摘要目的 探讨后颅窝神经根疾病术后复发再手术的临床特点和再手术的处理原则.方法 回顾分析2000至2007年临床收治的术后复发的后颅窝神经根疾病病例14例,包括三叉神经痛5例,面肌痉挛5例,舌咽神经痛4例,总结其临床和再手术术中发现特点.结果 5例三叉神经痛患者术后复发者,微血管减压术(microvascular decompression,MVD)2例,疼痛复发部位与术前相同,3例三叉神经感觉根第2、3支切断术后患者均为同侧第一支复发,其中4例接受再次感觉根部分切断手术,术后疼痛消失,随访2～11年未复发.5例而肌痉挛患者,4例再次梳理术后症状部分改善,1例没有改善.4例舌咽神经痛术后复发患者,2例发现舌咽神经再生吻合,1例发现舌咽神经近侧断端和迷走神经粘连,还有1例术中未发现舌咽神经再生及粘连情况,再次手术探查,切断再生神经及相邻2支迷走神经纤维根丝,随访2～5年无复发.术区一般病理改变包括:小脑与岩骨脑膜粘连严重;新生血管丰富,极易出血;行MVD患者的神经与周围相关血管和术中放置的涤纶布等减压材料粘连紧密,无法分离,初次手术部位局部瘢痕粘连,失去正常解剖结构,明显增加再次手术操作风险.结论 三义神经痛和面肌痉挛术后复发病因不明,舌咽神经痛复发可能的原因为神经纤维再生吻合、粘连及临近迷走神经纤维交通支引起.三叉神经痛、舌咽神经痛术后复发再次行神经纤维切断疗效确切.面肌痉挛复发再次面神经梳理手术效果较差.

abstractsObjective To report the clinical manifestations and the revision surgery principles of recurrent diseases of the posterior fossa nerves after primary surgery. Methods Between 2000 to 2007, fourteen patients with recurrent diseases of the posterior fossa nerves in Shandong provincial hospital were recruited in this study, all of whom were subjected to revision surgery. The clinical manifestations and surgical findings were retrospectively reviewed. Results Of the five patients with recurrent trigeminal neuralgia primarily, two underwent microvascular decompression (MVD); the remaining three firstly received the Ⅰand Ⅲ branches partial sensory rhizotomy and, subsequently, the pain reoccurred in the Ⅰbranch distribution area. The remnant sensor fibre was resected in the reoperation by which the sufferings were controlled completely in four of these patients during 2 to 11 years of follow-up. In five patients with hemifacial spasm underwent re-exploration, there appeared obvious fibrosis, conglutination, and the formation of new vessels around the facial nerve, with which the result of reoperation for this disorder was unsatisfied. In four glossopharyngeal neuralgia patients, reanstamosis of the glossopharyngeal nerve were found in two patients, adhesion between the glossopharyngeal nerve and the vagus nerve was found in one patient, but occurred in none of the another one. In the revision surgery, the regeneration of nerve fibre and two adjacent branches of vagus nerve fibre were resected, with no occurrence during 2 to 5 years of follow-up. The pathological changes found in revision were severe adhesion between cerebellum, meninges, terylene slim and structures around. Also, the formation of new vessels, cerebellum malacia, and bleeding could be found in the procedures. Conclusions The cause of recurrent of trigeminal neuralgia and hemifacial spasm are unclear. Recurrent giossopharyngeal neuralgia may attribute to the nerve fibers reanstamosis, adhesion or the communicating branches with vagus nerve. With respect to the treatment of the recurrence of trigeminal neuralgia, glossopharyngeal neuralgia after primary surgery, the effectiveness of nerve fibre resection is definite, whereas, the result of revision surgery for hemifacial spasm is poor.