BACKGROUND AND OBJECTIVES: Trigeminal neuralgia affects approximately 2% of patients with multiple sclerosis (MS) and often shows higher rates of pain recurrence after treatment. Previous studies on the effectiveness of stereotactic radiosurgery (SRS) for trigeminal neuralgia did not consider the different MS subtypes, including remitting relapsing (RRMS), primary progressive (PPMS), and secondary progressive (SPMS). Our objective was to investigate how MS subtypes are related to pain control (PC) rates after SRS. METHODS: We conducted a retrospective multicenter analysis of prospectively collected databases. Pain status was assessed using the Barrow National Institute Pain Intensity Scales. Time to recurrence was estimated through the Kaplan-Meier method and compared groups using log-rank tests. Logistic regression was used to calculate the odds ratio (OR). RESULTS: Two hundred and fifty-eight patients, 135 (52.4%) RRMS, 30 (11.6%) PPMS, and 93 (36%) SPMS, were included from 14 institutions. In total, 84.6% of patients achieved initial pain relief, with a median time of 1 month; 78.7% had some degree of pain recurrence with a median time of 10.2 months for RRMS, 8 months for PPMS, 8.1 months for SPMS ( P = .424). Achieving Barrow National Institute-I after SRS was a predictor for longer periods without recurrence ( P = .028). Analyzing PC at the last available follow-up and comparing with RRMS, PPMS was less likely to have PC (OR = 0.389; 95% CI 0.153-0.986; P = .047) and SPMS was more likely (OR = 2.0; 95% CI 0.967-4.136; P = .062). A subgroup of 149 patients did not have other procedures apart from SRS. The median times to recurrence in this group were 11.1, 9.8, and 19.6 months for RRMS, PPMS, and SPMS, respectively (log-rank, P = .045). CONCLUSION: This study is the first to investigate the relationship between MS subtypes and PC after SRS, and our results provide preliminary evidence that subtypes may influence pain outcomes, with PPMS posing the greatest challenge to pain management.
- MeSH
- bolest etiologie chirurgie MeSH
- lidé MeSH
- lokální recidiva nádoru chirurgie MeSH
- management bolesti metody MeSH
- neuralgie trigeminu * radioterapie chirurgie MeSH
- radiochirurgie * metody MeSH
- retrospektivní studie MeSH
- roztroušená skleróza * chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
Neuralgie trojklaného nervu je onemocnění, jehož léčba bývá v mnoha případech obtížná. Metodou první volby je farmakoterapie, avšak ta je u značné skupiny pacientů neúspěšná. Vzhledem k tomu, že se o pacienty s neuralgií trojklaného nervu starají lékaři hned několika odborností (neurologové, algeziologové, stomatologové, ORL či neurochirurgové), vzniká nejednota v terapeutickém postupu, což mnohdy vede k neadekvátní léčbě. Leksellův gama nůž (LGN) má v léčbě neuralgie trojklaného nervu (TN) významné uplatnění. Z dosavadních zkušeností a výsledků klinických studií vyplývá, že radiochirurgická léčba pomocí LGN je vhodnou a efektivní metodou u pacientů s idiopatickou, klasickou i sekundární TN, u kterých selhala farmakoterapie. Nejvyšší úspěšnost má tato metoda u idiopatické a klasické TN, kdy se redukuje bolest v průměru u 80 % případů. U sekundárních TN je efekt nižší (50 %). Při klasické TN (neurovaskulární konflikt) je LGN preferován zejména u pacientů starších, polymorbidních či u těch, kteří odmítají otevřený neurochirurgický výkon. Předchozí otevřená operace není kontraindikací k provedení radiochirurgické léčby. Při rekurenci bolesti po ozáření na LGN lze léčbu opakovat. Při druhé rekurenci je možné nabídnout radiochirurgickou talamotomii. V případě ostatních trigeminálních bolestí (postherpetická, iatrogen- ní) se v některých případech přistupuje rovnou k provedení talamotomie. Dominantně kontinuální bolest či dysestezie jsou negativním prediktivním faktorem efektu radiochirurgické léčby.
