EFFECT OF MICROVASCULAR DECOMPRESSION IN TRIGEMINAL NEURALGIA PATIENTS WITH OR WITHOUT CONSTANT PAIN

ABSTRACT OBJECTIVE To study the effect of microvascular decompression (MVD) in trigeminal neuralgia (TN) patients with or without constant pain. METHODS The study includes all first-time MVDs for facial pain performed by the senior author (PKE) during the 6-year period from 1999 to 2005 in the Department of Neurosurgery at the National Hospital. At the time of follow-up, pain relief was assessed using a standard mail questionnaire; those patients still having residual pain were further examined in the outpatient clinic or interviewed by phone. RESULTS The total study population includes 135 patients who underwent initial MVDs (67% of MVDs for TN without constant pain and 33% of MVDs for TN with constant pain). At the time of follow-up, the response rate was 95%, which provided us with 128 patients. The median observation period was 38 months (range, 12–87 mo). For episodic pain, MVD caused complete (i.e., 100%) pain relief in 78% of TN patients without constant pain and in 77% of TN patients with constant pain before MVD, and a significant pain relief (i.e., worst pain marked as 0–3 cm on a 10-cm visual analog scale) in 85 and 81%, respectively. For constant pain, MVD caused complete pain relief in 70% of the TN patients with constant pain before MVD, and significant pain relief in 77%. CONCLUSION In TN patients with constant pain before MVD, significant relief of episodic and constant pain was observed in 81 and 77%, respectively. Hence, the presence of constant pain should not prevent TN patients from being offered MVD.

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The Effect of Microvascular Decompression in Patients With Multiple Sclerosis and Trigeminal Neuralgia

Neurosurgery ◽

10.1227/01.neu.0000375491.81803.5d ◽

2010 ◽

Vol 67 (3) ◽

pp. 749-754 ◽

Cited By ~ 33

Author(s):

Tiril Sandell ◽

Per Kristian Eide

Keyword(s):

Multiple Sclerosis ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Senior Author ◽

Preoperative Pain ◽

Entry Zone ◽

Root Entry Zone ◽

Constant Pain ◽

First Time

Abstract BACKGROUND Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is thought to be caused by demyelinating plaques within the nerve root entry zone, the trigeminal nucleus, or the trigeminal tracts. OBJECTIVE To review our experience of microvascular decompression (MVD) in patients with MS and symptomatic TN. METHODS All first-time MVDs for symptomatic trigeminal neuralgia in patients with MS performed by the senior author during an 8-year period (1999–2007) in this department were reviewed. The preoperative pain components were differentiated as being 100% episodic pain, > 50% episodic pain, or > 50% constant pain. At follow-up, pain relief was assessed with a standard mail questionnaire; those still having residual pain were further examined in the outpatient clinic or interviewed by phone. RESULTS Of the 19 MS patients, 15 were available for follow-up. The median observation period was 55 months (range, 17–99 months). At follow-up, 7 of 15 patients (47%) were completely free of their episodic pain, and an additional 4 (27%) had significant relief of episodic pain (ie, worst pain marked as 0 to 3 cm on a 10-cm visual analog scale). Among the subgroup of 8 patients with a constant pain component, all were free of their constant pain, and 4 (50%) were free of their episodic pain. CONCLUSION In our 8-year experience of doing MVD in MS patients with TN, we found complete and significant relief of episodic TN in a large proportion of patients. Even those with a constant pain component before MVD were completely relieved of their constant pain. Thus, in patients with TN (with or without a constant pain component), the presence of MS should not prevent patients from being offered MVD.

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

Journal of Neurosurgery ◽

10.3171/jns.2002.96.3.0527 ◽

2002 ◽

Vol 96 (3) ◽

pp. 527-531 ◽

Cited By ~ 153

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.

