Jannetta Operation bei Dauerschmerzen im Gesicht

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Unten folgen 8 Originalpapiere der Wissenschaft zum Thema „Was wissen wir über den Erfolg der Jannetta Operation bei der sogenannten untypischen Trigeminusneuralgie?“. Die untypische Form der Trigeminusneuralgie ist hier in Zahnfilm.de deshalb von besonderem Interesse, weil sie praktisch nichts anderes darstellt als besonders starke neuropathische Mund/Gesichtsschmerzen.
 
Dieser Artikel spricht damit die Schmerzbetroffenen von Zahnfilm.de an, die a) unter einer Dauerschmerzstärke von mehr als 5 auf der Skala 0 bis 10 leiden und b) von den einschlägigen Medikamenten keine wesentliche Besserung erfahren. Ihnen soll das derzeit bekannte Wissen der besten Neurochirurgen weltweit für micro-vasculäre Dekompression (MVD) des Trigeminus Nerven bei atypischer Neuralgie zur Verfügung gestellt werden.
 
Erläuterungen
 
  • Jannetta OP = Micro vasculäre Dekompression der Trigeminus Wurzel
  • MVD = Micro vasculäre Dekompression, die Berührung des Trigeminus Nervs mit einer Arterie wird operativ aufgehoben
  • TN1 = Trigeminus Neuralgie Typ 1 nach Burchiel = typische Trigeminus Neuralgie = triggerbare einschießende Stärkstschmerzen für Sekunden/Minuten
  • TN2 = Trigeminus Neuralgie Typ 2 nach Burchiel = atypische Trigeminus Neuralgie Dauerschmerzen im Mund/Gesicht
 
 
 Vollbildaufzeichnung 13.02.2014 165005
 
 
 
 
 
 
 
J Neurosurg. 2002 Mar;96(3):527-31.

Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression.

Abstract

OBJECT:

Microvascular decompression (MVD) has become one of the primary treatments for typical trigeminal neuralgia (TN). Not all patients with facial pain, however, suffer from the typical form of this disease; many patients who present for surgical intervention actually have atypical TN. The authors compare the results of MVD performed for typical and atypical TN at their institution.

METHODS:

The results of 2675 MVDs in 2264 patients were reviewed using information obtained from the department database. The authors examined immediate postoperative relief in 2003 patients with typical and 672 with atypical TN, and long-term follow-up results in patients for whom more than 5 years of follow-up data were available (969 with typical and 219 with atypical TN). Outcomes were divided into three categories: excellent, pain relief without medication; good, mild or intermittent pain controlled with low-dose medication; and poor, no or poor pain relief with large amounts of medication. The results for typical and atypical TN were compared and patient history and pain characteristics were evaluated for possible predictive factors.

CONCLUSIONS:

In this study, MVD for typical TN resulted in complete postoperative pain relief in 80% of patients, compared with 47% with complete relief in those with atypical TN. Significant pain relief was achieved after 97% of MVDs in patients with typical TN and after 87% of these procedures for atypical TN. When patients were followed for more than 5 years, the long-term pain relief after MVD for those with typical TN was excellent in 73% and good in an additional 7%, for an overall significant pain relief in 80% of patients. In contrast, following MVD for atypical TN, the long-term results were excellent in only 35% of cases and good in an additional 16%, for overall significant pain relief in only 51%. Memorable onset and trigger points were predictive of better postoperative pain relief in both atypical and typical TN. Preoperative sensory loss was a negative predictor for good long-term results following MVD for atypical TN.

 

Kurzzusammenfassung

Direkt nach der MVD Operation sind 80% der typischen Trigeminus Neuralgie (TN) Patienten schmerzfrei, aber nur 47% der atypischen TN. Eine wesentliche Schmerzverbesserung tritt bei typischen TN 97%, und 87% bei atypischer TN ein (Excellenter und guter Schmerzrückgang zusammengerechnet). Wenn man die Fälle 5 Jahre später verfolgt, sind die Ergebnisse bei typischer TN noch excellent in 73% und gut in weiteren 7%, bei den atypischen TN excellent nur noch 35% und gut weitere 16%.

 


 

Acta Neurochir (Wien). 2006 Dec;148(12):1235-45; discussion 1245. Epub 2006 Sep 18.

Micro-vascular decompression for primary Trigeminal Neuralgia (typical or atypical). Long-term effectiveness on pain; prospective study with survival analysis in a consecutive series of 362 patients.