Treatment of trigeminal neuralgia is challenging in many cases. Pharmacotherapy is the method of first choice, but it is unsuccessful in a significant group of patients. Due to the fact that patients suffering from trigeminal neuralgia are treated by physicians of several specialties (neurologists, algesiologists, dentists, ENT, or neurosurgeons), there is an inconsistency in the therapeutic procedure, which often leads to inadequate treatment. The Leksell Gamma Knife (LGN) has significant applications in the treatment of trigeminal neuralgia (TN). Based on the experience and results of clinical studies to date, radiosurgical treatment using LGN is a suitable and effective method for patients with idiopathic, classic, and secondary TN in whom the pharmacotherapy has failed. This method has the highest success rate in idiopathic and classic TN, where the pain is reduced in an average of 80% of cases. For secondary TN, the effect is lower (50%). In classical TN (neurovascular conflict), LGN is preferred especially in elderly, polymorbid patients or in those who refuse classical neurosurgical operation (microvascular decompression). Previous surgery is not a contraindication to radiosurgical treatment. In the case of recurrence of pain after irradiation to the LGN, the treatment can be repeated. At the second recurrence, it is possible to offer radiosurgical thalamotomy. In the case of other trigeminal pain (postherpetic, iatrogenic), in some cases, a thalamotomy is performed directly. Dominantly continuous pain or dysesthesia is a negative predictive factor of the effect of radiosurgical treatment.
Extrakce zubů moudrosti, zejména hlouběji retinovaných nebo v intimním kontaktu s dolním alveolárním nervem, jsou zatíženy komplikací ve smyslu poranění tohoto nervu. Snahou lékaře je odstranit příčinu obtíží pacienta, jímž je myšlen problematický zub moudrosti, a zároveň nepřivodit nepříjemné komplikace nemocnému. Za tímto účelem jsou využívány stále dokonalejší zobrazovací metody a pokročilé chirurgické techniky. Občas se i při největší snaze ošetřujícího lékaře nevyhneme poranění nervu, ale i v nejtěžším případě poranění, jako je transsekce s defektem nervu, je možné komplikaci s velmi vysokým procentem úspěšnosti řešit a pacienta vyléčit. V tomto příspěvku prezentujeme kazuistiku pacientky léčené na naší klinice, u které došlo k traumatické lézi dolního alveolárního nervu během transalveolární extrakce zubu 48, a popisujeme následnou úspěšnou rekonstrukci pomocí štěpu z nervus suralis.
Extractions of wisdom teeth, especially those that are deeply impacted or in intimate contact with the lower alveolar nerve, are fraught with complications in the sense of injury to that nerve. The doctor‘s effort is to eliminate the cause of the patient‘s difficulties, which is the problematic wisdom tooth, and at the same time not causing unpleasant complications for the patient. For this purpose, increasingly sophisticated imaging techniques and advanced surgical techniques are used. Sometimes, even with the best efforts of the attending physician, nerve injury cannot be avoided, but even in the most severe case of injury, such as a transsection with a nerve defect, it is possible to solve the complication with a very high percentage of success and cure the patient. In this paper, we present the case report of a patient treated in our clinic who suffered a traumatic lesion of the lower alveolar nerve during the transalveolar extraction of tooth 48 and describe the subsequent successful reconstruction using a graft from the sural nerve.
- MeSH
- bolesti zubů chirurgie MeSH
- dospělí MeSH
- extrakce zubů metody MeSH
- iatrogenní nemoci MeSH
- lidé MeSH
- molár třetí chirurgie patologie MeSH
- nervový transfer metody MeSH
- poranění nervus mandibularis * chirurgie MeSH
- zaklíněný zub * chirurgie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- výukové testy MeSH
Trigeminal neuralgia (TN) is a rare form of chronic neuropathic pain characterized by spontaneous or elicited paroxysms of electric shock-like or stabbing pain in a region of the face. While most cases occur in a sporadic manner and are accompanied by intracranial vascular compression of the trigeminal nerve root, alteration of ion channels has emerged as a potential exacerbating factor. Recently, whole exome sequencing analysis of familial TN patients identified 19 rare variants in the gene CACNA1H encoding for Cav3.2T-type calcium channels. An initial analysis of 4 of these variants pointed to a pathogenic role. In this study, we assessed the electrophysiological properties of 13 additional TN-associated Cav3.2 variants expressed in tsA-201 cells. Our data indicate that 6 out of the 13 variants analyzed display alteration of their gating properties as evidenced by a hyperpolarizing shift of their voltage dependence of activation and/or inactivation resulting in an enhanced window current supported by Cav3.2 channels. An additional variant enhanced the recovery from inactivation. Simulation of neuronal electrical membrane potential using a computational model of reticular thalamic neuron suggests that TN-associated Cav3.2 variants could enhance neuronal excitability. Altogether, the present study adds to the notion that ion channel polymorphisms could contribute to the etiology of some cases of TN and further support a role for Cav3.2 channels.
