Surgical management for trigeminal neuralgia: an overview

Abstract

Trigeminal neuralgia is a potentially disturbing disease and may be resistant to classical medications such as anti-epileptic drugs. The first step is to check out the clear assessment of an essential trigeminal neuralgia so as to rule out specific etiologies of the trigeminal pain. There are mainly three kinds of surgical strategies: microsurgical neurovascular decompression, percutaneous gasserian lesioning and radiosurgery with Gamma knife. Microsurgical neurovascular decompression is an open surgery and the goal is to take away a vessel (mainly an artery) from the trigeminal nerve as it has been assumed that this conflit was the pathophysiological reason for the “epileptic-like” pain. This surgery has been around for at least 40 years. The results are very good, with 90% of the patients being satisfied and relieved from pain. Moreover, the results are long lasting with a 70% rate of satisfaction for the longest follow-up published. The morbidity is low even for elderly people in good health condition. There are several percutaneous techniques. The principle is doing a lesion on the retrogasserian part of the nerve, either by radiofrequency (thermic lesion), or by compression with a balloon (compressive lesion). The results are also good, with 90% of the patients being immediately relieved from pain, but there is a higher risk of recurrence and some potential morbidity (trigeminal numbness or trigeminal dysfunction mainly with radiofrequency lesion). The Gamma knife procedure is a radiosurgical procedure using cobalt radiation, in one shot, at a 80 Gy dosage, with a single 4 mm isocenter located at the entry zone. There is a delay in getting relief from pain. The results are good, with 80% of the patients being relieved. Somehow, there is a tendency of pain recurrence at mid-term follow-up and a 50% rate of patients being satisfied at a 5 year follow-up. The respective indications of each technique depend on the patient, the surgeon and their experience and the avaibility of the techniques. Altogether, it has been assumed that microvascular decompression is the first option for patients with neuralgia resistant to anti-convulsivant medications. Patient in poor medical conditions, or with MS lesion or refusing surgery, can be relieved by radiosurgery or percutaneous techniques.