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本次文献选自Huang B, Yao M, Chen Q, et al. Awake CT-guided percutaneous stylomastoid foramen puncture and radiofrequency ablation of facial nerve for treatment of hemifacial spasm [published online ahead of print, 2021 Apr 16]. J Neurosurg. 2021;1-7.本次学习由魏广福主治医师主讲。
方法
本研究方案由所有作者设计并评审，经嘉兴学院附属医院机构评审委员会和伦理委员会批准。所有研究对象都同意使用这些程序和他们的健康数据(包括治疗前和治疗后的图像)用于未来的研究和出版。
A total of 62 patients with a medical history of HFS and in whom medical treatments had failed were recruited between August 2018 and April 2020. Patients with radio-logical evidence of cerebellopontine lesions, a history of coagulopathy, ongoing pregnancy, or cardiac pacemaker or defibrillator implants were excluded from the study. Those who declined CT scans or the procedure were also excluded. Of the 62 recruited subjects, 9 decided to withdraw from the study prior to receiving the procedure, and thus were not included.
2018年8月至2020年4月，共招募62例HFS病史且治疗失败的患者。有桥小脑病变影像学证据、有凝血病史、正在怀孕或植入心脏起搏器或除颤器的患者被排除在研究之外。那些拒绝接受CT扫描或手术的人也被排除在外。在62名招募的受试者中，有9人在接受治疗前决定退出研究，因此未被纳入研究。
All remaining 53 patients who agreed to proceed with the procedure were relatively healthy: 9 were American Society of Anesthesiologists (ASA) class I, 34 were ASA class II, and 10 were ASA class III. Sixteen of them (3 ASA class I, 8 ASA class II, and 5 ASA class III) had failed to gain relief for HFS from previous botulinum toxin injections, and 6 patients (3 ASA class II and 3 ASA class III) with previous MVD experienced HFS recurrence. The remaining 31 patients, who had no prior surgery for HFS, declined other procedures offered (e.g., MVD, botulinum injection) and elected to proceed directly with CT-guided RFA of the facial nerve. Nine patients in the study cohort had a history of vascular compression of the facial nerve, and none had MRI evidence of cerebellopontine lesions or mass compressing the facial nerve. The patient demographics are summarized in Table 1.
其余53例同意继续手术的患者均相对健康:9例为ASA I级患者，34例为ASA II级患者，10例为ASA III级患者。16例(3例ASA I级，8例ASA II级，5例ASA III级)既往注射肉毒杆菌毒素后HFS未能得到缓解，6例(3例ASA II级，3例ASA III级)既往MVD患者HFS复发。剩下的31例患者之前没有接受过HFS手术，他们拒绝接受其他手术(如MVD、肉毒杆菌注射)，选择直接进行ct引导下的面神经射频成像。研究队列中有9例患者有血管压迫面神经的病史，没有MRI证据显示桥小脑病变或肿块压迫面神经。表1总结了患者的统计数据。
Procedural Protocol
All patients were provided with the standard preanes-thesia instructions per ASA recommendations, and their fasting status was confirmed on the day of the procedure.
研究步骤
所有患者均按照ASA建议提供标准的麻醉前指导，并在手术当天确认其禁食状态。
To ensure the consistency of the treatment protocol, the same senior attending physician was present to supervise all phases of the procedure and review all images during the case. After the placement of standard ASA monitors and appropriate preprocedural timeout, the patient was placed in the lateral decubitus position, and the head was stabilized on a pillow with a plastic elastic strap. The surgical site was confirmed, sterilely prepared, and draped (Fig. 1A). CT positioning grids were placed anterior and posterior to the patient’s ear. The head positioning and the mastoid region were scanned in 3-mm layers by using a maxillofa-cial CT scanning protocol. The stylomastoid foramen was identified on the image sequence (Syngo Multimodality Workplace [MMWP]; Siemens) as the puncture target. The depth and dimension of the target, and the puncture path were identified using the Syngo MMWP. We found that the stylomastoid foramen can be best accessed via insertion points either anterior (Fig. 1B) or posterior (Fig. 1C) to the mastoid bone; thus, the approach was arbitrarily chosen.
为确保治疗方案的一致性，同一位资深主治医师在场监督手术的所有阶段，并在病例期间复查所有图像。放置标准ASA监测仪并适当的术前暂停后，将患者置于侧卧位，头部用塑料弹性带固定在枕头上。确认手术部位，无菌准备，铺布(图1A)。在患者耳部前后放置CT定位网格。采用颌面部CT扫描方案，对头部定位和乳突区进行3 mm层扫描。茎突乳突孔在图像序列上被识别作为穿刺目标，使用Syngo MMWP识别靶的深度和尺寸以及穿刺路径。我们发现，茎突乳突孔最好通过乳突骨前(图1B)或后(图1C)的插入点进入；因此，这种方法是任意选择的。
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