Abstract

BACKGROUND:

Few publications on primary Trigeminal Neuralgia treated by Micro-Vascular Decompression (MVD) report large series, with long-term follow-up, using Kaplan-Meier (K-M) analysis. None was specifically directed to the comparative study of MVD effectiveness on Trigeminal Neuralgia with typical (i.e., with paroxysmal pain only) and atypical features (i.e., with association of a permanent background of pain).

METHOD:

The authors report a series of 362 patients having clearcut vascular compression and treated with pure MVD – i.e., without any additional cut or coagulation of the adjacent root fibers. Follow-up was 1 to 18 y (8 y on average, with a median of 7.2 y). Results were considered overall, then separately for patients with typical (237 (65.5%)) and atypical (125 (34.5%)) clinical presentation.

FINDINGS:

One year after operation, (294 (81.2%) of patients were totally-free – of paroxysmal pain, and also of permanent background pain – and not needing any medication) 13 (3.6%) still had a background of pain but without the need for medication which 55 patients (15.2%), treatment had failed. At latest review (8 y on average) the corresponding rates were 80, 4.9 and 15.1%, respectively. Kaplan-Meier analysis estimated the probability of total cure at 15 y to be 73.4%. There was no difference in the cure rate between patients with typical and atypical features at one year: 81 and 81.16%, respectively. The probability of cure at 15 y was identical for the two clinical presentations.

CONCLUSIONS:

Pure MVD offers patients affected by Trigeminal Neuralgia due to vascular compression a long-lasting cure in three-fourths of the cases. Both typical and atypical presentations respond well to MVD, view in contrast to the classical view that an atypical presentation has an adverse effect on outcome after surgery.

 


 

 

J Neurosurg. 2009 Dec;111(6):1231-4. doi: 10.3171/2008.6.17604.

Classification of trigeminal neuralgia: clinical, therapeutic, and prognostic implications in a series of 144 patients undergoing microvascular decompression.

Abstract

OBJECT:

Trigeminal neuralgia (TN) presents a diagnostic challenge because of the variety of symptoms, findings during microvascular decompression (MVD), and postsurgical outcomes observed among patients who suffer from this disorder. Recently, a new paradigm for classification of TN was proposed, based on the quality of pain. This study represents the first clinical analysis of this paradigm.

METHODS:

The authors analyzed 144 consecutive cases involving patients who underwent MVD for TN. Preoperative symptoms were classified into 1 of 2 categories based on the preponderance of shocklike (Type 1 TN) or constant (Type 2 TN) pain. Analysis of clinical characteristics, neurovascular pathology, and postoperative outcome was performed.

RESULTS:

Compared with Type 2 TN, Type 1 TN patients were older, were more likely to have right-sided symptoms, and reported a shorter duration of symptoms prior to evaluation. Previous treatment by percutaneous or radiosurgical procedures was not a predictor of symptoms, surgical findings, or outcome (p = 0.48). Type 1 TN was significantly more likely to be associated with arterial compression. Venous or no compression was more common among Type 2 TN patients (p < 0.01). Type 1 TN patients were also more likely to be pain-free immediately after surgery, and less likely to have a recurrence of pain within 2 years (p < 0.05). Although a subset of patients progressed from Type 1 to Type 2 TN over time, their pathological and prognostic profiles nevertheless resembled those of Type 1 TN.

CONCLUSIONS:

Type 1 and Type 2 TN represent distinct clinical, pathological, and prognostic entities. Classification of patients according to this paradigm should be helpful to determine how best to treat patients with this disorder.

 


 

 

Neurosurg Focus. 2009 Nov;27(5):E10. doi: 10.3171/2009.8.FOCUS09142.

Microvascular decompression in patients with isolated maxillary division trigeminal neuralgia, with particular attention to venous pathology.

Abstract

OBJECT:

The authors have the clinical impression that patients with isolated V2, or maxillary division, trigeminal neuralgia (TN) are most often women of a younger age with atypical pain features and a predominance of venous compression as the pathology. The aim of this study was to evaluate a specific subgroup of patients with V2 TN.

