彩色多普勒超声引导结合CT三维重建三叉神经痛眶下孔穿刺射频热凝手术1例

2019-10-08 黄哲浩 朴哲 隋国庆 中国实验诊断学

患者,女,53岁,因右侧颜面部口角外侧发作性电击样疼痛15日到我院就诊。患者入院前在当地医院就诊,口服卡马西平(1片/日)1周后出现头晕、呕吐。患者到我院就诊后,查体:意识清,右侧颜面口唇上方口角部位触痛阳性,VAS疼痛评分为9分,扳机点为右侧鼻唇沟近鼻小柱处,疼痛突发突止,每次发作时间少于1分钟,患者在刷牙或进食时可诱发出疼痛。头部核磁共振检查未见颅内占位病变。患者诊断为原发三叉神经痛(右侧第二

1.病例资料
 
患者,女,53岁,因右侧颜面部口角外侧发作性电击样疼痛15日到我院就诊。患者入院前在当地医院就诊,口服卡马西平(1片/日)1周后出现头晕、呕吐。患者到我院就诊后,查体:意识清,右侧颜面口唇上方口角部位触痛阳性,VAS疼痛评分为9分,扳机点为右侧鼻唇沟近鼻小柱处,疼痛突发突止,每次发作时间少于1分钟,患者在刷牙或进食时可诱发出疼痛。头部核磁共振检查未见颅内占位病变。患者诊断为原发三叉神经痛(右侧第二支)。
 
入院第二日,患者头部行薄层CT(0.625mm)扫描,3DCT三维重建图像显示:右侧眶下孔走行方向为由下至上、由内至外(图1A)。3DCT三维重建测量显示右侧眶下孔与颜面夹角的角度:矢状位为39.7°(图1B),轴位为35.6°(图1C)。患者住院后第三日,行彩色多普勒超声(M9型彩色多普勒超声诊断仪,Mindray,中国深圳)引导三叉神经痛颏孔射频热凝手术。术中患者取颈仰卧位,应用彩色多普勒超声定位确定眶下孔内动脉及静脉之间位置为穿刺靶点(图1D)。
 


图1 术前眶下孔颅骨3DCT重建图像及术中彩色多普勒超声引导眶下孔穿刺定位图像。A:3DCT重建图像显示眶下孔(箭头指向右侧眶下孔);B:3DCT重建图像显示轴位穿刺方向角度为35.6°;C:3DCT重建图像显示矢状位穿刺方向角度为39.7°;D:彩色多普勒超声图像显示穿刺靶点为眶下孔内动脉及静脉之间位置(白色长箭头指向眶下孔内动脉位置,白色短箭头指向眶下孔内静脉位置,黑色箭头指向穿刺靶点)
 
按照3DCT三维重建图像的矢状位和轴位数据穿刺进针。彩超证实穿刺针到达到眶下孔及眶下管,同时患者出现颜面部明显疼痛感。连接射频仪,分别给予感觉刺激(50Hz,1ms)和运动刺激(2Hz,1ms),电生理证实穿刺针尖处于控制三叉神经第二支右侧颜面口唇上方口角部位位置,且测试范围覆盖患者原疼痛区域。电生理感觉测试电压在0.1V,运动测试电压1.0V。给予静脉全醉,待患者意识消失后,给予75℃热凝射频毁损120秒1次。术后观察患者张口无受限,测试眼球运动无异常。术后患者VAS疼痛消失,随访18个月证实患者疼痛无复发。
 
2.讨论
 
目前,射频热凝治疗仪多用于卵圆孔穿刺三叉神经半月节三叉神经痛的热凝治疗。对于病程较短的三叉神经痛患者,三叉神经外周支的射频热凝治疗,文献也有报道。三叉神经外周支射频热凝治疗中,针对三叉神经第二支的穿刺手术,由于穿刺针不但需要准确进入眶下孔,而且需进入三叉神经第二支所处的眶下管,因而对手术的操作具有较高的要求。以往文献报道:术前应用3DCT重建方法可以有效的提高三叉神经痛卵圆孔穿刺的精准性。
 
在本例眶下孔穿刺射频热凝术的治疗过程中,我们术前应用颅骨3DCT重建方法,观察了眶下孔的位置、确定了穿刺过程中轴位和矢状位的穿刺方向的穿刺角度。术中,我们还应用彩色多普勒彩超声引导,根据眶下孔内动脉、静脉的位置,确定三叉神经第二支的穿刺靶点。我们在术前和术中应用的多种辅助手段定位,使手术到达了一次穿刺成功。术后随访证实患者预后良好。彩色多普勒超声引导结合术前3DCT三维重建对于三叉神经痛眶下孔穿刺射频热凝手术的成功,可以提供较大的帮助。
 
原始出处:

黄哲浩,朴哲,隋国庆,田宇,张环.彩色多普勒超声引导结合CT三维重建三叉神经痛眶下孔穿刺射频热凝手术1例[J].中国实验诊断学,2018,22(08):1352-1353.

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  7. 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objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=92775, encryptionId=b3fc92e7516, topicName=超声引导)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d66e38113145, createdName=guoyibin, createdTime=Thu Jun 11 12:56:00 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311948, encodeId=aec513119483f, content=<a href='/topic/show?id=21a6e54280e' target=_blank style='color:#2F92EE;'>#穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75428, encryptionId=21a6e54280e, topicName=穿刺)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8b48400, createdName=rgjl, createdTime=Thu Oct 10 03:56:00 CST 2019, time=2019-10-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1410754, encodeId=d7191410e54cf, 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createdBy=e1965265549, createdName=shenxlcyp, createdTime=Thu Oct 10 03:56:00 CST 2019, time=2019-10-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1540828, encodeId=4c6d1540828ae, content=<a href='/topic/show?id=ac8de440615' target=_blank style='color:#2F92EE;'>#神经痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74406, encryptionId=ac8de440615, topicName=神经痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0d8213287489, createdName=贵阳, createdTime=Thu Oct 10 03:56:00 CST 2019, time=2019-10-10, status=1, ipAttribution=)]
    2019-10-10 rgjl
  8. 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  9. 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    2019-10-10 贵阳

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