scholarly journals Microvascular decompression in trigeminal neuralgia: predictors of pain relief, complication avoidance, and lessons learned

2021 ◽  
Author(s):  
Johannes Herta ◽  
Tobias Schmied ◽  
Theresa Bettina Loidl ◽  
Wei-te Wang ◽  
Wolfgang Marik ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
The Elderly ◽  
Pain Intensity Score ◽  
Complication Rates ◽  
Safe Procedure ◽  
Neurovascular Conflict ◽  
Paroxysmal Pain

Abstract Objective To analyze characteristics associated with long-term pain relief after microvascular decompression (MVD) for trigeminal neuralgia (TGN). Description of associated morbidity and complication avoidance. Methods One hundred sixty-five patients with TGN underwent 171 MVD surgeries at the authors’ institution. Patient characteristics and magnetic resonance imaging (MRI) datasets were obtained through the hospital’s archiving system. Patients provided information about pre- and post-operative pain characteristics and neurologic outcome. Favorable outcome was defined as a Barrow Neurological Institute (BNI) pain intensity score of I to III with post-operative improvement of I grade. Results Type of TGN pain with purely paroxysmal pain (p = 0.0202*) and TGN classification with classical TGN (p = 0.0372*) were the only significant predictors for long-term pain relief. Immediate pain relief occurred in 90.6% of patients with a recurrence rate of 39.4% after 3.5 ± 4.6 years. MRI reporting of a neurovascular conflict had a low negative predictive value of 39.6%. Mortality was 0% with major complications observed in 8.2% of patients. Older age was associated with lower complication rates (p = 0.0009***). Re-MVD surgeries showed improved long-term pain relief in four out of five cases. Conclusions MVD is a safe and effective procedure even in the elderly. It has the unique potential to cure TGN if performed on a regular basis, and if key surgical steps are respected. Early MVD should be offered in case of medical treatment failure and paroxysmal pain symptoms. The presence of a neurovascular conflict on MRI is not mandatory. In case of recurrence, re-MVD is a good treatment option that should be discussed with patients. Highlights • Long-term analysis of pain relief after MVD. • Positive predictors for outcome: classical TGN and purely paroxysmal pain. • Presence of neurovascular conflict in MRI is not mandatory for MVD surgery. • Analysis of complications and surgical nuances for avoidance. • MVD is a safe procedure also in the elderly.

MICROVASCULAR DECOMPRESSION FOR TRIGEMINAL NEURALGIA IN THE ELDERLY

Neurosurgery ◽  
2009 ◽  
Vol 65 (3) ◽  
pp. 477-482 ◽  
Author(s):  
Thomas Günther ◽  
Venelin M. Gerganov ◽  
Lennart Stieglitz ◽  
Wolf Ludemann ◽  
Amir Samii ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
The Elderly ◽  
Safe Procedure ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Younger Patients ◽  
The Mean

Abstract OBJECTIVE Multiple studies have proved that microvascular decompression (MVD) is the treatment of choice in cases of medically refractory trigeminal neuralgia (TN). In the elderly, however, the surgical risks related to MVD are assumed to be unacceptably high and various alternative therapies have been proposed. We evaluated the outcomes of MVD in patients aged older than 65 years of age and compared them with the outcomes in a matched group of younger patients. The focus was on procedure-related morbidity rate and long-term outcome. METHODS This was a retrospective study of 112 patients with TN operated on consecutively over 22 years. The main outcome measures were immediate and long-term postoperative pain relief and neurological status, especially function of trigeminal, facial, and cochlear nerves, as well as surgical complications. A questionnaire was used to assess long-term outcome: pain relief, duration of a pain-free period, need for pain medications, time to recurrence, pain severity, and need for additional treatment. RESULTS The mean age was 70.35 years. The second and third branches of the trigeminal nerve were most frequently affected (37.3%). The mean follow-up period was 90 months (range, 48–295 months). Seventy-five percent of the patients were completely pain free, 11% were never pain free, and 14% experienced recurrences. No statistically significant differences existed in the outcome between the younger and older patient groups. Postoperative morbidity included trigeminal hypesthesia in 6.25%, hypacusis in 5.4%, and complete hearing loss, vertigo, and partial facial nerve palsy in 0.89% each. Cerebrospinal fluid leak and meningitis occurred in 1 patient each. There were no mortalities in both groups. CONCLUSION MVD for TN is a safe procedure even in the elderly. The risk of serious morbidity or mortality is similar to that in younger patients. Furthermore, no significant differences in short- and long-term outcome were found. Thus, MVD is the treatment of choice in patients with medically refractory TN, unless their general condition prohibits it.

