Long-term Results of 405 Refractory Trigeminal Neuralgia Surgeries in 256 Patients

Abstract

Background and Objectives: The initial response of trigeminal neuralgia to medication is about 69%. However drug therapy is ineffective in 25% of patients and about 8% become drug-intolerant. These patients proceed to surgical interventions, which require constant appraisal to determine their efficacy and acceptability. The purpose of this study was to evaluate the long-term outcome of surgical interventions for trigeminal neuralgia to offer a guide to patients and surgeons when choosing the right procedure for the appropriate patient and to investigate the effects of patients’ and surgeons’ preferences on the outcome.

Patients and Methods: The study design was consecutive case review. Participants were 256 consecutive patients with refractory trigeminal neuralgia, who underwent 405 surgical procedures to control trigeminal neuralgia. The main outcome measures were: the response rate, time to pain recurrence and surgical complications. 172 were fit for microvascular decompression (MVD), glycerol injection (GI) or radiofrequency thermocoagulation (RF) and were offered the choice between the three procedures; 95 went for MVD and 77 underwent either GI or RF. The choice between GI and RF was a surgical decision.

Results: The 3-year success rate was 54.8% in patients who underwent GI and 70.7% in patients who underwent percutaneous RF. In contrast 85.6% of patients who underwent MVD remained pain-free at 3 years. The complication rate following these surgical interventions was relatively low with no deaths.

Conclusions: Surgical intervention for the treatment of refractory trigeminal neuralgia is effective and safe and should be considered in patients after failed medical therapy. Whilst MVD offered the best long-term outcome in this series, percutaneous GI or RF offered a safe and reliable alternative for those who chose to undergo these procedures.

Zusammenfassung

Hintergrund und Ziele: Die anfängliche Reaktion der Trigeminusneuralgie auf Medikation beträgt etwa 69%. Die medikamentöse Therapie ist jedoch bei 25% der Patienten ineffektiv und 8% werden gegen die Arzneien intolerant. Diese Patienten setzen die Behandlung mit chirurgischen Eingriffen fort, welche ständige Auswertung benötigen damit sich ihre Wirksamkeit und Eignung ermitteln lässt. Das Ziel dieser Studie war es, Langzeit-Erkenntnisse über chirurgische Eingriffe bei Trigeminusneuralgie zu erhalten, welche Patienten und Chirurgen dabei helfen sollen, die richtige Vorgehensweise für den jeweiligen Patienten zu finden. Die Auswirkung der Erwartungen von Patient und Chirurg an das Resultat wurden ebenfalls untersucht.

Patienten und Methoden: Fortlaufende Fallstudien bildeten den Aufbau der Studie. Teilnehmer waren 256 aufeinander folgende Patienten mit hartnäckiger Trigeminusneuralgie, welche sich insgesamt 405 chirurgischen Eingriffen unterzogen um die rekurrierende Trigeminusneuralgie unter Kontrolle zu bringen. Die wichtigsten Masseinheiten für das Ergebnis waren: Erfolgsquote, Zeit bis zu erneutem Auftreten von Schmerz und chirurgische Komplikationen. 172 Teilnehmer waren für mikrovaskuläre Dekompression (MVD), Glycerin-Injektion (GI) oder Radiofrequenz-Thermokoagulation (RF) geeignet. Ihnen wurde die Wahl zwischen den drei Verfahren gegeben; 95 entschieden sich für MVD und 77 unterzogen sich entweder GI oder RF. Die Wahl zwischen GI und RF war eine chirurgische Entscheidung.

Ergebnisse: Über drei Jahre hinweg hatten GI-Patienten eine Erfolgsquote von 54,8% und Patienten die perkutane RF erhielten 70,7%. Im Gegensatz dazu blieben 85,6% der mit MVD behandelten Patienten auch nach drei Jahren schmerzfrei. Die Rate an durch diese chirurgischen Eingriffe ausgelösten Komplikationen war relativ niedrig, und es waren keine Todesfälle zu beklagen.

