Trigeminal Neuralgia Type 1: Earlier Microvascular Decompression is Associated with Improved Outcome

Abstract BACKGROUND Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood. OBJECTIVE To describe rates and predictors for pain freedom following MVD. METHODS Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors. RESULTS Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67). CONCLUSION Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations.

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Typical Trigeminal Neuralgia: Comparison of Results between Patients Older and Younger than 65 Years Operated on with Microvascular Decompression by Retrosigmoid Approach

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1693126 ◽

2019 ◽

Vol 81 (01) ◽

pp. 028-032 ◽

Cited By ~ 1

Author(s):

Luciano Mastronardi ◽

Franco Caputi ◽

Alessandro Rinaldi ◽

Guglielmo Cacciotti ◽

Raffaelino Roperto ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Cerebrospinal Fluid Leak ◽

The Elderly ◽

Retrosigmoid Approach ◽

Younger Patients ◽

Significant Difference ◽

Elderly Cohort

Abstract Objective The incidence of typical trigeminal neuralgia (TN) increases with age, and neurologists and neurosurgeons frequently observe patients with this disorder at age 65 years or older. Microvascular decompression (MVD) of the trigeminal root entry zone in the posterior cranial fossa represents the etiological treatment of typical TN with the highest efficacy and durability of all treatments. This procedure is associated with possible risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the alternative ablative procedures. Thus the safety of MVD in the elderly remains a topic of discussion. This study was conducted to determine whether MVD is a safe and effective treatment in older patients with TN compared with younger patients. Methods In this retrospective study, 28 patients older than 65 years (elderly cohort: mean age 70.9 ± 3.6 years) and 38 patients < 65 years (younger cohort: mean age 51.7 ± 6.3 years) underwent MVD via the keyhole retrosigmoid approach for type 1 TN (typical) or type 2a TN (typically chronic) from November 2011 to November 2017. A 75-year-old patient and three nonelderly patients with type 2b TN (atypical) were excluded. Elderly and younger cohorts were compared for outcome and complications. Results At a mean follow-up 26.0 ± 5.5 months, 25 patients of the elderly cohort (89.3%) reported a good outcome without the need for any medication for pain versus 34 (89.5%) of the younger cohort. Twenty-three elderly patients with type 1 TN were compared with 30 younger patients with type 1 TN, and no significant difference in outcomes was found (p > 0.05). Five elderly patients with type 2a TN were compared with eight younger patients with type 2a TN, and no significant difference in outcomes was noted (p > 0.05). There was one case of cerebrospinal fluid leak and one of a cerebellar hematoma, both in the younger cohort. Mortality was zero in both cohorts. Conclusions On the basis of our experience and the international literature, age itself does not seem to represent a major contraindication of MVD for TN.

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Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis

Journal of Neurosurgery ◽

10.3171/2010.6.jns10142 ◽

2011 ◽

Vol 114 (1) ◽

pp. 172-179 ◽

Cited By ~ 67

Author(s):

Raymond F. Sekula ◽

Andrew M. Frederickson ◽

Peter J. Jannetta ◽

Matthew R. Quigley ◽

Khaled M. Aziz ◽

...

Keyword(s):

Systematic Review ◽

Trigeminal Neuralgia ◽

Elderly Patients ◽

Prospective Study ◽

Microvascular Decompression ◽

Cranial Nerve ◽

Meta Analysis ◽

Complication Rates ◽

Significant Difference

Object Because the incidence of trigeminal neuralgia (TN) increases with age, neurosurgeons frequently encounter elderly patients with this disorder. Although microvascular decompression (MVD) is the only etiological therapy for TN with the highest initial efficacy and durability of all treatments, it is nonetheless associated with special risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the commonly performed ablative procedures. Thus, the safety of MVD in the elderly remains a concern. This prospective study and systematic review with meta-analysis was conducted to determine whether MVD is a safe and effective treatment in elderly patients with TN. Methods In this prospectively conducted analysis, 36 elderly patients (mean age 73.0 ± 5.9 years) and 53 nonelderly patients (mean age 52.9 ± 8.8 years) underwent MVD over the study period. Outcome and complication data were recorded. The authors also conducted a systematic review of the English literature published before December 2009 and providing outcomes and complications of MVD in patients with TN above the age of 60 years. Pooled complication rates of stroke, death, cerebellar hematoma, and permanent cranial nerve deficits were analyzed. Results Thirty-one elderly patients (86.1%) reported an excellent outcome after MVD (mean follow-up 20.0 ± 7.0 months). Twenty-five elderly patients with Type 1 TN were compared with 26 nonelderly patients with Type 1 TN, and no significant difference in outcomes was found (p = 0.046). Three elderly patients with Type 2a TN were compared with 12 nonelderly patients with Type 2a TN, and no significant difference in outcomes was noted (p = 1.0). Eight elderly patients with Type 2b TN were compared with 15 nonelderly patients with Type 2b TN, and no significant difference in outcomes was noted (p = 0.086). The median length of stay between cohorts was compared, and no significant difference was noted (2 days for each cohort, p = 0.33). There were no CSF leaks, no cerebellar hematomas, no strokes, and no deaths. Eight studies (1334 patients) met the inclusion criteria for the meta-analysis. For none of the complications was the incidence significantly more frequent in elderly patients than in the nonelderly. Conclusions Although patient selection remains important, the authors' experience and the results of this systematic review with meta-analysis suggest that the majority of elderly patients with TN can safely undergo MVD.