- MeSH
- elektrofyziologické jevy MeSH
- lidé MeSH
- membránové potenciály MeSH
- neuralgie trigeminu * genetika MeSH
- neurony MeSH
- vápníkové kanály MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
Tato práce popisuje specifické problémy bolestí hlavy u seniorů. Výskyt primárních bolestí hlavy (migréna, tenzní typ bolesti hlavy, cluster headache) s narůstajícím věkem klesá, výskyt sekundárních bolestí hlavy (organická nebo metabolická onemocnění) stoupá, některé typy bolestí hlavy se vyskytují téměř výlučně ve vyšším věku (obrovskobuněčná arteritis, hypnické bolesti hlavy). Ačkoliv léčba většiny primárních bolestí hlavy je dostupná, fyziologické změny spojené s věkem, komorbidity, kontraindikace, polyfarmacie a zvýšené riziko vedlejších účinků vyžadují přiměřenou léčbu ve vyšším věku. Jsou zmíněny specifické problémy akutní a profylaktické léčby primárních bolestí hlavy ve stáří. V druhé části práce jsou popsány sekundární bolesti hlavy, které mají zvýšený význam ve stáří. V případě přítomnosti tzv. červených praporků jsou indikována různá zobrazovací a laboratorní vyšetření.
This paper describes specific problems of headache in seniors. The occurrence of primary headaches (migraine, tension – type headache, cluster headache) decreases with increasing age, the occurrence of secondary headaches (organic or metabolic diseases) increases, certain types of headaches occur almost exclusively in the elderly (giant cell arteritis, hypnic headache). Although treatments for most common primary headaches are available, age-related physiologic changes, comorbidities, contra indications, polypharmacy and increased risk of side effects require appropriate treatment in the elderly. Specific problems of acute and prophylactic treatment in primary headaches in the elderly are mentioned. In the second part of this paper secondary headaches are described, which have increased significance in the elderly. Various imaging and laboratory evaluations are indicated in the presence of any red flag signs and symptoms.
- MeSH
- látky ovlivňující centrální nervový systém terapeutické užití MeSH
- lidé MeSH
- migréna farmakoterapie prevence a kontrola MeSH
- nádory mozku MeSH
- neuralgie trigeminu MeSH
- primární bolesti hlavy farmakoterapie prevence a kontrola MeSH
- rizikové faktory MeSH
- sekundární bolesti hlavy MeSH
- senioři MeSH
- stárnutí * MeSH
- Check Tag
- lidé MeSH
- senioři MeSH
Ablační procedury, které jsou součástí funkční neurochirurgie, prodělávají v posledních letech renesanci. Mezi tyto procedury se řadí i mediální talamotomie jako analgetický výkon u širokého spektra bolestivých stavů. Jednou z možných indikací k mediální talamotomii je refrakterní neural gie trigeminu. Management pacientů s refrakterní neuralgií trigeminu je svízelný a mediální talamotomie pomocí Leksellova gama nože těmto pacientům může pomoci. Následující článek má za cíl stručně a přehledně představit mediální talamotomii pomocí Leksellova gama nože jako bezpečnou a efektivní metodu v léčbě chronické bolesti a naše zkušenosti s touto metodou u pacientů s neuralgií trigeminu, u kterých farmako logická i chirurgická léčba selhala.
Ablative procedures, as an important part of functional neurosurgery, have experienced a renaissance in recent years. These procedures include medial thalamotomy as an analgesic procedure for a wide range of pain syndromes. Refractory trigeminal neuralgia is one of the indications for medial thalamotomy. Management of patients with refractory trigeminal neuralgia is challenging, and medial thalamotomy using the Leksell gamma knife may help these patients. This article aims to briefly and clearly present medial thalamotomy using the Leksell gamma knife as a safe and effective method in the treatment of chronic pain and our experience with this procedure in patients with trigeminal neuralgia in whom pharmacological and surgical treatment has failed.