scholarly journals Gamma Knife Radiosurgery for Primary and Secondary Trigeminal Neuralgia

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Sunil K Gupta
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Treatment Modality ◽  
Pain Control ◽  
Treatment Options ◽  
Gamma Knife Radiosurgery ◽  
Clinical Criteria ◽  
Grade Iii

Abstract INTRODUCTION Trigeminal neuralgia has always been a disease of conflict from pathological and management perspectives. Despite advances in the radiological imaging, evidence from autopsy studies, and intraoperative findings, concrete answers are not in sight. GKRS has been a strong contender among available treatment options for the management of trigeminal neuralgia. METHODS All patients were evaluated on clinical criteria, BNI scale for intensity of pain, and facial hypoesthesia (if any) in a protocol-based manner. Only patients with BNI III to V were offered GKRS as a treatment modality. The Marseille point was targeted with a 70 to 90 Gy dose at 50% isodose. Patients were informed about all available treatment options with long-term prognosis and pain control rates. Patients in need of an immediate pain relief, in failed GKRS, and in a severe pain jeopardizing routine life and eating habits were not offered GKRS and were managed with microvascular decompression. RESULTS A total of 108 (65 males, 43 females) patients received GKRS with the Perfexion model since 2009. Eighty-two percent of the patients received GKRS for primary trigeminal neuralgia, while the rest received GKRS for secondary trigeminal neuralgia due to skull base lesions (meningioma, schwannoma, cerebellar AVM, etc). A total of 78% of the patients had preoperative BNI scale IV, while 19% and 3% of the patients had grade III and V scale pain, respectively. Ninety-four percent patients gained BNI scale III intensity pain within 3 mo of GKRS. The 3-yr pain control rate (BNI I-II) could be attained in 81% of the patients. Twelve percent of the patients remained in BNI grade III. Two patients needed redo GKRS for their pain recurrence. CONCLUSION It remains uncontested that MVD provides the best long-term pain-free control in patients of trigeminal neuralgia; however, GKRS remains a valuable feasible option for a selected group of patients. GKRS should be offered as an alternative treatment modality in patients not in urgent need of pain relief. In failed GKRS, authors did not encounter any difficulty in microvascular decompression.

A novel scoring system as a preoperative predictor for pain-free survival after microsurgery for trigeminal neuralgia

2020 ◽  
Vol 132 (1) ◽  
pp. 217-224 ◽  
Author(s):  
Fran A. Hardaway ◽  
Hanna C. Gustafsson ◽  
Katherine Holste ◽  
Kim J. Burchiel ◽  
Ahmed M. Raslan
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Scoring System ◽  
Neurovascular Conflict ◽  
Radiographic Findings ◽  
Free Survival ◽  
Cox Regression Analysis ◽  
Mri Studies ◽  
Internal Neurolysis

OBJECTIVEPain relief following microvascular decompression (MVD) for trigeminal neuralgia (TN) may be related to pain type, degree of neurovascular conflict, arterial compression, and location of compression. The objective of this study was to construct a predictive pain-free scoring system based on clinical and radiographic factors that can be used to preoperatively prognosticate long-term outcomes for TN patients following surgical intervention (MVD or internal neurolysis [IN]). It was hypothesized that contributing factors would include pain type, presence of an artery or vein, neurovascular conflict severity, and compression location (root entry zone).METHODSAt the authors’ institution 275 patients with type 1 or type 2 TN (TN1 or TN2) underwent MVD or IN following preoperative high-resolution brain MRI studies. Outcome data were obtained retrospectively by chart review and/or phone follow-up. Characteristics of neurovascular conflict were obtained from preoperative MRI studies. Factors that resulted in a probability value of < 0.05 on univariate logistic regression analyses were entered into a multivariate Cox regression analysis in a backward stepwise fashion. For the multivariate analysis, significance at the 0.15 level was used. A prognostic system was then devised with 4 possible scores (0, 1, 2, or 3) and pain-free survival analyses conducted.RESULTSUnivariate predictors of pain-free survival were pain type (p = 0.013), presence of any vessel (p = 0.042), and neurovascular compression severity (p = 0.038). Scores of 0, 1, 2, and 3 were found to be significantly different in regard to pain-free survival (log rank, p = 0.005). At 5 and 10 years there were 36%, 43%, 61%, and 69%, and 36%, 43%, 56%, and 67% pain-free survival rates in groups 0, 1, 2, and 3, respectively. While TN2 patients had worse outcomes regardless of score, a subgroup analysis of TN1 patients with higher neurovascular conflict (score of 3) had significantly better outcomes than TN1 patients without severe neurovascular conflict (score of 1) (log rank, p = 0.005). Regardless of pain type, those patients with severe neurovascular conflict were more likely to have arterial compression (99%) compared to those with low neurovascular conflict (p < 0.001).CONCLUSIONSPain-free survival was predicted by a scoring system based on preoperative clinical and radiographic findings. Higher scores predicted significantly better pain relief than lower scores. TN1 patients with severe neurovascular conflict had the best long-term pain-free outcome.

Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression

2002 ◽  
Vol 96 (3) ◽  
pp. 527-531 ◽  
Author(s):  
Elizabeth C. Tyler-Kabara ◽  
Amin B. Kassam ◽  
Michael H. Horowitz ◽  
Louise Urgo ◽  
Constantinos Hadjipanayis ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Long Term Results ◽  
Content Type ◽  
Significant Pain ◽  
Fine Print

Object. Microvascular decompression (MVD) has become one of the primary treatments for typical trigeminal neuralgia (TN). Not all patients with facial pain, however, suffer from the typical form of this disease; many patients who present for surgical intervention actually have atypical TN. The authors compare the results of MVD performed for typical and atypical TN at their institution. Methods. The results of 2675 MVDs in 2264 patients were reviewed using information obtained from the department database. The authors examined immediate postoperative relief in 2003 patients with typical and 672 with atypical TN, and long-term follow-up results in patients for whom more than 5 years of follow-up data were available (969 with typical and 219 with atypical TN). Outcomes were divided into three categories: excellent, pain relief without medication; good, mild or intermittent pain controlled with low-dose medication; and poor, no or poor pain relief with large amounts of medication. The results for typical and atypical TN were compared and patient history and pain characteristics were evaluated for possible predictive factors. Conclusions. In this study, MVD for typical TN resulted in complete postoperative pain relief in 80% of patients, compared with 47% with complete relief in those with atypical TN. Significant pain relief was achieved after 97% of MVDs in patients with typical TN and after 87% of these procedures for atypical TN. When patients were followed for more than 5 years, the long-term pain relief after MVD for those with typical TN was excellent in 73% and good in an additional 7%, for an overall significant pain relief in 80% of patients. In contrast, following MVD for atypical TN, the long-term results were excellent in only 35% of cases and good in an additional 16%, for overall significant pain relief in only 51%. Memorable onset and trigger points were predictive of better postoperative pain relief in both atypical and typical TN. Preoperative sensory loss was a negative predictor for good long-term results following MVD for atypical TN.

scholarly journals The Durability of Pain Relief Following Endoscope-Assisted Microvascular Decompression for Trigeminal Neuralgia

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Alexandra D Baker ◽  
Melvin Field
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Recurrence Rate ◽  
Microvascular Decompression ◽  
Retrospective Chart Review ◽  
Postoperative Recurrence ◽  
Pain Scale ◽  
Neurovascular Compression ◽  
Recurrence Rates

Abstract INTRODUCTION Trigeminal neuralgia (TGN) is a facial pain disorder that is paroxysmal, stabbing, and produces a shooting pain that affects the face due to the compression of the trigeminal nerve. Literature has suggested that the use of an endoscope for microvascular decompression (eMVD), as opposed to a microscope alone, is more likely to identify the source of neurovascular compression and ensure that the nerve is adequately decompressed. However, the recurrence of TGN pain continues to be an issue for patients. This project will assess the long-term success of eMVD using the reduction in Barrow Pain Scale score and recurrence rate at 1 yr. METHODS This retrospective chart review aims at exploring the efficacy of eMVD for TGN by studying rates of recurrence in a cohort of 300 patients and comparing them to the literature using descriptive statistics. This is the largest study to date evaluating postoperative recurrence for eMVD for TGN. RESULTS In this cohort, on average, patients reduced their pain scale by 2.99 units on the Barrow Pain Scale. Additionally, 95.5% of patients experienced an immediate pain relief after eMVD surgery, while only 4.3% had no improvement in TGN pain after the procedure. In this eMVD patient cohort, 22% of patients had partial recurrence of TGN pain. CONCLUSION The endoscope seems to provide long-term success for eliminating TGN pain and is at least as successful as traditional MVD. Over 95% of patients with follow-up data experienced an immediate pain relief, indicating that the efficacy of this procedure is excellent. Recurrence rates of TGN pain seem to be comparable to the existing literature on traditional MVD approaches. This cohort had a partial recurrence rate of 22%, while previous MVD studies have shown significant recurrence rates between 3% and 32%. This indicates that significant recurrence rates of TGN need to be further investigated.

