Comparison of first-time microvascular decompression with percutaneous surgery for trigeminal neuralgia: long-term outcomes and prognostic factors

Imran Noorani,Andrew Durnford,Amanda Lodge,Girish Vajramani,Owen Sparrow

doi:10.1007/s00701-021-04793-4

Abstract

ObjectiveCommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and percutaneous procedures (glycerol rhizolysis; thermocoagulation; and balloon compression). Although the efficacy of each procedure has been documented, direct comparisons of their relative efficacies for TN are lacking. We aimed to directly compare long-term outcomes after first-time MVD with percutaneous surgery in primary (idiopathic and classical) TN and identify predictors of outcome.MethodsWe conducted a retrospective analysis of prospectively collected data on 185 patients undergoing MVD and 129 undergoing percutaneous surgery. Procedures were performed by one of two neurosurgeons in a single centre; an independent observer collected long-term follow-up data by interviews, using the same outcome measures for all procedures.ResultsMVD patients were younger than those undergoing percutaneous surgery (P <.001). MVD provided superior initial pain relief (P <.001): 87.0% had Barrow Neurological Institute class I or II pain scores after MVD compared with 67.2% after percutaneous surgery. The complication rate for percutaneous procedures was 35.7% and for MVDs was 24.9% (P =.04), including minor and transient complications. Kaplan-Meier analysis demonstrated that MVD provided longer pain relief than percutaneous procedures (P <.001); 25% of patients had recurrence at 96 months following MVD compared with 12 months after percutaneous surgery. Subgroup analysis showed that balloon compression provided more durable relief amongst percutaneous procedures. Multivariate analysis revealed that post-operative numbness and age were prognostic factors for percutaneous procedures (P =.03 and .01, respectively).ConclusionsMVD provides better initial pain relief and longer durability of relief than percutaneous surgery, although carrying a small risk of major complications. Amongst percutaneous procedures, balloon compression gave the most durable relief from pain. Older age and post-operative numbness were predictors of good outcome from percutaneous surgery. These results can help clinicians to counsel patients with primary TN on neurosurgical treatment selection for pain relief.

Highlights

Trigeminal neuralgia (TN) is a syndrome of paroxysmal, severe facial pain in the trigeminal nerve sensory distribution
Patients undergoing microvascular decompression (MVD) were significantly younger than those undergoing a percutaneous procedure and had a shorter duration a b
Comparing the distributions of initial pain relief demonstrated that MVDs provided significantly better initial relief compared with percutaneous procedures (2-sided chi-square test, P < .001; Fig. 2a)

Summary

Introduction

Trigeminal neuralgia (TN) is a syndrome of paroxysmal, severe facial pain in the trigeminal nerve sensory distribution. Other surgical treatments are ablative, aiming to injure the nerve to improve pain, and include three percutaneous procedures (glycerol rhizolysis, GR; thermocoagulation, TC; balloon compression, BC) and stereotactic radiosurgery (SRS). Many studies report outcomes for individual types of procedure, few studies have directly compared MVD with percutaneous procedures in terms of long-term outcomes while controlling for potentially confounding patient factors [48, 49] such as atypical TN, recurrent pain or repeat surgery, and multiple sclerosis (MS). A direct comparison of MVD versus percutaneous procedures with long-term outcomes, in the context of firsttime surgery for patients with primary (classical or idiopathic) TN, would be important in guiding clinicians on neurosurgical decision-making and counselling TN patients on surgical options

Methods

Results

Discussion

Conclusion