Infraorbital nerve avulsion

Infraorbital nerve extraction is used for the treatment of trigeminal neuralgia. The largest of the trigeminal cranial nerves are the sensory nerves in the anterior cranial, facial, eyelid, nasal and oral regions, as well as the movement and sensory nerves of the masticatory muscles. In the intracranial trigeminal nerve, the sensory root (most part) and the moving root (small part) are connected to the pons. The roots of the trigeminal nerve at the tip of the tibial rock are spread into a flat semilunar ganglion. The semilunar ganglion cells converge into three nerve trunks, called the ocular nerve (the supraorbital nerve), the maxillary nerve (the submental nerve), and the mandibular nerve (the inferior alveolar nerve and the lingual nerve). . The movement root is thinner, and it is emitted by the cerebral trigeminal motor nucleus. After the pons, it clings to the lower part of the semilunar ganglion and enters the mandibular nerve, which controls the masticatory muscle. Therefore, the ocular nerve and the maxillary nerve are sensory nerves, while the mandibular nerve is a mixed nerve. The distribution of trigeminal sensory fibers on the face is bounded by eye cracks and cracks, and the boundary between them is clear. Primary trigeminal neuralgia is a syndrome characterized by facial paroxysmal pain, which is characterized by a trigger point. Slight contact with the trigger points distributed in the trigeminal innervation area can result in severe pain episodes, while during the interval of 2 pain episodes, the pain completely disappears without leaving any neurological dysfunction. Primary trigeminal neuralgia is a common neuropathic pain in the mouth and maxillofacial region. It is different from symptomatic trigeminal neuralgia. The cause of the disease is still unclear, so there is no cure for it. In the choice of treatment methods, first consider drug therapy and conservative treatment, followed by semi-monthly temperature-controlled radiofrequency thermocoagulation. In the case where the above method is ineffective, surgery and nerve destruction treatment methods such as peripheral nerve avulsion are further employed. The infraorbital nerve is the distal branch of the second branch of the trigeminal nerve (the maxillary nerve). When performing this avulsion, try to get the avulsion of the nerve at the base of the fundus to reduce the postoperative recurrence. Treating diseases: trigeminal neuralgia Indication Infraorbital nerve extraction is applicable to: 1. A diagnosis of the second trigeminal nerve pain, in the case of other methods of treatment is ineffective, then underarm (or maxillary) nerve avulsion. 2. Primary trigeminal neuralgia, determine that there are several (including subgingival branch) pain symptoms, while performing other avulsion of the distal branch, underarm (or maxillary) nerve avulsion. Contraindications 1. Qualitative is not clear, it is not suitable for surgery. 2. Inaccurate positioning is not suitable for surgery. 3. For those with shorter course and less pain, conservative treatment should be given first, and surgery should not be given. 4. For patients with pathogenic factors in the high nerves, it is not appropriate to perform distal 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. If the operation is performed through the maxillary sinus, the maxillary sinus radical surgery should be used for preoperative preparation. 5. Before the operation, explain the situation to the patient, so that it is psychologically prepared for numbness in the relevant area after surgery. Surgical procedure 1. facial incision, underarm avulsion Under the inferior temporal margin, the inner and middle 1/3 junction planes can touch the incision site, which is the position of the inferior hole. About 1 cm below the lower edge of the affected side, an arc-shaped incision of about 2 cm was made, the skin was cut, and the lower edge of the orbicularis muscle was bluntly separated until the bone surface revealed the infraorbital hole. Carefully separate the infraorbital nerve of the infraorbital hole at the inferior temporal hole, taking care to avoid damage to the infraorbital blood vessels accompanying it, lifting the infraorbital nerve with a small hook, and using a hemostasis clamp at the proximal end of each branch of the infraorbital nerve. After living the nerve, slowly twist the hemostatic forceps to the outside of the hole, and then pull the nerve trunk from the underarm tube until it is avulsed. At the same time, the nerve endings of each branch should be avulsed from the skin. The wound is then sutured in layers. 