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C.07 Trigeminal neuralgia due to dolichoectatic vertebrobasilar artery compression: a 20 year experience

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.85 ◽

2017 ◽

Vol 44 (S2) ◽

pp. S14-S14

Author(s):

CM Honey ◽

AM Kaufmann

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Senior Author ◽

High Rate ◽

Hospital Length Of Stay ◽

Case Volume ◽

Average Hospital ◽

Vertebrobasilar Artery

Background: Trigeminal Neuralgia (TN) is rarely caused by a dolichoectatic vertebrobasilar artery (eVB) compression of the trigeminal nerve. These patients present a surgical challenge and are often not considered for microvascular decompression (MVD) due to assumed risk. We present our experience demonstrating the technique and outcomes of MVD in these patients. Methods: A retrospective chart review of patients who were surgically treated by the senior author between 1997 and 2016 with an admitting diagnosis of TN was performed. Patients with pre-operative neuroimaging demonstrating eVB compression of their trigeminal nerve root were included. Results: During the 20-year review, 552 patients underwent microvascular decompression for TN and 13 (2.4%) had dolichoectactic vertebrobasilar compressions (10 male, 3 female). The average hospital length of stay was 2.8 days (Range 2-7) with no major complications. At final follow-up (>2 years): 7 had no pain with no medications (78%), 2 had persistent pain (22%) – one of which underwent a successful glycerol rhizotomy at 8 months, 2 were lost to follow-up, and 2 had surgery within 2 years. Conclusions: Microvascular Decompression for Trigeminal Neuralgia caused by a dolichoectatic vertebrobasilar artery can be performed with a high rate of safety and success in the setting of a high case volume centre.

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A Review of Percutaneous Treatments for Trigeminal Neuralgia

Operative Neurosurgery ◽

10.1227/neu.00000000000001687 ◽

2013 ◽

Vol 10 (1) ◽

pp. 25-33 ◽

Cited By ~ 17

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.

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

Operative Neurosurgery ◽

10.1093/ons/opaa044 ◽

2020 ◽

Vol 19 (3) ◽

pp. 226-233 ◽

Cited By ~ 2

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.

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Long-term pain outcomes for recurrent idiopathic trigeminal neuralgia after stereotactic radiosurgery: a prospective comparison of first-time microvascular decompression and repeat stereotactic radiosurgery

Journal of Neurosurgery ◽

10.3171/2018.5.jns172243 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1207-1215 ◽

Cited By ~ 1

Author(s):

Kunal P. Raygor ◽

Doris D. Wang ◽

Mariann M. Ward ◽

Nicholas M. Barbaro ◽

Edward F. Chang

Keyword(s):

Trigeminal Neuralgia ◽

Stereotactic Radiosurgery ◽

San Francisco ◽

Microvascular Decompression ◽

Favorable Outcome ◽

Prospective Comparison ◽

Pain Outcomes ◽

Sensory Changes ◽

First Time

OBJECTIVEMicrovascular decompression (MVD) and stereotactic radiosurgery (SRS) are common surgical treatments for trigeminal neuralgia (TN). Many patients who receive SRS have pain recurrence; the ideal second intervention is unknown. The authors directly compared pain outcomes after MVD and repeat SRS in a population of patients in whom SRS failed as their first-line procedure for TN, and they identified predictors of pain control.METHODSThe authors reviewed a prospectively collected database of patients undergoing surgery for TN between 1997 and 2014 at the University of California, San Francisco (UCSF). Standardized data collection focused on preoperative clinical characteristics, surgical characteristics, and postoperative outcomes. Patients with typical type 1, idiopathic TN with ≥ 1 year of follow-up were included.RESULTSIn total, 168 patients underwent SRS as their first procedure. Of these patients, 90 had residual or recurrent pain. Thirty of these patients underwent a second procedure at UCSF and had ≥ 1 year of follow-up; 15 underwent first-time MVD and 15 underwent repeat SRS. Patients undergoing MVD were younger than those receiving repeat SRS and were more likely to receive ≥ 80 Gy during the initial SRS. The average follow-up was 44.9 ± 33.6 months for MVD and 48.3 ± 45.3 months for SRS. All patients achieved complete pain freedom without medication at some point during their follow-up. At last follow-up, 80% of MVD-treated patients and 33.3% of SRS-treated patients had a favorable outcome, defined as Barrow Neurological Institute Pain Intensity scores of I–IIIa (p < 0.05). Percentages of patients with favorable outcome at 1 and 5 years were 86% and 75% for the MVD cohort and 73% and 27% for the SRS cohort, respectively (p < 0.05). Multivariate Cox proportional hazards analysis demonstrated that performing MVD was statistically significantly associated with favorable outcome (HR 0.12, 95% CI 0.02–0.60, p < 0.01). There were no statistically significant predictors of favorable outcome in the MVD cohort; however, the presence of sensory changes after repeat SRS was associated with pain relief (p < 0.01).CONCLUSIONSPatients who received MVD after failed SRS had a longer duration of favorable outcome compared to those who received repeat SRS; however, both modalities are safe and effective. The presence of post-SRS sensory changes was predictive of a favorable pain outcome in the SRS cohort.

