High cut and avulsion of maxillary nerve

High maxillary avulsion of the maxillary nerve for the treatment of maxillary neuralgia in the trigeminal nerve. Trigeminal neuralgia, the common surgical method is the infraorbital nerve avulsion of the maxillary nerve. This method is simple, safe and reliable, and can relieve pain, but the pain can occur from any branch of the nerve. After the pain recurrence rate is high, in order to improve the therapeutic effect of the infraorbital nerve avulsion, the authors propose a surgical method in the sinus, mainly in the maxillary sinus to the axillary segment and the external axillary nerve avulsion, the surgical effect Far better than avulsion of the underarm nerve. In clinical work, we found that many patients with maxillary neuralgia have a slap point in the ankle, posterior superior molar, and even in the nasal mucosa, when the lesion occurs in the superior alveolar nerve or iliac crest of the pterygopalatine fossa. In the nerves and other branches, it is difficult to solve the pain caused by the above nerves, the anatomy and movement of the maxillary nerve, whether it is the intracranial meningeal nerve, the branches of the pterygoid nerve of the pterygopalatine fossa, and the upper teeth of the sinus In front of the trough, the middle nerve, these nerves have a deep branching position, and the terminal branches are small and mostly travel through the bone tissue. For these neurogenic lesions, it is difficult to perform avulsion like the mandibular nerve branch, except for the infraorbital nerve. However, it is not uncommon to have lesions in the upper part of the infraorbital nerve. This may also be the reason for the high recurrence rate of the maxillary nerve, the short recurrence period, and the limitation of the pain range. Intracranial trigeminal sensory root resection has a better therapeutic effect, but still has a high recurrence rate (18% to 39%) and more serious complications such as postoperative coma, epilepsy and death. Patients and their relatives are often difficult to accept. . According to anatomical studies and clinical application studies, the reason for the high recurrence rate after avulsion of the trigeminal nerve is as follows: 1 The abutment of a single branch does not solve the problem of branching of other nerves. From the observation data of the mandibular nerve, the clinical symptoms of the buccal nerve, the lingual nerve and the inferior alveolar nerve are usually 1 or 2 branches, and the above 3 nerve branches rarely show pain, but in 3 resections. There are varying degrees of pathological changes in the nerve specimens. 2 The common surgical method for maxillary neuralgia is infraorbital nerve avulsion, and the infraorbital nerve is only a branch of the maxillary nerve, so the avulsion of the simple infraorbital nerve can not solve the pain problem of other branches of the superior sacral nerve, as above The alveolar nerve, the descending nerve and so on. 3 The anatomy of the maxillary nerve is also significantly different from the anatomy of the mandibular nerve. The branch of the mandibular nerve (except the inferior alveolar nerve) is basically in the soft tissue, but the maxillary nerve is not. In addition to the infraorbital nerve, other nerve branches Within the bone tissue, and the terminal branches are small, this may be the reason why the maxillary nerve has only had an axillary nerve avulsion for a long time. The method of documenting the upper and lower diameter of the maxillary nerve mouth is better in the literature, but the outer diameter of the mouth is more traumatic. The high-cutting of the maxillary nerve needs to break the zygomatic arch. Sometimes it may damage the facial nerve branch, and the surgical scar remains after the operation. The patient also has scruples. Oral diameter road high cutting can not only preserve the advantages of high intracranial nerve sensory root resection, but also avoid the risk of intracranial surgery and trauma and the lack of extraoral surgery. The maxillary nerve can be cut at the outer hole of the round hole, basically including The branches of the maxillary nerve have better solved the trigeminal neuralgia caused by the maxillary posterior superior alveolar nerve and the radial nerve. High-level mandibular nerve cutting has been reported by scholars in China as the internal diameter of the inferior temporal incision. Here is the surgical approach using the maxillary sinus pterygoid fossa in the mouth. Compared with the extra-orbital sacral approach, the surgical approach has a slightly longer path, but its advantages are: 1 surgery can cut the nerve in the high position (outer hole); 2 surgical incision in the oral vestibule, no scar on the face, does not affect Face; 3 small tissue in the maxillary sinus, the visual field is also clear, can directly cut the nerve at the outer hole of the round hole of the pterygopalatine fossa; 4 small trauma, rapid recovery after surgery. The incidence of maxillary neuralgia in the trigeminal nerve is high. Because the maxillary nerve is complicated from the intracranial to the facial stroke, it passes through the pterygopalatine fossa, the infraorbital fissure, the inferior sulcus, the infraorbital canal, etc., so that the extracranial segment of the maxillary nerve is cut off and avulsed. The approach to surgery is more difficult. Treating diseases: trigeminal neuralgia Indication High maxillary avulsion of the maxillary nerve is suitable for: 1. Diagnosis of primary trigeminal neuralgia, located in the branch of the maxillary nerve, in the case of drug treatment and other treatments are ineffective, the upper maxillary nerve multi-segment avulsion surgery. 