scholarly journals A Review of Percutaneous Treatments for Trigeminal Neuralgia

2013 ◽  
Vol 10 (1) ◽  
pp. 25-33 ◽  
Author(s):  
Jason S. Cheng ◽  
Daniel A. Lim ◽  
Edward F. Chang ◽  
Nicholas M. Barbaro
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Pain Control ◽  
Gamma Knife Radiosurgery ◽  
Senior Author ◽  
Complication Rates ◽  
Percutaneous Procedures ◽  
Multiple Treatments ◽  
Effective Pain Relief

Abstract BACKGROUND: Common treatments for trigeminal neuralgia include percutaneous techniques, microvascular decompression, and Gamma Knife radiosurgery. Although microvascular decompression is considered the gold standard for treatment, percutaneous techniques remain an effective option for select patients. OBJECTIVE: To review the historical development, advantages, and limitations of the most common percutaneous procedures for trigeminal neuralgia: balloon compression (BC), glycerol rhizotomy (GR), and radiofrequency thermocoagulation (RF). METHODS: Publications reporting clinical outcomes after BC, GR, and RF were reviewed and included. Operative technique was based on the experience of the primary surgeon and senior author. RESULTS: All 3 percutaneous techniques (BC, GR, and RF) provide effective pain relief but differ in method and specificity of nerve injury. BC selectively injures larger pain fibers while sparing small fibers and does not require an awake, cooperative patient. Pain control rates up to 91% at 6 months and 66% at 3 years have been reported. RF allows somatotopic nerve mapping and selective division lesioning and provides pain relief in up to 97% of patients initially and 58% at 5 years. Multiple treatments improve outcomes but carry significant morbidity risk. GR offers similar pain-free outcomes of 90% at 6 months and 54% at 3 years but with higher complication rates (25% vs 16%) compared with BC. Advantages of percutaneous techniques include shorter procedure duration, minimal anesthesia risk, and in the case of GR and RF, immediate patient feedback. CONCLUSION: Percutaneous treatments for trigeminal neuralgia remain safe, simple, and effective for achieving good pain control while minimizing procedural risk.

A Novel Technical Refinement of Microvascular Decompression: Pain Relief and Complication Rate in a Consecutive Series of Patients With Trigeminal Neuralgia

2020 ◽  
Vol 19 (3) ◽  
pp. 226-233 ◽  
Author(s):  
Francesco Tomasello ◽  
Antonino Germanò ◽  
Angelo Lavano ◽  
Alberto Romano ◽  
Daniele Cafarella ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Complication Rate ◽  
Csf Leak ◽  
Complication Rates ◽  
Patient Reported ◽  
Facial Numbness

Abstract BACKGROUND Microvascular decompression (MVD) represents a milestone for the treatment of trigeminal neuralgia (TN). Nevertheless, several complications still occur and may negatively affect the outcome. We recently proposed some technical nuances for complication avoidance related to MVD. OBJECTIVE To verify the efficacy of the proposed refinement of the standard MVD technique in terms of resolution of the pain and reduction of complication rates. METHODS We analyzed surgical and outcome data of patients with TN using a novel surgical refinement to MVD, over the last 4 yr. Outcome variables included pain relief, facial numbness, muscular atrophy, local cutaneous occipital and temporal pain or numbness, cerebellar injury, hearing loss, cranial nerve deficits, wound infection, and cerebrospinal fluid (CSF) leak. Overall complication rate was defined as the occurrence of any of the aforementioned items. RESULTS A total of 72 consecutive patients were enrolled in the study. Pain relief was achieved in 91.6% and 88.8% of patients at 1- and 4-yr follow-up, respectively. No patient reported postoperative facial numbness during the entire follow-up period. The incidence of CSF leak was 1.4%. One patient developed a complete hearing loss and another a minor cerebellar ischemia. There was no mortality. The overall complication rate was 5.6%, but only 1.4% of patients experienced permanent sequelae. CONCLUSION The proposed refinement of the standard MVD technique has proved effective in maintaining excellent results in terms of pain relief while minimizing the overall complication rate associated with this surgical approach.

