. Endoscopically assisted minimally invasive microvascular decompression of hemifacial spasm [J]. Otol Neurotol, 2002, 23(2): 122-128.

医思倍微信
医思倍移动端
医思倍小程序