第一部分：显微血管减压术治疗责任血管包括椎动脉的面肌痉挛

目的：

探讨显微血管减压术（microvascular decompression, MVD）治疗责任血管包括椎动脉（vertebral artery, VA）的面肌痉挛（hemifacial spasm, HFS）的手术技巧、疗效以及并发症。

方法：　

回顾性纳入2010年1月至2012年2月中日友好医院神经外科同一术者采用MVD治疗的783例HFS患者，其中125例（16.0%）责任血管中包括VA（VA组），658例（84.0%）责任血管中不包括VA（非VA组）。分析两组的临床特点、手术技巧、疗效以及并发症情况。

结果：　

VA组中，责任血管为VA合并其它动脉者120例（96.0%），其中VA单独或共同作为主要责任血管者11例，VA为次要责任血管者109例；VA为唯一责任血管者５例（4.0%）。与非VA组相比，VA组多发于男性（P<0.05），HFS多位于左侧（P<0.05）。术后平均随访51个月（46~60个月）。VA组的手术延迟治愈率、中位延迟治愈时间以及患侧听力严重受损、患侧即刻面瘫、患侧迟发性面瘫、后组脑神经损伤、颅内出血的发生率均高于非VA组（均P<0.05），VA组与非VA组在年龄、发病病程、手术总有效率等方面的差异均无统计学意义（均P>0.05）。

结论：　  

在HFS MVD中VA作为唯一责任血管者少见；VA与其它动脉共同压迫时多为次要责任血管。MVD治疗责任血管包括VA的HFS的疗效确切，但与责任血管不包括VA者相比更易出现延迟治愈，且延迟治愈时间较长；术后患侧听力严重受损、患侧即刻面瘫、患侧迟发性面瘫、后组脑神经损伤、颅内出血等并发症的发生率高于责任血管不包括VA者。

关键词：面肌痉挛；显微血管减压术；椎动脉；治疗结果；手术后并发症

第二部分:显微血管减压术治疗非动脉压迫因素导致的三叉神经痛

目的：

探讨MVD治疗非动脉压迫因素导致的三叉神经痛（trigeminal neuralgia，TN）的手术方式、技巧、疗效以及并发症。

方法：

回顾性分析2006年5月至2016年12月中日友好医院神经外科同一术者采用MVD治疗的临床资料完整的251例TN患者，其中36例患者（14.3%）为非动脉压迫导致（非A组），215例患者责任血管为动脉或动脉合并静脉（A组）。非A组36例患者中19例为单纯静脉压迫，其中12例行常规MVD且减压满意，7例患者因对责任静脉无法满意进行减压，且年龄超过60岁，加行三叉神经感觉根选择性部分切断( partial rhizotomy, PR)，切断范围1/3~2/3；非A组36例患者中17例为探查未发现责任血管，其中12例将三叉神经感觉根自脑干至麦氏囊全程充分解剖，使其在轴位上彻底松解，5例患者年龄大于60岁，加行三叉神经感觉根PR。A组215例患者中190例患者常规行责任动脉MVD，25例术中因困难减压等情况导致减压不充分，且患者年龄高于60岁，行三叉神经感觉根PR。

结果：

非A组中，责任血管为单纯岩上静脉属支的患者有19例（52.8%），无明确责任血管者有17例（47.2%）；A组中，责任血管由小脑上动脉（superior cerebellar artery，SCA）、小脑前下动脉（anterior inferiorcerebellar artery,AICA）、岩上静脉属支或基底动脉（basilar artery，BA）构成。术后平均随访67个月（14~142个月）。非A组术后总有效率88.9%（32/36），复发率为5.9%(2/34),术后脑神经相关并发症发生率为8.3%（3/36）；A组术后总有效率85.6%（184/215），复发率为4.2%（8/192），术后脑神经相关并发症发生率为8.4%（18/215）。非A组患者在年龄、性别、患病侧别、病程、术后总有效率、复发率、脑神经相关并发症发生率等方面与A组相比差异无统计学显著意义（均P>0.05）。

结论：

在TN MVD术中，责任血管为非动脉压迫因素者并不少见，包括单纯静脉压迫和未发现责任血管两种情况。作为唯一责任血管的岩上静脉属支应尽量充分松解游离后行MVD；无血管压迫者应充分松解三叉神经感觉根周围的粘连；年龄大于60岁的患者可加行三叉神经感觉根PR。按照上述原则处理的非动脉压迫因素TN患者同样可获得优良疗效。

关键词：三叉神经痛；显微血管减压术；责任血管；非动脉压迫

Part one：Microvascular Decompression for Hemifacial Spasm Included Vertebral Artery

Objective:

To disscuss the surgical techniques, outcomes and complications of microvascular decompression (MVD) for treatment of hemifacial spasm (HFS) with offending vessels includingthe vertebral artery (VA).