2. Primary trigeminal neuralgia, to determine the presence of several pain symptoms in the maxillary nerve, the upper maxillary nerve multi-segment avulsion surgery. Contraindications 1. If the nature is not clear, it is not suitable for surgery. 2. If the positioning is not accurate, it is not suitable for surgery. 3. For patients with short course of disease and mild pain, conservative treatment should be given first, and surgery should not be performed temporarily. 4. For patients with pathogenic factors in the high nerves, it is not appropriate to perform distal avulsion and avulsion. Preoperative preparation 1. Detailed medical history, careful positioning examination, to find out whether it is primary or symptomatic trigeminal neuralgia, providing a basis for surgery. 2. For patients with a wide range of facial episodes of severe pain, distinguish the primary and secondary, and do a good job before the operation. 3. For young or menopausal women, facial pain occurs, and the diagnosis should be carefully diagnosed before surgery, especially to eliminate the pain caused by mental factors. 4. For patients undergoing surgery from the oral route, the teeth should be cleaned and the mouth should be cleaned before surgery to treat the odontogenic infection. 5. For patients undergoing surgery under general anesthesia, perform a general examination before surgery to understand the function of heart, lung, liver and kidney. Surgical procedure In the affected side of the cheek and sulcus from the central incisor to the molars to make a 4 cm long incision, incision of the mucosa, submucosal tissue, blunt separation on the surface of the periosteum, flaps, up to the lower edge of the inferior foramen, pull up with a hook, The anterior wall of the maxillary sinus and the infraorbital nerve vascular bundle were exposed, the infraorbital nerve was ligated outside the infraorbital orifice, and the distal end was avulsed and sewed. In the canine concave area, a 2cm-diameter periosteal pedicle is placed on the upper part of the periosteum bone flap. The periosteum around the bone flap of the periosteum pedicle is cut, and the periosteum around the bone flap is separated to reveal the bone wall. A high-speed turbine drill was used to cut the bone around the periosteal bone flap (Fig. 10.4.7.4-4), and the pedicle was retained. The pedicled periosteal bone flap was lifted outward with a small bone knife or stripper to cause a fracture, and the bone flap was lifted up and kept connected to the periosteal pedicle to clearly reveal the maxillary sinus cavity. Then, the maxillary sinus mucosa was separated at the posterior wall of the maxillary sinus, that is, the posterior wall of the maxillary sinus, and the posterior wall of the maxillary sinus was gently knocked with a bone chisel to remove the bone tissue of about 1.0 cm×1.5 cm into the pterygopalatine fossa. Lightly separate the soft tissue, use the nerve hook to hook out the nerve. After confirmation, use a hemostat clamp to gently pull outward, rinse with saline and clean up the deep surgery, see the round hole and the resulting maxillary nerve, and then The nerve is severed outside the circular orifice and abutted with the corresponding branch. Then, at the top of the maxillary sinus (the bottom of the sac), the subgingival tube was gently tapped with a small bone chisel to extract the infraorbital nerve. The saline was washed and the maxillary sinus cavity was cleaned. The inner wall of the maxillary sinus was punched into the opposite side of the lower nasal passage. The sinus cavity was filled with iodoform gauze, and the tail of the gauze was pulled from the hole to the lower nasal passage for drainage. The pedicled periosteal bone flap was repositioned to repair the bone defect of the anterior wall of the maxillary sinus and the mucosal wound of the lip and cheek groove was sutured. complication 1. Regional sensory disturbances. In the area where the maxillary nerve is distributed, the affected side has a long-term numbness after surgery, and most patients will gradually adapt to it without special treatment. 2. There is a trace reaction after surgery. After the trigeminal nerve branch was cut, about 1/3 of the patients had neuropathic pains ranging from 2 to 7 days after surgery. Most patients had fewer neuralgia attacks than before surgery. The degree of pain was not severe before surgery, but There are also a small number of patients with pain that is similar to or even heavier before surgery. This phenomenon is called "marking reaction" clinically, but the mechanism is still unclear. Patients with postoperative trace reaction should be given appropriate treatment, especially those who have 3 to 5 times of daily episodes. They can temporarily treat trigeminal neuralgia drugs to relieve the pain of patients and reduce the mentality of patients. burden. When clinical symptoms are not consistent with anatomy, consideration should be given to whether there are mental factors. 3. General anesthesia is prone to pneumonia after surgery. The measures to prevent postoperative pneumonia are: 1 anesthesia cannula, the balloon should be inflated or filled with pharyngeal cavity safe and reliable; 2 before the extubation, try to suck out the secretions or aspiration in the trachea; 3 postoperative atomization Inhalation, encourage cough up the sticky; 4 postoperatively turn the patient over, beat the chest, back. Once pneumonia occurs, the amount of broad-spectrum antibiotics should be strengthened, the amount of infusion should be properly controlled, and the chest should be treated with ultrashort wave physiotherapy.