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

Acta Neurochirurgica ◽

10.1007/s00701-021-04793-4 ◽

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.

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Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery

Neurosurgical FOCUS ◽

10.3171/2020.7.focus20446 ◽

2020 ◽

Vol 49 (4) ◽

pp. E23

Author(s):

Kunal P. Raygor ◽

Anthony T. Lee ◽

Noah Nichols ◽

Doris D. Wang ◽

Mariann M. Ward ◽

...

Keyword(s):

Adverse Event ◽

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Pain Control ◽

The Elderly ◽

Surgical Treatments ◽

First Time

OBJECTIVECommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly.METHODSA prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up.RESULTSOne hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I–IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control.CONCLUSIONSIn this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient’s unique condition and wishes.

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Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis

Neurosurgical FOCUS ◽

10.3171/foc.2005.18.5.14 ◽

2005 ◽

Vol 18 (5) ◽

pp. 1-5 ◽

Cited By ~ 39

Author(s):

Jason S. Cheng ◽

Rene O. Sanchez-Mejia ◽

Mary Limbo ◽

Mariann M. Ward ◽

Nicholas M. Barbaro

Keyword(s):

Multiple Sclerosis ◽

Radiofrequency Ablation ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

San Francisco ◽

Clinical History ◽

Senior Author ◽

Electrical Shock ◽

Complete Pain Relief

Object Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief. Methods Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V). Conclusions Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.

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Neurapraxia in patients with trigeminal neuralgia but no identifiable neurovascular conflict during microvascular decompression: a retrospective analysis of 26 cases

BMC Surgery ◽

10.1186/s12893-022-01469-3 ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Juan Li ◽

Min Zhou ◽

Yuhai Wang ◽

Sze Chai Kwok ◽

Jia Yin

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Herpes Labialis ◽

Efficacy And Safety ◽

Neurovascular Conflict ◽

Aneurysm Clip ◽

First Choice ◽

Trigeminal Nerve Root

Abstract Background Microvascular decompression (MVD) is the first choice in patients with classic trigeminal neuralgia (TGN) that could not be sufficiently controlled by pharmacological treatment. However, neurovascular conflict (NVC) could not be identified during MVD in all patients. To describe the efficacy and safety of treatment with aneurysm clips in these situations. Methods A total of 205 patients underwent MVD for classic TGN at our center from January 1, 2015 to December 31, 2019. In patients without identifiable NVC upon dissection of the entire trigeminal nerve root, neurapraxia was performed using a Yasargil temporary titanium aneurysm clip (force: 90 g) for 40 s (or a total of 60 s if the process must be suspended temporarily due to bradycardia or hypertension). Results A total of 26 patients (median age: 64 years; 15 women) underwent neurapraxia. Five out of the 26 patients received prior MVD but relapsed. Immediate complete pain relief was achieved in all 26 cases. Within a median follow-up of 3 years (range: 1.0–6.0), recurrence was noted in 3 cases (11.5%). Postoperative complications included hemifacial numbness, herpes labialis, masseter weakness; most were transient and dissipated within 3–6 months. Conclusions Neurapraxia using aneurysm clip is safe and effective in patients with classic TGN but no identifiable NVC during MVD. Whether this method could be developed into a standardizable method needs further investigation.

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