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Classification of trigeminal neuralgia: clinical, therapeutic, and prognostic implications in a series of 144 patients undergoing microvascular decompression

Journal of Neurosurgery ◽

10.3171/2008.6.17604 ◽

2009 ◽

Vol 111 (6) ◽

pp. 1231-1234 ◽

Cited By ~ 65

Author(s):

Jonathan P. Miller ◽

Feridun Acar ◽

Kim J. Burchiel

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Postoperative Outcome ◽

Clinical Analysis ◽

New Paradigm ◽

Diagnostic Challenge ◽

Duration Of Symptoms

Object Trigeminal neuralgia (TN) presents a diagnostic challenge because of the variety of symptoms, findings during microvascular decompression (MVD), and postsurgical outcomes observed among patients who suffer from this disorder. Recently, a new paradigm for classification of TN was proposed, based on the quality of pain. This study represents the first clinical analysis of this paradigm. Methods The authors analyzed 144 consecutive cases involving patients who underwent MVD for TN. Preoperative symptoms were classified into 1 of 2 categories based on the preponderance of shocklike (Type 1 TN) or constant (Type 2 TN) pain. Analysis of clinical characteristics, neurovascular pathology, and postoperative outcome was performed. Results Compared with Type 2 TN, Type 1 TN patients were older, were more likely to have right-sided symptoms, and reported a shorter duration of symptoms prior to evaluation. Previous treatment by percutaneous or radiosurgical procedures was not a predictor of symptoms, surgical findings, or outcome (p = 0.48). Type 1 TN was significantly more likely to be associated with arterial compression. Venous or no compression was more common among Type 2 TN patients (p < 0.01). Type 1 TN patients were also more likely to be pain-free immediately after surgery, and less likely to have a recurrence of pain within 2 years (p < 0.05). Although a subset of patients progressed from Type 1 to Type 2 TN over time, their pathological and prognostic profiles nevertheless resembled those of Type 1 TN. Conclusions Type 1 and Type 2 TN represent distinct clinical, pathological, and prognostic entities. Classification of patients according to this paradigm should be helpful to determine how best to treat patients with this disorder.

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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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Typical trigeminal neuralgia in patients older than 65: Safety and efficacy of microvascular decompression by the retrosigmoid approach

Indonesian Journal of Neurosurgery ◽

10.15562/ijn.v1i1.2 ◽

2018 ◽

Vol 1 (1) ◽

Author(s):

Luciano Mastronardi ◽

Franco Caputi ◽

Alessandro Rinaldi ◽

Guglielmo Cacciotti

Keyword(s):

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

The Elderly ◽

Retrosigmoid Approach ◽

Csf Leak ◽

Old Patients ◽

Younger Patients ◽

Significant Difference

AbstractOBJECT: Incidence of typical trigeminal neuralgia (TN) increases with age and neurologists and neurosurgeons frequently observe patients with this disorder at the age of 65 or more. Microvascular decompression (MVD) of the trigeminal root entry zone in posterior cranial fossa is the only etiological therapy for typical TN with the highest efficacy and durability of all treatments. This procedure is associated with possible risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the alternative ablative procedures. Thus, the safety of MVD in the elderly remains non definitively demonstrated. This study was conducted to determine whether MVD is a safe and effective treatment in elderly patients with TN in comparison to younger patients.METHODS: In this retrospective study, 25 patients older than 65 (mean age 70.1 ± 3.7 years) and 32 aging <65 (mean age 51.1 ± 6.2 years) underwent MVD by key-hole retrosigmoid approach for Type 1 TN (typical) or Type 2a TN (typical chronicized) from November 2011 to November 2016. A 75 y-o patient had Type 2b TN (atypical) versus 3 nonelderly patients were excluded. Elderly and younger groups were compared in relation to outcome and complication data.RESULTS: At a mean follow-up 23.0 ± 5.5 months, 22 old patients (88%) reported a very good outcome without necessity of any medication for pain, versus 28 (87,5%) of the younger group. Twenty elderly patients with Type 1 TN were compared with 24 younger patients with Type 1 TN, and no significant difference in outcomes was found (p > 0.05). Five elderly patients with Type 2a TN were compared with 8 younger patients with Type 2a TN, and no significant difference in outcomes was noted (p > 0.05). There was one case of CSF leak and one case of cerebellar hematoma both in the younger cohort. Mortality was zero in both groups.CONCLUSIONS: On the basis of our experience and of the international literature, age itself seems not to represent a major contraindication against MVD for TN. Keywords: Elderly, Microvascular Decompression, Retrosigmoid approach, Trigeminal neuralgia, Tic douloureux

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