Controversies in Surgical Treatment of Trigeminal Neuralgia

Abstract

Aim: To share our experience in diagnosis and surgical treatment of Trigeminal neuralgia (TN). Material and Methods: During the period 1990-2012 363 patients (age 27-85 years.) with mean age 60.65 years. were operated on for TN (185 female > 178 male or 50.94% > 49.04%). Pain was located to the right side in 194 pts., to the left side in 169 pts. and bilaterally in 5 pts. According to clinical presentation, V2 and V3 divisions were involved in 63.24%, all three divisions in 22.19%, and V1 plus V2 divisions in 14.57%. According to Classification of TN (Burchiel K et al., 2003) TN1 - 85%, TN2A - 10% (long history) and sensory deficit among the series was at ∼5%. The series of 363 pts. operated on, is divided in two subgroups: 219 cases treated by microvascular decompression (MVD) and 144patients- by percutaneous Glycerol Rhizolysis (PRGR). Results: Severity of Pain was assessed with McGill PQ and VAS. Preoperative examination includes an MRI with FIESTA/ CISS technologies for visualization of neurovascular structures in the cerebello-potine angle. Within the group of patients operated on with open surgery (retro mastoid, suboccipital craniotomy and MVD) early control of pain was nearly 90%. We had 28 primary recurrences treated by 5 MVD, 13 PSR and 10GR. Secondary recurrences were observed in 7 patients followed by 4 PSR and 3 GR. Our late results included ∼84% excellent pain control, with recurrence rate of 9.17%. Within the group of 144 patients treated with PRGR, the early control of pain was nearly 89%. We had 46 pts. with primary recurrence (11 MVD, 6 percutaneous stereotactic radiofrequency lesioning (PSR), 29 GR) and 13 pts.with secondary recurrence (2 MVD, 2 PSR, 9 GR). The late results were with 65% excellent pain control and recurrence rate of 34.21%. There were 5 pts. with 3 recurrences, 3 pts. with 4 and 1 pt with 5, which means that TN tends to recur within the time despite of the progress in imaging and surgical technique. Statistical analysis included Cox -Mantel Test, Cox F Test, Gehan’s Wilcoxon Test, Log Rank Test, Peto and Peto, and Kaplan Meier survival time. Conclusion: MVD is safe and effective surgical option for patients with TN type1, younger than 75 years of age. PRGR is good surgical option for older patients, for those that are not fit for general anesthesia, or when patients’ preference is against open surgery. PRGR is easy and effective option without major complications, and can be used for TN type 2 as well, as for TN type1 and symptomatic patients. However, the treatment of TN is still a vital problem in spite of the available arsenal.