2. Facial incision, high avulsion The position of the incision is the same as before, and the arc incision is about 3 cm long. Cut through the periosteum and find the bundle of infraorbital nerve vessels coming out of the underarm. The periosteum was lifted on the muscle surface with a periosteal separator, and the periosteum and the sacral floor were carefully separated upwards over the infraorbital margin. Use the thyroid gland to pull the tendon tissue and the eyeball up slightly below the periosteum. At this point, the neurovascular bundle in the inferior sulcus behind the infraorbital canal is exposed. To prevent the neurovascular bundle from rupturing before avulsion, insert a subgingival tube over the infraorbital vascular bundle with a 7 gauge needle until the tip of the needle protrudes from the inferior temporal sulcus. Then use the osteotome to cut the bone above the inferior foramen and the top wall of the infraorbital tube. At this point, the lower jaw, the inferior canal and the inferior sulcus can be joined together. The inner segment of the maxillary branch of the trigeminal nerve is completely exposed. After separating the nerves in the iliac crest from the blood vessels, the nerve trunk is clamped with a vascular clamp near the inferior sacral hole. At this point, the distal end of the nerve trunk can be lifted from the underside of the infraorbital sulcus and the infraorbital canal with a nerve hook. Then use another vascular clamp to gently pull the proximal end of the first vascular clamp. In this way, the third and fourth vascular clamps are sequentially clamped to the proximal end of the nerve trunk, and the nerve trunk is gradually pulled out. In this way, the nerve trunk torn off is often as long as about 4 cm. After the high nerve avulsion, the bone wax is filled in the infraorbital tube. Subsequently, the branches outside the inferior foramina are avulsed from the skin. The wound was layered and the rubber sheet was placed for drainage. 3. Intraoral incision, underarm avulsion The incision was made through the maxillary canine of the mouth to the lip and cheek groove of the second bicuspid, up to 4 cm, until the periosteum. The bone surface is peeled off and separated upwards to the inferior temporal cavity. The infraorbital nerve bundle is seen in parallel to the soft tissue that is turned up. The bone surface around the infraorbital hole is carefully revealed, the nerve bundle is clearly dissected, and the nerve after the hole is removed. Free one section, clamp the nerve bundle with a mosquito clamp in the near hole plane, gently pull and twist the vascular clamp, pull the nerve out as much as possible, and then cut the nerve in the soft tissue at the distal end. It is still possible to inject about 0.5 ml of absolute ethanol into the inferior sacral hole, and take the nearby small bone or the periosteum into the hole. The nerve branch in the soft tissue is torn off as much as possible, and the stump is displaced and sutured. 4. Intraoral incision, sinus avulsion Make an incision about 4cm in length on the affected side of the cusp and buccal mucosa, until the bone surface, upward separation, pick up the soft tissue of the cheek, expose the infraorbital nerve vascular bundle, and avulsion according to the "intraoral incision, underarm avulsion" method The branch of the inferior nerve is attached and the inferior vault is ligated. The anterior wall of the maxillary sinus was opened, and the bone of the anterior wall of the maxillary sinus was excised from the underside of the inferior sinus with a bone chisel, about 2 cm in diameter, revealing the maxillary sinus mucosa. Cut a mucosal flap on the upper (underarm) side along the edge of the bone hole. The mucosa of the sinus apex is then cut along the direction of the inferior iliac crest, and the sinus apical wall is exposed. Use a small bone chisel to cut the sinus bone wall in the direction of the lower tube, carefully separate the nerve bundles of the infraorbital and inferior sulcus, and tear it off as much as possible. Subsequently, the sinus mucosa was repositioned, and the mucosal flap of the pedicle was turned upside down, sutured with the periosteum of the infraorbital margin, and a barrier was set up to help reduce postoperative recurrence. Open the window on the inside of the maxillary sinus, establish drainage to the ipsilateral lower nasal passage, and tightly suture the incision of the mucosa. complication Infraorbital nerve extraction is a destructive operation. The numbness of the affected area is affected by the sacral area. Most patients will gradually adapt and have no special treatment.

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