三叉神经痛(TN)是一种非常痛苦的疾病,很难诊断和治疗。在欧洲,TN患者由许多不同的专业管理。因此,非常需要全面的欧洲TN管理指南。欧洲神经病学学会要求专家小组针对一系列问题提出建议,这些问题对于TN患者的日常临床管理至关重要。
对文献进行了系统回顾,并根据等级制定了建议,在可行的情况下;如果不可行,给出了良好的实践声明。
建议使用最新的分类系统,将TN诊断为主要TN,根据神经血管接触的程度,无论是经典还是特发性,或由神经血管接触以外的病理引起的继发性TN。磁共振成像(MRI),使用三个高分辨率序列的组合,应作为TN患者检查的一部分进行,因为没有临床特征可以排除继发性TN。如果MRI不可能,可以使用三叉神经反射。神经血管接触在原发性TN,但是神经血管接触的证明不应用于确认TN的诊断。相反,它可能有助于决定患者是否以及何时应该接受微血管减压术。在疼痛急性加重时,可以使用静脉输注福苯妥英或利多卡因。长期治疗,卡马西平或奥卡西平被推荐为首选药物。拉莫三嗪,加巴喷丁,A型肉毒杆菌毒素,普瑞巴林,巴氯芬和苯妥英可以单独使用或作为附加疗法使用。如果疼痛在医学上没有得到充分控制或药物治疗耐受性差,建议患者应接受手术治疗。推荐微血管减压术作为经典TN患者的一线手术。对于特发性TN患者,没有任何神经消融治疗或它们与微血管减压术之间的选择建议。如果MRI未显示任何神经血管接触,则应首选神经消融治疗。继发性TN患者的治疗通常应遵循与原发性TN相同的原则。除了医疗和外科管理,建议为患者提供心理和护理支持。
与以前的TN指南相比,在诊断和影像学方面有重要变化.这些可以更好地表征患者,并有助于制定有关医疗和手术管理计划的决策。有关药理和手术管理的建议已更新。非常需要未来对TN的各个方面进行研究,包括病理生理学和管理。
Trigeminal neuralgia (TN) is an extremely painful condition which can be difficult to diagnose and treat. In Europe, TN patients are managed by many different specialities. Therefore, there is a great need for comprehensive European
guidelines for the management of TN. The European Academy of Neurology asked an expert panel to develop recommendations for a series of questions that are essential for daily clinical management of patients with TN.
A systematic review of the literature was performed and recommendations was developed based on GRADE, where feasible; if not, a good practice statement was given.
The use of the most recent classification system is recommended, which diagnoses TN as primary TN, either classical or idiopathic depending on the degree of neurovascular contact, or as secondary TN caused by pathology other than neurovascular contact. Magnetic resonance imaging (MRI), using a combination of three high-resolution sequences, should be performed as part of the work-up in TN patients, because no clinical characteristics can exclude secondary TN. If MRI is not possible, trigeminal reflexes can be used. Neurovascular contact plays an important role in primary TN, but demonstration of a neurovascular contact should not be used to confirm the diagnosis of TN. Rather, it may help to decide if and when a patient should be referred for microvascular decompression. In acute exacerbations of pain, intravenous infusion of fosphenytoin or lidocaine can be used. For long-term treatment, carbamazepine or oxcarbazepine are recommended as drugs of first choice. Lamotrigine, gabapentin, botulinum toxin type A, pregabalin, baclofen and
phenytoin may be used either alone or as add-on therapy. It is recommended that patients should be offered surgery if pain is not sufficiently controlled medically or if medical treatment is poorly tolerated. Microvascular decompression is recommended as first-line surgery in patients with classical TN. No recommendation can be given for choice between any neuroablative treatments or between them and microvascular decompression in patients with idiopathic TN. Neuroablative treatments should be the preferred choice if MRI does not demonstrate any neurovascular contact. Treatment for patients with secondary TN should in general follow the same principles as for primary TN. In addition to medical and surgical management, it is recommended that patients are offered psychological and nursing support.
Compared with previous TN
guidelines, there are important changes regarding diagnosis and imaging. These allow better characterization of patients and help in decision making regarding the planning of medical and surgical management. Recommendations on pharmacological and surgical management have been updated. There is a great need for future research on all aspects of TN, including pathophysiology and management.