Methods:

A total of 783 patients with HFS undergoing MVD at Deparment of Neurosurgery, China-Japan FriendshipHospital from January 2010 and February 2012 by the same surgeon were retrospectively enrolled into this study. Among them, 125 cases (16.0%) were found to have offending vsessels including VA and were classified into VA group. The other 685 cases (84.0%) did not have VA as the offending vessel and belonged to non-VA (NVA) group. The clinical characteristics, surgical techniques, efficacies and complications were analyzed for the two groups.

Results:

In the VA group, 120 cases (96.0%) had offending vessels including VA and other arteries. Out of the 120 cases, VA acted as the only main offending vessel or one of the main offending vessels in 11 cases, and as the secondary offending vessel in 109 cases. VA was identified as the only offending vessel in 5 cases (4.0%). Compared with the NVA group, the symptoms in VA group seemed to affect more commonly the left side and male patients (all P<0.05). The mean follow-up time is 51 months (ranged from 46 to 60 months). In the VA group, the operative delayed curing rate, median delayed curing time and rates of significant ipsilateral hearing loss, immediate postoperative facial paralysis, delayed facial paralysis, injury of posterior group of cranial nerves as well as intracranial bleeding were all higher than those in NVA group, and the differences were statistically significant (all P<0.05). Between the two groups, no difference was identified in the patients age, duration of illness and effective rate of operation (all P>0.05).

Conclusions:

It seems uncommon that VA acts as the only major offending vessel, which tends to be the secondary offending vessel and results in compression together with other arteris. The efficacy of MVD in HFS involing offending vessels including VA is suggested to be certain. Compared with the NVA patients, delayed curing is more likely to occur with later remission in VA patients. The postoperative complicationsrates of significant ipsilateral hearing loss, immediate postoperative facial paralysis, delayed facial paralysis, injury of posterior group of cranial nerves as well as intracranial bleeding post MVD were more commonly obeseved in VA patients than in NVA patients.

Key words: Microvascular decompression; Hemifacial spasm; Vertebral artery; Treatment outcome; Postoperative complications

Part two: Microvascular Decompression for Treatment of Trigeminal Neuralgia Caused by Non-arterial Compression Factors

Objective:

To discuss the surgical methods, techniques, outcomes, and complications of microvascular decompression (MVD) for treatment of trigeminal neuralgia (TN) caused by non-arterial compression factors.

Methods:

A total of 251 patients withcomplete clinical data of TN undergoing MVD at Department of Neurosurgery, China-Japan FriendshipHospital from May 2006 and December 2016 by the same surgeon were retrospectively enrolled into this study.Among them, 36 patients (14.3%) were caused by non-arterial compression (NA group ); 215 patients (85.7%) were caused by arterial compression(A group ). In the NA group, 19 cases were caused by single offending vein compression，of which 12 cases were undertaken MVD successfully, 7 cases over 60 years of age were undertaken selective partial rhizotomy (PR) after unsatisfied MVD, and the PR range of trigeminal sensory root was 1/3~2/3;17 cases in the NA group of 36 cases were found no offending vessels, of which 12 cases were undertaken radical release of trigeminal nerve root, and the trigeminal nerve root was completely dissected from the brain stem to the Meckel`scave  making it completely loosened on the axis, and 5 patientsover 60 years of age were then undertaken PR. In A group of the 215 patients, 190 cases were routinely performed MVD, and 25 cases over 60 years of age were undertaken PR after difficult MVD.

Results:

In the NA group, 19 cases(52.8%) had only offending vessels of superior petrosal veins and branches, and 17 cases(47.2%) had no offending vessels. In the A group, the offending vesselscomposed of SCA, AICA, superior petrosal vein branche, and basilar artery (BA). The mean follow-up time is 67 months(range from 14 to 142 months).Inthe NA group, the total effective rate was 88.9% (32/36), the recurrence rate was 5.9% (2/34), and the incidence of postoperativecerebralnerve related complications was 8.3% (3/36); In the A group, the total effective rate of was 85.6% (184/215), the recurrence rate was 4.2% (8/192), and the incidence of postoperativecerebral nerve related complications was 8.4% (18/215). Compared with the A group, there was no significant difference in age, sex, diseased side, course, total effective rate, recurrence rate, and the incidence of cerebral nerve related complications in the NA group(P>0.05).

Conclusions:

It seems that non-arterial compression factors were not uncommon in the TN MVD. The offending vessels of superior petrosal vein branches should be fully loosened and free after MVD; we should fully release the adhesions around the sensory root of the trigeminal nerve if we found no offending vessels; of which the patients older than 60 years old should be undertaken PR after MVD. According to the above principles, the non arterial compression factors ofTN patients also get good results.

Key words: Trigeminal neuralgia; Microvascular decompression; Offending vessels; Non-arterial compression;