Schlussfolgerungen: Chirurgische Eingriffe zur Behandlung von hartnäckiger Trigeminusneuralgie sind wirksam und sicher. Sie sollten bei Patienten mit Trigeminusneuralgie in Erwägung gezogen werden. Während MVD die besten Langzeit-Ergebnisse in dieser Untersuchung zeigte, boten perkutane GI oder RF eine sichere und zuverlässige Alternative für diejenigen an, die sich für diese Behandlungsmethoden entschieden.

Key words

facial pain - glycerol injection - microvascular decompression - neuralgia - radiofrequency - trigeminal nerve

Schlüsselwörter

Gesichtsschmerz - Glycerol-Injektion - mikrovaskuläre Dekompression - Neuralgie - Trigeminus

References

• 1 Apfelbaum RI. A comparison of percutaneous radiofrequency trigeminal neurolysis and microvascular decompression of the trigeminal nerve for the treatment of tic douloureux.  Neurosurgery. 1977;  1 16-21
• 2 Ashkan K, Marsh H. Microvascular decompression for trigeminal neuralgia in the elderly: a review of the safety and efficacy.  Neurosurgery. 2004;  55 840-848
• 3 Balansard ChF, Meller R, Bruzzo M, Chays A, Girard N, Magnan J. Trigeminal neuralgia: results of microsurgical and endoscopic-assisted vascular decompression.  Ann Oto-Lar Chir Cerv-Fac. 2003;  120 330-337
• 4 Barker FG, Jannetta PJ, Bissonette PJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia.  N Engl J Med. 1996;  334 ((17)) 1077-1083
• 5 Barolat G, Knobler RL, Lublin FD. Trigeminal neuralgia in a patient with multiple sclerosis treated with high cervical spinal cord stimulation. Case report.  Appl Neurophy. 1988;  51 333-337
• 6 Burchiel KJ, Clarke H, Hagland M, Loeser JD. Long-term efficacy of microvascular decompression in trigeminal neuralgia.  J Neurosurg. 1988;  69 35-38
• 7 Fisher A, Zakrzewska JM, Patsalos PN. Trigeminal neuralgia: current treatments and future developments.  Exp Op Emerg Drug. 2003;  8 123-143
• 8 Grazzi L, Usai S, Rigamonti A. Facial pain in children and adolescents.  Neurol Scien. 2005;  26 ((Suppl 2)) 101-103
• 9 Goss BW, Frighetto L, DeSalles AAF, Smith Z, Solberg T, Selch M. Linear accelerator radiosurgery using 90 Grays for essential trigeminal neuralgia: results and dose volume histogram analysis.  Neurosurgery. 2003;  53 823-830
• 10 Hall WA, Orner JB, Gerbi BJ, Dusenbery KE. Long-term follow-up of trigeminal neuralgia treatment using a linear accelerator.  Stereot Funct Neurosurg. 2004;  82 244-249
• 11 Hakanson S. Trigeminal neuralgia treated by the injection of glycerol into the trigeminal cistern.  Neurosurgery. 1981;  9 638-646
• 12 Hitotsumatsu T, Matsushima T, Inoue T. Microvascular decompression for treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia: three surgical approach variations: technical note.  Neurosurgery. 2003;  53 1436-1441
• 13 Hosobuchi Y, Adams JE, Rutkin B. Chronic thalamic stimulation for the control of facial anesthesia dolorosa.  Arch Neurol. 1973;  29 158-161
• 14 Janetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia.  J Neurosurg. 1967;  26 ((Suppl)) 159-162
• 15 Kalkanis SN, Eskandar EN, Carter BS, Barker FG. Microvascular decompression surgery in the United States, 1996–2000: mortality rates and the effects of hospital and surgeon volumes.  Neurosurgery. 2003;  52 1251-1256
• 16 Kobayashi T, Mori Y, Kida Y. Gamma Knife radiosurgery.  Gan Kagaku Ryoho [Jap J Can Chem]. 2003;  30 2043-2049
• 17 Kondziolka D, Lunsford LD, Flickinger JC. Stereotactic radiosurgery for the treatment of trigeminal neuralgia.  Clin J Pain. 2002;  18 42-47
