A 10-year experience in the treatment of trigeminal neuralgia. Comparison of percutaneous stereotaxic rhizotomy and posterior fossa exploration.

Abstract

Of 1000 patients with classic trigeminal neuralgia who were treated during the last 10 years, 90% had an initial favorable response to medical therapy, but 75% (750 patients) failed to achieve satisfactory long-term relief. Of these, 700 patients were treated by percutaneous stereotaxic rhizotomy (PSR) and 50 were selected for posterior fossa exploration (PFE). Of the 50 patients undergoing PFE, 82% had neurovascular contact at the trigeminal root entry zone, but only 46% were judged to have had significant neurovascular compression. Exploration was negative in 16% of patients and revealed neural compression by bone in 2%. Patients with neurovascular compression were treated by microvascular decompression (MVD); all other patients with exploratory surgery underwent partial sensory rhizotomy. At 3 years after PFE, 84% of patients are pain-free. Results are excellent in 68%, good in 12%, fair in 4%; 12% had a recurrence of their neuralgia. The 700 patients treated by P SR have been followed for 6 years. Results area excellent in 61%, good in 13%, fair in 5%, and poor in 1%; 20% had a recurrence. This study indicates that there is no significant difference in results between PSR and PFE in the treatment of trigeminal neuralgia. The concept that neurovascular compression is a mechanical factor in the etiology of trigeminal neuralgia was supported, but neurovascular compression was less common than previously reported. Percutaneous stereotaxic rhizotomy is a less formidable procedure than PFE, and is easily repeated. Recent technical advances have improved the results obtained with PSR. Therefore, PSR remains the procedure of choice for the majority of patients with trigeminal neuralgia.