scholarly journals Comparison of first-time microvascular decompression with percutaneous surgery for trigeminal neuralgia: long-term outcomes and prognostic factors

2021 ◽  
Author(s):  
Imran Noorani ◽  
Amanda Lodge ◽  
Andrew Durnford ◽  
Girish Vajramani ◽  
Owen Sparrow
Keyword(s):  
Prognostic Factors ◽  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Percutaneous Surgery ◽  
Long Term Outcomes ◽  
Balloon Compression ◽  
Percutaneous Procedures ◽  
First Time

Abstract Objective Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and percutaneous procedures (glycerol rhizolysis; thermocoagulation; and balloon compression). Although the efficacy of each procedure has been documented, direct comparisons of their relative efficacies for TN are lacking. We aimed to directly compare long-term outcomes after first-time MVD with percutaneous surgery in primary (idiopathic and classical) TN and identify predictors of outcome. Methods We conducted a retrospective analysis of prospectively collected data on 185 patients undergoing MVD and 129 undergoing percutaneous surgery. Procedures were performed by one of two neurosurgeons in a single centre; an independent observer collected long-term follow-up data by interviews, using the same outcome measures for all procedures. Results MVD patients were younger than those undergoing percutaneous surgery (P <.001). MVD provided superior initial pain relief (P <.001): 87.0% had Barrow Neurological Institute class I or II pain scores after MVD compared with 67.2% after percutaneous surgery. The complication rate for percutaneous procedures was 35.7% and for MVDs was 24.9% (P =.04), including minor and transient complications. Kaplan-Meier analysis demonstrated that MVD provided longer pain relief than percutaneous procedures (P <.001); 25% of patients had recurrence at 96 months following MVD compared with 12 months after percutaneous surgery. Subgroup analysis showed that balloon compression provided more durable relief amongst percutaneous procedures. Multivariate analysis revealed that post-operative numbness and age were prognostic factors for percutaneous procedures (P =.03 and .01, respectively). Conclusions MVD provides better initial pain relief and longer durability of relief than percutaneous surgery, although carrying a small risk of major complications. Amongst percutaneous procedures, balloon compression gave the most durable relief from pain. Older age and post-operative numbness were predictors of good outcome from percutaneous surgery. These results can help clinicians to counsel patients with primary TN on neurosurgical treatment selection for pain relief.

Predictors of long-term success after microvascular decompression for trigeminal neuralgia

2009 ◽  
Vol 110 (4) ◽  
pp. 620-626 ◽  
Author(s):  
Jonathan P. Miller ◽  
Stephen T. Magill ◽  
Feridun Acar ◽  
Kim J. Burchiel
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Excellent Result ◽  
Preoperative Pain ◽  
Term Outcome ◽  
Long Term Outcome

Object Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia (TN). However, many patients do not experience complete pain relief, and relapse can occur even after an initial excellent result. This study was designed to identify characteristics associated with improved long-term outcome after MVD. Methods One hundred seventy-nine consecutive patients who had undergone MVD for TN at the authors' institution were contacted, and 95 were enrolled in the study. Patients provided information about preoperative pain characteristics including preponderance of shock-like (Type 1 TN) or constant (Type 2 TN) pain, preoperative duration, trigger points, anticonvulsant therapy response, memorable onset, and pain-free intervals. Three groups were defined based on outcome: 1) excellent, pain relief without medication; 2) good, mild or intermittent pain controlled with low-dose medication; and 3) poor, severe persistent pain or need for additional surgical treatment. Results Type of TN pain (Type 1 TN vs Type 2 TN) was the only significant predictor of outcome after MVD. Results were excellent, good, and poor for Type 1 TN versus Type 2 TN patients in 60 versus 25%, 24 versus 39%, and 16 versus 36%, respectively. Among patients with each TN type, there was a significant trend toward better outcome with greater proportional contribution of Type 1 TN (lancinating) symptoms (p < 0.05). Conclusions Pain relief after MVD is strongly correlated with the lancinating pain component, and therefore type of TN pain is the best predictor of long-term outcome after MVD. Application of this information should be helpful in the selection of TN patients likely to benefit from MVD.

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