- Klíčová slova
- radiochirurgická talamotomie,
- MeSH
- lidé MeSH
- neuralgie trigeminu * chirurgie radioterapie MeSH
- radiochirurgie metody MeSH
- thalamus chirurgie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- MeSH
- hořčík metabolismus MeSH
- kationtové kanály TRPM * MeSH
- lidé MeSH
- neuralgie trigeminu * MeSH
- protein-serin-threoninkinasy MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- dopisy MeSH
- práce podpořená grantem MeSH
- MeSH
- bolest chirurgie MeSH
- duševní poruchy chirurgie MeSH
- elektrická stimulace * metody MeSH
- epilepsie * chirurgie MeSH
- hluboká mozková stimulace * metody MeSH
- lidé MeSH
- management bolesti MeSH
- neuralgie trigeminu chirurgie MeSH
- Parkinsonova nemoc chirurgie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
Trigeminal nerve schwannomas (TS) are uncommon intracranial tumors, frequently presenting with debilitating trigeminal and/or oculomotor nerve dysfunction. While surgical resection has been described, its morbidity and mortality rates are non-negligible. Stereotactic radiosurgery (SRS) has emerged with variable results as a valuable alternative. Here, we aimed at reviewing the medical literature on TS treated with SRS so as to investigate rates of tumor control and symptomatic improvement. We reviewed manuscripts published between January 1990 and December 2019 on PubMed. Tumor control and symptomatic improvement rates were evaluated with separate meta-analyses. This meta-analysis included 18 studies comprising a total of 564 patients. Among them, only one reported the outcomes of linear accelerators (Linac), while the others of GK. Tumor control rates after SRS were 92.3% (range 90.1-94.5; p < 0.001), and tumor decrease rates were 62.7% (range 54.3-71, p < 0.001). Tumor progression rates were 9.4% (range 6.8-11.9, p < 0.001). Clinical improvement rates of trigeminal neuralgia were 63.5% (52.9-74.1, p < 0.001) and of oculomotor nerves were 48.2% (range 36-60.5, p < 0.001). Clinical worsening rate was 10.7% (range 7.6-13.8, p < 0.001). Stereotactic radiosurgery for TS is associated with high tumor control rates and favorable clinical outcomes, especially for trigeminal neuralgia and oculomotor nerves. However, patients should be correctly advised about the risk of tumor progression and potential clinical worsening. Future clinical studies should focus on standard reporting of clinical outcomes.
- MeSH
- lidé MeSH
- nádory kraniálních nervů * MeSH
- následné studie MeSH
- neuralgie trigeminu * chirurgie MeSH
- neurilemom * chirurgie MeSH
- radiochirurgie * MeSH
- retrospektivní studie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- přehledy MeSH
- systematický přehled MeSH
INTRODUCTION: Trigeminal neuralgia (TN) secondary to tumors is encountered in up to 6% of patients with facial pain syndromes and is considered to be associated with tumors affecting the trigeminal nerve pathways. The most frequent are meningiomas and vestibular schwannomas (VS). Stereotactic radiosurgery (SRS) has emerged as a valuable treatment, with heterogeneity of clinical results. We sought to review the medical literature on TN treated with SRS for meningiomas and VS and investigate the rates of improvement of TN symptoms. METHODS: We reviewed articles published between January 1990 and December 2019 in PubMed. Pain relief after SRS, the maintenance of pain relief, and TN recurrence and complications were evaluated with separate meta-analyses, taking into account the data on individual patients. RESULTS: Pain relief after SRS was reported as Barrow Neurological Institute (BNI) pain intensity scores of BNI I in 50.5% (range 36-65.1%) of patients and BNI I-IIIb in 83.8% (range 77.8-89.8%). There was no significant difference in series discussing outcomes for tumor targeting versus tumor and nerve targeting. Recurrences were described in 34.7% (range 21.7-47.6; tumor targeting). Maintenance of BNI I was reported in 36.4% (range 20.1-52.7) and BNI I-IIIb in 41.2% (range 29.8-52.7; tumor targeting series). When both the nerve and the tumor were targeted, only 1 series reported 86.7% with BNI I-IIIb at last follow-up. Complications were encountered in 12.6% (range 6.3-18.8; tumor targeting series) of patients; however, they were much higher, as high as 26.7%, in the only study reporting them after targeting both the nerve and the tumor. The most common complication was facial numbness. CONCLUSION: SRS for TNB secondary to benign tumors, such as meningiomas and VS, is associated with favorable clinical course, but less favorable than in idiopathic TN. There was, however, heterogeneity among reports and targeting approaches. Although targeting both the nerve and the tumor seemed to achieve better long-term results, the rate of complications was much higher and the number of patients treated was limited. Future clinical studies should focus on the standard reporting of clinical outcomes and randomization of targeting methods.
- MeSH
- lidé MeSH
- management bolesti metody MeSH
- meningeální nádory komplikace diagnóza chirurgie MeSH
- meningeom komplikace diagnóza chirurgie MeSH
- neuralgie trigeminu diagnóza etiologie chirurgie MeSH
- radiochirurgie metody trendy MeSH
- retrospektivní studie MeSH
- vestibulární schwannom komplikace diagnóza chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- práce podpořená grantem MeSH
- systematický přehled MeSH