METHODS:

Among 120 patients who underwent microvascular decompression (MVD) for TN in 2007, data were available for 114; 6 patients were lost to follow-up. Patients were stratified according to typical (Burchiel Type 1), mixed (Burchiel Type 2a), or atypical (Burchiel Type 2b) TN. A pain-free status without medication was used to determine the efficacy of MVD. All patients were contacted in June 2008 and again in January 2009 at 12-24 months after surgery (median 18.4 months) and asked to rate their response to MVD as excellent (complete pain relief without medication), fair (complete pain relief with medication or some relief with or without medication), or poor (continued pain despite medication; that is, no change from their preoperative baseline pain status.

RESULTS:

Of 114 patients, 14 (12%) had isolated V2 TN. Among these 14 were 2 typical (14%), 1 mixed (7%), and 11 atypical cases (79%) of TN. Among the remaining 100 cases were 37 typical (37%), 14 mixed (14%), and 49 atypical cases (49%) of TN. In the isolated V2 TN group, all patients were women as compared with 72% of women in the larger group of 100 patients (p = 0.05, chi-square test). The average age in the isolated V2 TN group was 51.2 years (median 48.1 years) versus 54.2 years (median 54.0 years) in the remainder of the group (p = NS, unpaired Student t-test). In the isolated V2 TN group, there was a predominance of atypical pain cases (79%) versus 49% in the remainder of the group, and this finding trended toward statistical significance (p = 0.07, chi-square test). Venous contact or compression (partly or wholly) was noted in 93% of the patients with isolated V2 versus 69% of the remainder of the group (p = 0.13, chi-square test). The likelihood of excellent outcomes in the patients with V2 TN (71%) was compared with that in typical pain cases (79%) among patients in the rest of the group (that is, the bestoutcome group), and no difference was found between the 2 groups (p = 0.8, chi-square test).

CONCLUSIONS:

The authors confirmed that patients with isolated V2 TN were more likely to be female, tended toward an atypical pain classification with venous pathology at surgery, and fared just as well as those presenting with typical pain.

 


 

Radiology. 2006 Feb;238(2):689-92.

Nerve atrophy in severe trigeminal neuralgia: noninvasive confirmation at MR imaging–initial experience.

Abstract

PURPOSE:

To retrospectively evaluate the size of the trigeminal nerve on magnetic resonance (MR) images of patients with unilateral trigeminal neuralgia.

MATERIALS AND METHODS:

Institutional review board approval was obtained and informed consent was waived for this HIPAA-compliant study. The sizes of the trigeminal nerves in 31 patients (18 men and 13 women; mean age, 68 years; age range, 44-84 years) with clinically confirmed intractable unilateral trigeminal neuralgia were measured before treatment with gamma knife radiosurgery. Images were analyzed separately by two neuroradiologists who were blinded to the side of the face with symptoms. Coronal projection images were used to determine the diameter and cross-sectional area of the trigeminal nerves at 5 mm from the entry point of the nerve into the pons. Comparisons were made by using a paired t test. Interobserver variability was assessed by using the Pearson correlation coefficient.

RESULTS:

The mean diameter of the trigeminal nerve on the symptomatic side was significantly smaller than the mean diameter on the asymptomatic side in 30 of 31 patients (2.11 mm +/- 0.40 [standard deviation] and 2.62 mm +/- 0.56, P < .001, 95% confidence interval: -0.35, -0.67 mm). The mean cross-sectional area on the symptomatic side was significantly smaller than the area on the asymptomatic side in 27 of 31 patients (4.50 mm(2) +/- 1.75 and 6.28 mm(2) +/- 2.19, P < .001, 95% confidence interval: -2.41, -1.16 mm(2)).

CONCLUSION:

The results indicate that trigeminal nerve atrophy can be depicted noninvasively in patients with trigeminal neuralgia.

(c) RSNA, 2006

 


 

Int J Radiat Oncol Biol Phys. 2007 Oct 1;69(2):397-403. Epub 2007 Apr 30.

Efficacy and quality of life outcomes in patients with atypical trigeminal neuralgia treated with gamma-knife radiosurgery.

Abstract

PURPOSE:

To assess efficacy and quality of life (QOL) outcomes associated with gamma-knife radiosurgery (GK-RS) in treating atypical trigeminal neuralgia (ATN) compared with classic trigeminal neuralgia (CTN).

METHODS AND MATERIALS:

Between September 1996 and September 2004, 35 cases of ATN were treated with GK-RS. Patients were categorized into two groups: Group I comprised patients presenting with ATN (57%); Group II consisted of patients presenting with CTN then progressing to ATN (43%). Median prescription dose 75 Gy (range, 70-80 Gy) was delivered to trigeminal nerve root entry zone. Treatment efficacy and QOL improvements were assessed with a standardized questionnaire.

