Microvascular decompression in the treatment of essential trigeminal neuralgia

INTRODUCTION AND OBJECTIVE: We pretend to evaluate the surgical procedure and clinical results of microvascular decompression (MVD) of 21 patients suffering from essential trigeminal neuralgia between 1989 and 1997. PATIENTS AND METHODS: Selection criteria included: ineffectiveness of pharmacological treatment, good general condition, more than five years life expectancy, and do not have undergone ablative-lesive surgical procedures before. RESULTS: After a post-surgical follow-up of between three months and three years, it was obtained a 100% success rate of immediate pain relief, with only a 14.2% recurrence. There were no sequels as those typically found in lesive techniques as paresthesias and dysesthesias, painful and/or corneal anaesthesia and motor disorders. There were no deaths, although there were three cases of post-surgical complications. CONCLUSIONS: To evaluate the long-term results of different surgical techniques in the treatment of the essential trigeminal neuralgia is outstanding the patients satisfaction rate, which not only depends on pain relief and absence of recurrence, but also and very specially on the neurological deficiencies following the procedure. So, we consider that MVD is the most effective technique both in symptoms relief and neural functions and structures preservation, even though the possibility of appearance of complications following any major surgery.     

Diagnosis and treatment of the patient with trigeminal neuralgia

Lipid-loaded macrophages were produced in vitro by incubation with acetylated or copper-oxidized LDL. In order to establish whether cellular membrane traffic is generally perturbed by such loading, we assessed endocytosis of fluid; cell surface binding, internalisation and degradation of a soluble ligand and of a particulate preparation; and exocytosis of lysosmal enzymes. Fluid-phase pinocytosis of sucrose was unaffected by either form of loading. Binding, uptake and degradation of soluble (mannosylated-BSA) and particulate (zymosan) ligands by these lipid-loaded and by non-loaded cells were compared. Loading with oxidized LDL decreased the processing of both ligands, while loading with acetylated LDL had little effect. Loading with oxidized LDL (Ox-LDL) also decreased zymosan binding at 4 degrees C; and the internalisation and degradation of ligands in Ox-LDL loaded and non-loaded cells reflected the extent of surface binding. Changes in binding and uptake of mannosylated-BSA and zymosan were not due to changes in viability or cell number. Zymosan stimulated release of lysosomal beta-N-acetyl-D-glucosaminidase from the cells. Loading with Ox- but not Ac-LDL decreased beta-N-acetyl-D-glucosaminidase secretion. After incubation with zymosan, intracellular levels of the enzyme were increased in the Ox-LDL loaded cells. Zymosan uptake and beta-N-acetyl-D-glucosaminidase secretion were correlated, but enzyme activity per culture rose more in the absence than in the presence of zymosan. We conclude that membrane traffic is perturbed in model foam cells, particularly those loaded with Ox-LDL.     

Surgical versus medical treatment of idiopathic trigeminal neuralgia

The primary treatment of idiopathic trigeminal neuralgia is medical. Surgery is reserved for unresponsive patients or in case of long lasting, tedious or dangerous side effects of the medication. The surgeon has to inform the patient about risks and benefits of the different surgical methods and consider the patient's expectations and fears in order to choose the best surgical alternative. We describe the clinical picture of trigeminal neuralgia, the steps leading to the diagnosis. We also discuss the pathogenesis and the different treatment modalities with emphasis on surgical methods.     

Radiofrequency-thermocoagulation in the treatment of trigeminal neuralgia: analysis of 100 cases

A series of 100 patients suffering from trigeminal neuralgia treated by percutaneous radiofrequency thermocoagulation of the trigeminal ganglion is reported. The authors make some considerations about the basic principles of the thermocoagulation and comment a few important methods of treatment used prior to this new technique. The whole sequency of the surgical procedure is described and its results analysed. The final conclusion is that percutaneous radiofrequency thermocoagulation has become the treatment of choice for trigeminal neuralgia when the clinical treatment is not anymore effective or the side-effects of the drugs contraindicate its use.     

Partial sensory rhizotomy as an alternative treatment of trigeminal neuralgia

Microvascular decompression is a well established technique in the treatment of medically refractory trigeminal neuralgia when a significant vascular contact is identified during posterior fossa exploration. However, in patients with recurrent trigeminal neuralgia after this type of surgery or if no significant vascular indentation is found during surgery, a partial sensory rhizotomy is often the preferred alternative mode of treatment. For eight such patients, partial sensory trigeminal rhizotomy was performed with the involved distribution. Two patients were cases of previous failure, while the other six cases showed a lack of vascular indentation during operation. All the patient underwent microvascular decompression in addition to partial sensory trigeminal rhizotomy with dissector disruption. Sensory examination was performed during the outpatient department follow-up. In these eight such patients, five had excellent results, two continued to have mild pain that was well controlled with carbamazepine, and one had poor results. The mean follow-up period was 58 months. Our study indicates that sensory loss is compatible with the extent of nerve section and that touch loss is less evidence than sensory loss. Partial sensory trigeminal rhizotomy is recommended as the alternative treatment strategy of choice for patients with trigeminal neuralgia who lack significant vascular contact during operation.     

Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia

PURPOSE: The purpose of this study was to evaluate the effectiveness of radiofrequency thermal rhizotomy (RTR) for trigeminal neuralgia, after failure of pharmacological management. PATIENTS AND METHODS: Two hundred fifteen patients underwent RTR from 1991 to 1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face, and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring reoperation, and the type and rate of complications. They were followed-up by serial clinical evaluation and telephone interview. Patients were categorized into groups: 1) Successful result: excellent, good pain relief; and 2) Unsuccessful result: fair, poor, or no pain relief. The RTR group was compared with historical controls. Follow-up ranged from 9 to 68 months (mean, 32 months) and results were evaluated at early and long-term follow-up. RESULTS: At early follow-up (defined as immediately postoperatively to 6 months), pain relief of excellent or good quality (successful result) occurred in 198 of 215 patients (92%). Fair or poor or no pain relief (unsuccessful result) occurred in 17 (8%) patients. At long-term follow-up (>6 months to 68 months), recurrence of pain that required reoperation occurred in 24 patients (11%) and recurrence of pain that did not require reoperation (medically managed) occurred in 34 patients (16%). Dysesthesia developed in 18 patients (8%); seven patients (3%) had dysesthesia alone (medically managed) and 11 patients (5%) had dysesthesia with recurrence of pain (medically or surgically managed). "Anesthesia/analgesia dolorosa" developed in four patients (1.8%) and was medically managed. At long-term follow-up, 83% of patients had good to excellent pain relief (successful result). There were no mortalities, no significant morbidity, and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic approach and management algorithm, patients with trigeminal neuralgia can be successfully managed.     

When is facial pain trigeminal neuralgia?

The pain of trigeminal neuralgia can be excruciating and debilitating. Fortunately, effective medical and surgical therapies for the disorder exist. Successful treatment hinges on thorough history taking and accurate diagnosis. Diagnostic evaluation of patients with orofacial pain should include complete head and neck, dental, and neurologic examinations combined with radiologic imaging of the head and appropriate laboratory tests.     

The place of ganglion or root alcohol injection in trigeminal neuralgia

Of 157 patients with trigeminal neuralgia, referred for neurosurgery, 81 underwent 85 ganglion or root injections. The results, which are analysed with regard to pain relief and sensory loss, compare favourably with results from the literature of other forms of surgery, particularly open temporal root section.     

Neurosurgical treatment of trigeminal neuralgia. A comparative study of alcohol block, neurectomy and electrocoagulation

The objective was to assess the present condition of patients previously treated with neurosurgical procedures for trigeminal neuralgia (TN). Between 1976 and 1991, 383 patients were treated for TN at the Department of Neurosurgery, Hvidovre Hospital. The latest surgical intervention performed was radiofrequency coagulation (64%), neurectomy (18%), alcohol block (16%), trigeminal tractotomy (1%), and microvascular decompression (1%). Questionnaires were sent to 316 patients treated neurosurgically for trigeminal neuralgia during the 16 year period. After radiofrequency coagulation, neurectomy and alcohol block, 83, 51 and 42% respectively experienced a pain free postoperative period. At present 49, 17 and 18% were without pain and 33, 21 and 36% had less pain compared with the preoperative state. Sequelae were described in 65, 57 and 49% of the patients. The four most common sequelae were hypaesthesia, paraesthesia, eye complaints, and dysaesthesia. If relevant pharmacotherapy has been tried without benefit, radiofrequency coagulation may still be considered as a treatment of trigeminal neuralgia.     

Recovery of nerve conduction following microvascular decompression for trigeminal neuralgia

OBJECTIVE: To assess the function of trigeminal nerve before and after microvascular decompression for trigeminal neuralgia. BACKGROUND: To date there is no direct evidence that microvascular decompression of the trigeminal root restores normal conduction in the nerve. METHODS: The authors examined 10 patients with trigeminal neuralgia in whom preoperative MRI and MR angiography demonstrated neurovascular contact. During microvascular decompression, the trigeminal nerve was monitored by recording early scalp trigeminal evoked potentials immediately before, during, and after decompression. Direct recordings from the root entry zone were also performed. RESULTS: In all patients preoperative scalp evoked potentials showed impaired conduction of the trigeminal root. Microvascular decompression was associated with immediate recovery of conduction in seven patients, demonstrated by both scalp evoked potentials and direct root recordings. All 10 patients were pain free postoperatively. CONCLUSIONS: Improvement in trigeminal neuralgia following microvascular decompression is often associated with normalization of neurophysiologic data, suggesting recovery of nerve function. Rapid electrophysiologic recovery and pain relief following microvascular decompression argue that neither phenomenon is linked to remyelination. It is possible that the trigeminal evoked potentials might predict an effective microvascular decompression.     

Malpositioned endolymphatic subarachnoid shunt causing trigeminal neuralgia: case report

A case is presented of a 64-year-old female with a fifteen year history of right facial pain. The last nine years the facial pain is described as an intense, stabbing pain in the maxillary division of the right trigeminal nerve. The patient had Meniere's Disease for which an endolymphatic subarachnoid shunt was placed fifteen years prior. The patient underwent intensive medical and several surgical therapies for pain. Some of the procedures were initially successful but none provided lasting relief. Because of severe recurrent right facial pain, the patient underwent a right open partial rhizotomy of the trigeminal nerve via a retrosigmoid approach. Intraoperative findings included the end of the endolymphatic subarachnoid shunt in association with the trigeminal nerve roots. The end of the shunt was removed at the time of surgery. Postoperatively the patient has been pain free for thirty months. It is proposed a malpositioned or migrated endolymphatic subarachnoid shunt may be a cause of trigeminal neuralgia.     

How I treat... trigeminal neuralgia in patients older than 60 years

Randomized controlled clinical study of Sulperazon (Sulbactam/Cefoperazon) was made in the surgical field. 35 cases were treated with Sulperazon and 32 cases with Ceftazidime. In the Sulperazon group (35 patients), the effective rate was 88.6% as compared with 90.6% of the patients in the Ceftazidime group (32 patients) (P > 0.05). The bacterial eradication rate was 86.2% in the Sulperazon group as compared with 88.5% in the Ceftazidime group. No significant difference was noted in both groups. In the Sulperazon group, side effects were not observed except nausea in one case.