Нейростоматология. Синдромы
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Trigeminal Neuralgia [14] 7 Surgery Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain signals from getting through to the brain. In trained hands, surgery has been reported to have an initial success rate approaching 90 percent. However, some patients require follow-up procedures if a recurrence of the pain begins. Of the five surgical options, the microvascular decompression, also known as the Janetta procedure [15] , is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a 25-millimetre (1 in) hole behind the ear. The nerve is then explored for an offending blood vessel, and when one is found, the vessel and nerve are separated or "decompressed" with a small pad, usually made from an inert surgical material such as Teflon. When successful, MVD procedures can give permanent pain relief with little to no facial numbness. Three other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions.Excellent success rates using a cost effective percutaneous surgical procedure known as balloon compression have been reported [16] This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression. Similar success rates have been reported with glycerol injections and radiofrequency rhizotomies. Glycerol injections involve injecting an alcohol-like substance into the cavern that bathes the nerve near its junction. This liquid is corrosive to the nerve fibers and can mildly injure the nerve enough to hinder the errant pain signals. In a radiofrequency rhizotomy, the surgeon uses an electrode to heat the selected division or divisions of the nerve. Done well, this procedure can target the exact regions of the errant pain triggers and disable them with minimal numbness. Stereotactic radiation therapy The nerve can also be damaged to prevent pain signal transmission using Gamma Knife or a linear accelerator-based radiation therapy (e.g. Trilogy, Novalis, CyberKnife). No incisions are involved in this procedure. It uses very precisely targeted radiation to bombard the nerve root, this time targeting the selective damage at the same point where vessel compressions are often found. This option is used especially for those people who are medically unfit for a long general anaesthetic, or who are taking medications for prevention of blood clotting (e.g., warfarin,heparin, aspirin). A prospective Phase I trial performed at Marseille, France, showed that 83% of patients were pain-free at 12 months, with 58% pain-free and off all medications. Side effects were mild, with 6% experiencing mild tingling and 4% experiencing mild numbness. [17] There has only been one prospective clinical trial for surgical therapy for trigeminal neuralgia. In a prospective cohort trial, microvacular decompression was found to be significantly superior to stereotactic radiosurgery in achieving and maintaining a pain-free status in patients with trigeminal neuralgia and provided similar early and superior longer- term patient satisfaction rates compared with those treated with stereotactic radiosurgery [18] Social consequences of trigeminal neuralgia Most suffers of TN do not present with any outwardly noticeable symptoms, though some will exhibit brief facial spasms during an attack. Some physicians will seek a psychological root cause rather than a physiological abnormality. This is especially true of those suffering from atypical TN, who may not have any compression of the TN and in whom the sole criterion of the diagnosis may be the complaint of severe pain 8 (constant electric-like shocks, constant crushing or pressure sensations, or a constant severe ache) and in this case trigeminal neuralgia still exists but is not visible to physicians because it was caused by the nerve being damaged during a dental procedure such as root canals, extractions, gum surgeries or it may be a condition secondary to multiple sclerosis. Many TN sufferers are confined to their homes or are unable to work because of the frequency of their attacks. It is important for friends and family to educate themselves on the intense severity of TN pain and to be understanding of limitations that TN places upon the sufferer.However, at the same time, the TN patient must be extremely proactive in furthering his or her rehabilitative efforts. Enrolling in a chronic pain support group, or seeking one-on-one counseling, can help to teach a TN patient how to adapt to the newfound affliction. As with any chronic pain syndrome, TN not being the exception, clinical depression has the potential to set in, especially in younger patients who often are undertreated for chronic pain. Friends and family, as well as clinicians, must be alert to the signs of a rapid change in behavior and should take appropriate measures when necessary. It must be constantly reinforced to the sufferer of TN that treatment options do exist. Литература 1. Голубев Ю Л ., Вейн А М Неврологические синдромы Руководство для врачей Издательство Эйдос - Медиа . -2002.-832 с 2 Грачев Ю В ., Шмырев В И Тригеминальная лицевая боль : систематика клинических форм , принципы диагностики и лечения 10 с 3. Гречко В Е Неотложная помощь в нейростоматологии Москва , Медицина .-1981.- 200 с 4. 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