Trigeminal Neuralgia: Venous Conflict and Recurrence Issue

Microvascular decompression (MVD) is the first choice of treatment of idiopathic trigeminal neuralgia (TN): it is a safe, conservative, and definitively resolutive technique in most cases. However, recurrence of neuralgia after MVD is not an exceptional event. In this study we try to define treatment of recurrences, since there are no unanimously shared guidelines available. We retrospectively studied 257 consecutive TN-affected patients treated by MVD from 1998 to 2005. The population's age ranged from 21 to 87 years, with a mean age of 58 years and a male:female ratio of 1:1. Follow-up ranged from 10 months to 25 years, with an average follow-up of 7.5 years. We observed a recurrence rate of 9% (23 cases). Time between operation and neuralgia recurrence ranged from 3 months to 17 years. In arterious, venous, and both arterious and venous conflicts, recurrence rates were 5% (7 cases), 14% (4 cases), and 17% (10 cases), respectively. Four of 7 patients presenting with arterious conflict successfully underwent MVD again. The remaining 3 patients were not re-explored. None of the 4 patients presenting with venous conflict underwent MVD again cause intraoperative evidence of not displaceable vein. Eight of 10 patients presenting with both arterious and venous conflict were re-explored: a new conflict (venous) was found in only 1 case. In our experience, MVD proves to be the first-choice treatment of TN recurrence when a clear neurovascular conflict was found at previous operation and the implicated vessel was displaceable. Recurrences of TN caused by venous and both arterious and venous conflict need a thorough evaluation of the previous anatomical pattern: in several cases gamma knife or percutaneous treatments can be a reasonable alternative to MVD.