Il dolore nelle nevralgie e trattamento chirurgico

Transcription

1 Il dolore nelle nevralgie e trattamento chirurgico F. TOMASELLO Clinica Neurochirurgica, Università di Messina Napoli, 28 Maggio 2012

2 NEUROVASCULAR COMPRESSION SYNDROMES Trigeminal neuralgia (V cranial nerve) Hemifacial spasm (VII cranial nerve) Glossopharyngeal neuralgia (IX & X cranial nerves) Disabling vertigo (VIII cranial nerve) Spasmodic torticollis (XI nerve) Neurogenic hypertension (RVL left medulla oblongata) Pyramidal tract signs and cranial nerve dysfunction (VL portion of medulla oblongata)

3 EPIDEMIOLOGY - Trigeminal neuralgia 4.5/ /yr (Love el at., Brain 2001) - Hemifacial spasm 0.8/ /yr (Auger et al., Arch Neurol 1990) - Glossopharyngeal 0.8/ /yr (Katusic et al., Neuroepidemiol 1991) neuralgia - Spasmodic torticollis few cases (Alafaci et al., Neurosurgery 2000)

4 September 2000, Volume 47, Number 3 Page 768 Case Report Spasmodic Torticollis Due to Neurovascular Compression of the Spinal Accessory Nerve by the Anteroinferior Cerebellar Artery: Case Report Concetta Alafaci, M.D.; Francesco M. Salpietro, M.D.; Gaspare Montemagno, M.D.; Giovanni Grasso, M.D.; Francesco Tomasello, M.D. Department of Neurosurgery, University of Messina, Messina, Italy

5 GLOSSOPHARYNGEAL NEURALGIA and MVD Most offending vessel: Other offending vessels PICA VA Good outcome: 58-94% Recurrence: n.a. Results for GFN Surgery (relevant literature) Series Cases Good outcome Recurrence Mean Outcome Laha, Wakiya, yr Sindou, Resnick, yr Kondo, yr Patel, % 4yr

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12 Sites for Neurovascular Compression Syndromes NVC syndromes arise from vascular contact along the REZ CNS Structure similar to that of white matter of the CNS More vulnerable to microtrauma NVC syndromes incidence should be higher in nerves with longer CNS segments Ridder, D Neurosurgery, 2002

13 Ephaptic transmission Hilton DA et al Neurosurgery, 1994

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16 3D-CISS 3D-TOF Fusion

17 Virtual Cisternography 3D CISS data set was managed by Fly-through function of Leonardo workstation. This function allows to create the dynamic 3D views in the volumetric data from a virtual camera, which can be moved and rotated in a complex way. The viewing angle can be adjusted between 30 and 120 degrees. The position of the virtual camera was indicated on multiplanar reconstruction images as the intersection of crossed lines. The projection and viewing angle was indicated as a pyramid-shaped beam. The anatomic structures closer to the virtual camera eye are displayed in the foreground, the structures more distant from the virtual eye are displayed in the background

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20 CASE 1 V - SCA a V b N c d

21 TREATMENT OF CHOICE MVD Trigeminal neuralgia (TN): microvascular decompression and percutaneous ablation surgery Hemifacial spasm (HFS): microvascular decompression and Botulinum toxin type A (BtA) Glossopharingeal neuralgia (GPN): microvascular decompression and pulsed radiofrequency

22 MICROVASCULAR DECOMPRESSION Interposing technique Sling retraction technique

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24 SUPERIOR PETROSAL VEIN TRIGEMINAL NERVE

25 GENERAL VIEW OF CP ANGLE Relation between cranial nerves and vessels

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27 Microvascular decompression Good outcome shorter duration typical presentation single artery compression complete decompression Poor outcome longer duration venous compression atypical presentation partial decompression

28 MICROVASCULAR DECOMPRESSION Ashkan, Neurosurgery, 2004 Mortality 0.3% (Kalkanis, Neurosurgery, 2003) Main complications (McLaughlin, Neurosurgery, 1999) Cerebellar injuries (hemorrhage/contusion) 0.68% Hearing deficits 1.45% CSF leaks 2.17% Less frequent complications Facial Numbness Cranial nerve dysfunction Wound infection

29 FAILED MVD Autologous tissue (muscle, fascia, periosteum, subcutaneous fat) { reabsorption adhesions fibrosis arachnoiditis Synthetic implants Granulomas (teflon) Yamaki et al, 1992 Rath et al, 1996 Chen et al, 2000 Premsagar et al, 1997 Megerian et al, 1995 Aseptic meningitis (dacron, teflon) Wakamoto et al, 2002 Bobek and Sagher, 1999

30 Sindou et al,

31 NEUROENDOSCOPY

32 RADIOSURGERY Trigeminal neuralgia Glossopharyngeal neuralgia Gamma Knife Sheehan et al, J. Neurosurg, 2005 Tawk et al, J. Neurosurg, 2005 Shetter et al, J. Neurosurg, 2005 Alpert et al, J. Neurosurg, 2005 Stieber et al, J. Neurosurg, 2005 LINAC Kubicec et al, Stereotact Funct Neurosurg, 2004 Gerbi et al, J. Appl. Clin. Med, Phys, 2004

33 Bulbar compression by ectatic vertebral artery A new clinical entity?

34 Francesco Tomasello, M.D., Concetta Alafaci, M.D., Francesco M. Salpietro, M.D., Marcello Longo, M.D.

35 Bulbar compression by ectatic vertebral artery causing compression and distortion of the medulla oblongata with pyramidal tract signs and low cranial nerve dysfunction. Literature review. Kim P et al: J Neurosurg, 1985 Maruyama K et al: Rins Shink 1989 Vincentelli F et al: Neurosurgery, 1991 Hongo K et al: J Neurosurg, 1993 Moss MS & West RJ: Br J Neurosurg, 1996 Hongo K et al: Neurosurgery, 1999 Salvi F et al: Neurology, 2000 Koyama S et al: J Neurosurg, 2001 Takano S et al: No Shinkei Geka,2001 Ubogu EE et al: J Neurosurg, 2002 Tomasello F et al: Neurosurgery, caso 1 caso 1 caso 1 caso 1 caso 2 casi 2 casi 1 caso 1 caso 1 caso 5 casi

36 Giovanni Grasso, M.D., Concetta Alafaci, M.D., Marcello Passalacqua, M.D., Manfred Tschabitscher, M.D., Francesco M. Salpietro, M.D., FrancescoTomasello, M.D.

37 Relationship between the vertebral artery and the medulla oblongata Right VA within the cranial portion of the lateral cerebellomedullary cistern. Mean distance between VA and medulla is 5 mm Asterisk, PICA, proximal course between cranial nerves IX and X.; Arrows, perforators arising from VA.

38 VA TRANSPOSITION Literature Kim P et al: J Neurosurg, 1985 Ravlison JN & Coakham HB: Br J Neurosurg, 1988 Vincentelli T et al: Neurosurgery, 1991 Ogawa A et al: Surg Neurol, 1992 Stone Jl et al: J Neurosurg, 1993 Fukushima T: Neurovascular Surg, 1995 Bejjani GK & Sekhar LN: J Neurosurg, 1997 Kondo A: J Neurosurg, 1998 Hongo K et al: Neurosurgery, 1999 Taki W et al: Acta Neurochir, 2003 Tomasello F et al: Neurosurg, 2005

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40 Case 1 Pre Post

41 Case 3 Pre Post

42 Case 3 Pre Post

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