RESULTS:

With median follow-up of 29 months (range, 3-74 months), 72% reported excellent/good outcomes, with mean time to relief of 5.8 weeks (range, 0-24 weeks) and mean duration of relief of 62 weeks (range, 1-163 weeks). This rate of pain relief is similar to rate achieved in our previously reported experience treating CTN with GK-RS (p = 0.36). There was a trend toward longer time to relief (p = 0.059), and shorter duration of relief (p = 0.067) in patients with ATN. There was no difference in rate of, time to, or duration of pain relief between Groups I and II. Of the patients with ATN, 88% discontinued or decreased the use of pain medications. Among the patients with sustained pain relief, QOL improved an average of 85%.

CONCLUSION:

This is the largest reported GK-RS experience for the treatment of ATN. Patients with ATN can achieve rates of pain relief similar to those in patients with CTN. Further follow-up is necessary to assess adequately the durability of response

 
 

 
J Neurosurg. 2002 Mar;96(3):532-43.

Mechanism of trigeminal neuralgia: an ultrastructural analysis of trigeminal root specimens obtained during microvascular decompression surgery.

Abstract

OBJECT:

Recent progress in the understanding of abnormal electrical behavior in injured sensory neurons motivated an examination, at the ultrastructural level, of trigeminal roots of patients with trigeminal neuralgia (TN).

METHODS:

In 12 patients biopsy specimens of trigeminal root were obtained during surgery for microvascular decompression. Pathological changes in tissue included axonopathy and axonal loss, demyelination, a range of less severe myelin abnormalities (dysmyelination), residual myelin debris, and the presence of excess collagen, including condensed collagen masses in two cases. Within zones of demyelination, groups of axons were often closely apposed without an intervening glial process. Pathological characteristics of nerve fibers were clearly graded with the degrees of root compression noted at operation. Pain also occurred, however, in some patients who did not appear to have a severe compressive injury.

CONCLUSIONS:

Findings were consistent with the ignition hypothesis of TN. This model can be used to explain the major positive and negative symptoms of TN by axonopathy-induced changes in the electrical excitability of afferent axons in the trigeminal root and of neuronal somata in the trigeminal ganglion. The key pathophysiological changes include ectopic impulse discharge, spontaneous and triggered afterdischarge, and crossexcitation among neighboring afferents.

 


 

J Neurosurg. 2008 May;108(5):916-20. doi: 10.3171/JNS/2008/108/5/0916.

Repeat posterior fossa exploration for patients with persistent or recurrent idiopathic trigeminal neuralgia.

Abstract

OBJECT:

Patients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. The outcomes and risks of repeat posterior fossa exploration (PFE) for these patients are not clearly understood.

METHODS:

From September 2000 to November 2006, 29 patients (14 men, 15 women) underwent repeat PFE. The mean number of surgeries per patient at the time of repeat PFE was 3.2 (range 1-6). The mean follow-up duration after surgery was 33.7 months.

RESULTS:

Compression of the trigeminal nerve was noted in 24 patients (83%) by an artery (13 patients, 45%), vein (4 patients, 14%), or Teflon (7 patients, 24%). Four patients (14%) who underwent operations elsewhere had incorrect cranial nerves decompressed at their first surgery. Only MVD was performed in 18 patients (62%) and a partial nerve section (PNS) was performed in 11 patients (38%). An excellent facial pain outcome (no pain, no medications required) was achieved and maintained for 80% and 75% of patients at 1 and 3 years after surgery, respectively. Patients with Burchiel Type 1 TN were pain free without medications (91% at 1 year and 85% at 3 years) more frequently than patients with Burchiel Type 2 TN (27% at both 1 and 3 years; hazard ratio = 5.4, 95% confidence interval 1.4-21.1, p = 0.02). Fifteen patients (52%) had new or increased facial numbness. Two patients (7%) developed anesthesia dolorosa; both had undergone PNS. Two patients (7%) had hearing loss after surgery.

CONCLUSIONS:

Repeat PFE for patients with idiopathic TN has facial pain outcomes that are comparable with both percutaneous needle-based techniques and stereotactic radiosurgery. Patients with persistent or recurrent TN should be considered for repeat PFE, especially if other less invasive surgeries have not relieved their facial pain.

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