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山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。
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。
Discussion
The pathophysiology of HFS is characterized by involuntary spasm of facial muscles secondary to a progressive dystrophy, demyelination, and hyperexcitability of the facial nerve and facial motor nucleus. The majority of HFS cases are thought to be caused by physical compression by nearby vasculatures or lesions,making MVD the mainstream surgical treatment for HFS. Although MVD is considered safe and effective with good microsurgical techniques,achieving an average 80% recovery rate within the first year of surgery, it is nonetheless invasive and requires general anesthesia and intraoperative neural monitoring. Furthermore, MVD would be less useful for those patients without evidence of nerve compression,such as those with facial nerve hyperexcitability, or neuropathy. Pharmacological treatments such as anticonvulsants and anticholinergics have limited efficacy. Botulinum toxin injection into facial muscles, which blocks the presynaptic acetylcholine release, is a less invasive method that can provide temporary relief to patients with HFS. A major limitation of botulinum toxin injection is that it often requires frequent reinjection, which can be a significant burden to the patients, and may not be feasible for those with limited access to a healthcare facility. Furthermore, botulinum toxin injections can lead to cosmetic concerns, such as drooping, bruising, and edema of the face. Despite this, it is currently the only nonpharmacological option for patients who are not good surgical candidates (e.g., no nerve compression), or who cannot tolerate general anesthesia.
讨论
HFS的病理生理特征是面肌不自主痉挛，继发于进行性营养不良、脱髓鞘和面神经及面肌运动核的过度兴奋。大多数HFS病例被认为是由附近血管或病变的物理压迫引起的，使得MVD成为HFS的主流手术治疗方法。虽然由于良好的显微外科技术，MVD被认为是安全有效的，在手术的第一年内达到平均80%的恢复率，它仍然是有创的，需要全麻和术中神经监测。此外，对于那些没有神经压迫证据的患者，如面神经过度兴奋或神经病变患者，MVD的作用将会减弱。抗惊厥药物和抗胆碱能药物等药物治疗效果有限。肉毒杆菌毒素注射面部肌肉可以阻断突触前乙酰胆碱的释放，是一种侵袭性较小的方法，可以为hfs患者提供暂时的缓解。对那些无法获得医疗保健设施的人来说可能不可行。此外，肉毒杆菌毒素注射可能导致美容问题，如下垂，瘀伤和脸部水肿。尽管如此，对于那些不适合手术的患者(例如，没有神经压迫)或不能忍受全身麻醉的患者，它是目前唯一的非药物选择。
Our data indicate that RFA is a minimally invasive alternative for treating HFS. RFA is typically done with fluoroscopy, and has been shown to be useful in treating trigeminal neuralgia, a condition that shares similar pathophysiology with HFS, even for patients who failed to gain relief with MVD. Previous studies also demonstrated preliminary success in treating small cohorts of patients with HFS by using fluoroscopy-guided RFA. With the advancement of imaging techniques over the years, high-resolution 3D-reconstructed CT images can now be obtained at real time intraoperatively, allowing a better characterization of anatomical variation among patients, which potentially decreases the likelihood of damaging nearby structures and causing associated complications. Our previous work using high-precision CT-guided RFA of the trigeminal nerve has shown success with minimal side effects in patients with trigeminal neuralgia. Here, we investigated the clinical outcome of patients with HFS who underwent CT-guided awake RFA of the facial nerve, and reported favorable and long-lasting outcomes. Our data show that 91% (48/53) of our patients had resolution of facial spasm during the study period. Although 5 of 53 patients had recurrence of HFS symptoms, all recurred at least 7 months after the procedure, which suggests that RFA, even when it is less successful, can offer a longer and more sustainable therapeutic window than botulinum toxin injection.
我们的数据表明射频消融是一种微创治疗HFS的选择。RFA通常是通过透视来完成的，并且已经被证明对治疗三叉神经痛很有用，三叉神经痛，一种与HFS有相似的病理生理特征的情况，甚至对于mvd未能获得缓解的患者。以往的研究也显示了使用荧光透视引导的射频成像治疗小群HFS患者的初步成功。随着多年来成像技术的进步，高分辨率的3d重建CT图像现在可以在术中实时获得。可以更好地描述患者的解剖变异，这可能会减少损伤附近结构和导致相关并发症的可能性。我们之前使用高精度ct引导的三叉神经射频成像技术在三叉神经痛患者中取得了成功，且副作用最小。在这里，我们调查了接受ct引导下面神经清醒射频消融治疗的HFS患者的临床结局，并报道了良好的和长期的结局。我们的数据显示，91%(48/53)的患者在研究期间面部痉挛得到了缓解。尽管53例患者中有5例HFS症状复发，但所有患者都在手术后至少7个月复发，这表明射频消融，即使不太成功，也比肉毒杆菌毒素注射提供了一个更长的、更可持续的治疗窗口。
Although MVD remains the best treatment option for HFS with a high long-term success rate, for patients who are poor candidates for MVD or who cannot tolerate general anesthesia, CT-guided RFA is a viable alternative. It can be performed under local anesthesia with just a few operating room staff (e.g., 1 pain specialist, 1 nurse, and 1 radiology technician). It is also a relatively quick procedure, with an average of only 32–34 minutes of procedural time. It requires a shorter postoperative hospital stay than MVD (e.g., 1 day vs up to 5–7 days for MVD). More importantly, without the need for general anesthesia, RFA allows the surgeon to monitor the motor function in an awake patient and to titrate the dosage and duration of the ablation. This is a superior monitoring technique because the surgeon can now observe the real-time effect of the nerve ablation, whereas the traditional neural monitoring technique (e.g., abnormal muscle response) has been shown to be unreliable for predicting clinical response.31Last, RFA of the facial nerve produced significant symptomatic relief for patients with HFS during the study period, with a 1-year estimated relief rate of 91.7%. Therefore, the CT-guided awake RFA technique described here is minimally invasive and can be an effective and low-cost alternative treatment for HFS.
虽然MVD仍然是HFS的最佳治疗选择，长期成功率高，对于MVD不适合或不能耐受全身麻醉的患者，但ct引导的RFA是一个可行的选择。它可以在局部麻醉下进行，只需几个手术室工作人员(例如，1名疼痛专家，1名护士和1名放射技师)。这也是一个相对快速的程序，平均程序时间只有32-34分钟。它需要比MVD更短的术后住院时间(例如，MVD为1天，而MVD为5-7天)更重要的是，在不需要全身麻醉的情况下，RFA允许外科医生监测清醒患者的运动功能，并滴定消融的剂量和持续时间。这是一种优越的监测技术，因为外科医生现在可以实时观察神经消融的效果，而传统的神经监测技术(例如，异常肌肉反应)已经被证明在预测临床反应方面是不可靠的最后，在研究期间，面部神经RFA对HFS患者产生了显著的症状缓解，1年的估计缓解率为91.7%。因此，本文描述的ct引导清醒RFA技术具有微创性，是一种有效且低成本的HFS替代治疗方法。
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