目的:手术可以有效治疗三叉神经痛,但术后疼痛复发或无反应是常见的。经常提供重复手术,但指导选择抢救手术程序的数据有限。我们旨在比较重复微血管减压术(MVD)后疼痛缓解结果,经皮脊神经切断术(PR),或立体定向放射外科(SRS)来确定哪种方式对手术难治性TN最有效。
方法:进行了PRISMA系统评价和荟萃分析,包括对患有经典或特发性TN的成年人进行重复手术的研究。主要结局包括末次随访时完全缓解(CPR)和充分缓解(APR)疼痛,在比例的多元混合效应元回归中进行分析。次要结果是初始疼痛缓解和面部麻木。
结果:在筛选的1299条记录中,61项研究,68个治疗组(29个MVD,14PR,和25个SRS),包括2165名患者。组合MVD,PR,和SRS研究数据,68.8%的人在重复TN手术后实现了初始CPR。平均而言,MVD合并样本的49.6%,PR,SRS在最后一次随访时接受了心肺复苏术,平均为术后2.99年。最终随访时实现CPR的比例(95%CI)为MVD为0.57(0.51-0.62),PR为0.60(0.52-0.68),SRS为0.35(0.30-0.41),SRS缓解疼痛的比例明显降低。MVD的初始CPR估计为0.82(0.78-0.85),PR为0.68(0.6-0.76),SRS为0.41(0.35-0.48)。
结论:整个MVD,PR,和SRS,约一半的TN患者在重复手术后3年的平均随访时间内维持完整的CPR.在治疗难治性或复发性TN时,MVD和PR在初始疼痛缓解和最终随访时的长期疼痛缓解方面均优于SRS。这些发现可以为这个具有挑战性的人群的手术决策提供信息。
Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited data exist to guide the selection of salvage surgical procedures. We aimed to compare pain relief outcomes after repeat microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS) to determine which modality was most efficacious for surgically refractory TN.
A PRISMA systematic
review and meta-analysis was performed, including studies of adults with classical or idiopathic TN undergoing repeat surgery. Primary outcomes included complete (CPR) and adequate (APR) pain relief at last follow-up, analyzed in a multivariate mixed-effect meta-regression of proportions. Secondary outcomes were initial pain relief and facial numbness.
Of 1299 records screened, 61 studies with 68 treatment arms (29 MVD, 14 PR, and 25 SRS) comprising 2165 patients were included. Combining MVD, PR, and SRS study data, 68.8% achieved initial CPR after a repeat TN procedure. On average, 49.6% of the combined sample of MVD, PR, and SRS had CPR at final follow-up, which was on average 2.99 years postoperatively. The proportion (with 95% CI) achieving CPR at final follow-up was 0.57 (0.51-0.62) for MVD, 0.60 (0.52-0.68) for PR, and 0.35 (0.30-0.41) for SRS, with a significantly lower proportion of pain relief with SRS. Estimates of initial CPR for MVD were 0.82 (0.78-0.85), 0.68 for PR (0.6-0.76), and 0.41 for SRS (0.35-0.48).
Across MVD, PR, and SRS, about half of TN patients maintain complete CPR at an average follow-up time of 3 years after repeat surgery. In treating refractory or recurrent TN, MVD and PR were superior to SRS in both initial pain relief and long-term pain relief at final follow-up. These findings can inform surgical decision-making in this challenging population.