MICROVASCULAR DECOMPRESSION FOR TRIGEMINAL NEURALGIA IN THE ELDERLY

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.

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

Acta Neurochirurgica ◽

10.1007/s00701-021-05028-2 ◽

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.

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

Journal of Neurosurgery ◽

10.3171/2008.9.17660 ◽

2009 ◽

Vol 110 (4) ◽

pp. 620-626 ◽

Cited By ~ 60

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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The long-term outcome of microvascular decompression for trigeminal neuralgia

British Journal of Neurosurgery ◽

10.3109/02688690903370289 ◽

2010 ◽

Vol 24 (1) ◽

pp. 18-25 ◽

Cited By ~ 66

Author(s):

Zaid Sarsam ◽

Marta Garcia-Fiñana ◽

Turo J. Nurmikko ◽

Thelekat R. K. Varma ◽

Paul Eldridge

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Term Outcome ◽

Long Term Outcome

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Commentary: Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression

Neurosurgery ◽

10.1093/neuros/nyz446 ◽

2019 ◽

Vol 87 (1) ◽

pp. E12-E13

Author(s):

Xiaofei Zhou ◽

Jonathan Pace ◽

Jonathan Miller

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Scoring System ◽

Term Outcome ◽

Long Term Outcome

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The Long-Term Outcome of 3-Dimensional CT-Guided Percutaneous Radiofrequency Thermocoagulation for Tumor-Related Trigeminal Neuralgia

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.e467 ◽

2019 ◽

Vol 5 (22;5) ◽

pp. E467-E475

Author(s):

Luo Fang

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Small Sample ◽

Cochrane Library ◽

Gasserian Ganglion ◽

Term Outcome ◽

Long Term Outcome ◽

Ct Guided ◽

Radiofrequency Thermocoagulation

Background: Percutaneous radiofrequency thermocoagulation (PRFT) has been widely used to treat trigeminal neuralgia. By querying MEDLINE, EMBASE, and the Cochrane Library, no study has reported the long-term outcome of PRFT for tumor-related trigeminal neuralgia (TRTN). Objectives: In this study, we aimed to evaluate the long-term efficacy and safety of PRFT as an alternative treatment for TRTN. Study Design: A retrospective study. Setting: The interventional pain management center in Beijing Tiantan hospital. Methods: We retrospectively analyzed data of all patients who underwent PRFT applied to the Gasserian ganglion under computed tomography guidance for TRTN through a combination of available institutional electronic medical records, patient notes, and radiologic images. Results: Among 38 patients with PRFT treated between March 2007 and February 2018, 13 patients were men and 25 were women. All patients were evaluated as modified Barrow Neurological Institute (BNI) IV-V before the operation and had a total symptom duration of 45.55 ± 23.31 months. The mean operation duration was 59.63 ± 16.89 minutes. All patients experienced satisfactory pain relief defined as a classification of BNI I-IIIb within 3 days after PRFT. The median remission length with satisfactory pain relief was 33 (range, 4-132) months. No serious intraoperative complications, except bradycardia in 6 patients, were recorded. Postprocedure complications, including masticatory muscle weakness, were reported in 5 patients. Although all 38 patients experienced facial dysesthesia, the patients’ Likert scale rating represented that quality of life significantly increased after the procedure. Limitations: The small sample size may have unavoidably caused selection bias in our study. Larger prospective, randomized, multicenter trials are necessary to validate our outcomes. Conclusions: PRFT is an effective and safe treatment that should be considered as an alternative for pain control in the treatment of TRTN. Key words: Pain, secondary trigeminal neuralgia, radiofrequency thermocoagulation, trigeminal neuralgia

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Surgical Outcomes After Microvascular Decompression With Internal Neurolysis and Partial Neurectomy for Patients With Trigeminal Neuralgia and Negative Neurovascular Compression

Neurosurgery ◽

10.1093/neuros/nyz310_450 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Amanda Carpenter ◽

James K Liu

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Neurovascular Compression ◽

Term Outcome ◽

Long Term Outcome ◽

Root Entry Zone ◽

Internal Neurolysis ◽

Facial Numbness

Abstract INTRODUCTION Microvascular decompression (MVD) is an effective and durable treatment for patients with trigeminal neuralgia (TN) due to neurovascular compression (NVC). In the absence of NVC, the traditional MVD is less effective in achieving long-term pain relief. Internal neurolysis at the root entry zone (REZ) of the trigeminal nerve has been described in the literature; however, there are few reports of long-term outcome after this procedure. Furthermore, this is the first study to combine this procedure with additional partial neurectomy. METHODS This is a retrospective review of the senior author's patients with TN who underwent retrosigmoid craniectomy for MVD with internal neurolysis and partial neurectomy. Primary indications were patients with TN and no evidence of NVC intraoperatively. A total of 9 patients were included in the analysis. Three cases were of recurrent TN. The technique was performed with an 11-blade or arachnoid knife to open the perineurium in a longitudinal fashion at the REZ. A disc dissector was used to comb the fascicles along the longitudinal course, and a partial neurectomy was performed with a microscissors to make three selective cuts into the fascicles at the REZ. Barrow Neurological Institute (BNI) facial pain and numbness scales were used as postoperative assessment. RESULTS At median follow up of 12 mo (range: 2 to 34), 8 of 9 patients (89%) had a BNI-pain score of I (no trigeminal pain, no medications). Two of nine patients (22%) had a BNI-numbness score of I (no numbness); seven (78%) had a BNI-numbness score of II (mild facial numbness that is not bothersome). CONCLUSION Internal neurolysis with partial neurectomy appears to be an effective and potentially durable treatment option for patients with TN (primary or recurrent) without NVC. Larger series with longer follow-up is indicated to further evaluate the utility of this procedure.

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