Microvascular decompression for trigeminal neuralgia

Abstract

The contribution of Sekula et al.1 highlights several aspects of the surgical treatment of trigeminal neuralgia (TN) that are worthy of consideration and discussion. Their paper continues a previous theme of microvascular decompression (MVD) in the elderly.2 Their thesis is strengthened by a prospective design and a more discrete, standardized classification of the facial pain syndromes and postoperative outcomes. Several limitations of the study are apparent. Their prospective series is small and the follow-up is short, although the authors concede both of these points. Further, the literature review is not independent of their current prospective series given that the authors included their recent results in the meta-analysis. Nevertheless, the evidence from their unique prospective series could be classified as Class II, which further strengthens the literature on this subject. The authors do make a good point in their suggestion that the risks of trigeminal destructive procedures in the elderly have tended to be underemphasized. The risks of facial neuropathic pain from radiofrequency lesioning, glycerol injection, balloon compression, and radiosurgery are substantial and probably increase with advancing age. With repeated destructive procedures, the burden of trigeminal neuropathy is also probably cumulative. The risks of MVD are certainly serious but uncommon, while the potential adverse consequences of a destructive procedure cannot be underestimated. Specifically, although the incidence of cerebellar hemorrhage or stroke from MVD appears to be quite small, the risks of trigeminal deafferentation pain from destructive procedures are in the neighborhood of 15%. An elderly patient who suffers a complication of intentional trigeminal injury, such as facial dysesthesias or, worse, full-blown anesthesia dolorosa, is not at all happy with the outcome or the surgeon. The authors’ conclusions will stir some controversy, but they derive from an increasing evidence base. Thoughtful patient selection is clearly a hallmark of any surgical practice. However, the results of this series and the systematic review suggest that in contrast to previous assumptions, elderly patients with TN can undergo MVD as safely and effectively as a younger cohort.