• 18 Lopes PG, Castro Jr ES, Lopes LH. Trigeminal neuralgia in children: two case reports.  Neurology. 2002;  26 309-310
• 19 Lopez BC, Hamlyn PJ, Zakrzewska JM. Stereotactic radiosurgery for primary trigeminal neuralgia: state of the evidence and recommendations for future reports.  J Neurol Neurosurg Psych. 2004;  75 1019-1024
• 20 Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia.  Neurosurgery. 2004;  54 973-982
• 21 MacLaughlin MR, Jannetta PJ, Clyde BL, Subach BR, Comay CH, Resnick DK. Microvascular decompression of cranial nerves: lessons learned after 4400 operations.  J Neurosurg. 1999;  90 ((1)) 1-8
• 22 Meglio M, Cioni B, Moles A, Visocchi M. Microvascular decompression versus percutaneous procedures for typical trigeminal neuralgia; personal experience.  Stereotact Funct Neurosurg. 1990;  55 76-79
• 23 Mullan S, Lichtor T. Percutaneous microcompression of the trigeminal ganglion for trigeminal neuralgia.  J Neurosurg. 1989;  59 1007-1012
• 24 Pollock BE. Percutaneous retrogasserian glycerol rhizotomy for patients with idiopathic trigeminal neuralgia; a prospective analysis of factors related to pain relief.  J Neurosurg. 2005;  102 223-228
• 25 Pollock B, Ecker R. A prospective cost-effectiveness study of trigeminal neuralgia surgery.  Clin J Pain. 2005;  21 317-322
• 26 Rainov NG, Heidecke V. Motor cortex stimulation for neuropathic facial pain.  Neurolog Res. 2003;  25 157-161
• 27 Roldan P, Broseta J, Barcia-Salorio JL. Chronic VPM stimulation for anesthesia dolorosa following trigeminal surgery.  Appl Neurophy. 1982;  45 112-113
• 28 Sindou M, Howeidy T, Aceverdo G. Anatomical observations during microvascular decompression for idiopathic trigeminal neuralgia (with correlation between topography of pain and site of microvascular conflict). Prospective study in a series of 579 patients.  Acta Neurochir (Wien). 2002;  144 ((1)) 1-12
• 29 Sindou M, Leston J, Howeidy T, Decullier E, Chapuis F. Microvascular decompression for primary trigeminal neuralgia (typical or atypical), long-term effectiveness on pain, prospective study with survival analysis in a consecutive series of 362 patients.  Acta Neurochir (Wien). 2006;  148 ((12)) 1235-1245
• 30 Taylor JC, Brauer S, Espir ML. Long-term treatment of trigeminal neuralgia with carbamazepine.  Postgr Med J. 1981;  57 16-18
• 31 Theodosopoulos PV, Marco E, Applebury C, Lamborn KR, Wilson CB. Predictive model for pain recurrence after posterior fossa surgery for trigeminal neuralgia.  Arch Neurol. 2002;  59 1297-1302
• 32 Tronnier VM, Rasche D, Hamer J, Kienle A-L, Kunze S. Treatment of idiopathic trigeminal neuralgia; comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression.  Neurosurgery. 2001;  48 1261-1267
• 33 Tyler-Kabra EC, Kassam A. 845 management of trigeminal neuralgia; predictors of outcome for microvascular decompression.  Neurosurgery. 2000;  47 541-542
• 34 Loveren H van, Tew Jr JM, Keller JT, Nurre MA. A 10-year experience in the treatment of trigeminal neuralgia; comparison of percutaneous stereotactic rhizotomy and posterior fossa exploration.  J Neurosurg. 1982;  57 757-764
• 35 Waidhauser E, Steude U. Evaluation of patients with atypical trigeminal neuralgia for permanent electrode implant by test stimulation of the ganglion gasseri.  Stereot Funct Neurosurg. 1994;  62 304-308
• 36 Zakrzewska JM. Quality of reporting in evaluation of surgical treatment of trigeminal neuralgia: recommendations for future reports.  Neurosurgery. 2003;  53 973-982

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