Traitements chirurgicaux de la névralgie trigéminale classique

Abstract

Neurosurgical management of classical trigeminal neuralgia is based on three types of techniques: an “etiological” and nondestructive technique, microvascular decompression (MVD), which consists in decompressing the trigeminal nerve in the cerebello-pontine angle, where a vascular compression is frequently found at the origin of pain; percutaneous lesioning techniques (thermorhizotomy, microcompression by balloon, injection of glycerol), aimed at disrupting the transmission of the nociceptive message; and radiosurgery. During the consultation, the neurosurgeon will try to answer three questions: “Is this a trigeminal neuralgia?”; “Is it a classical form?”; and “Is it resistant to medical treatment?”. He will present to the patient the different surgical possibilities, emphasizing the “benefit/risk” balance, and propose the most adapted to his case. In a patient in good general condition, with a clear vascular compression at magnetic resonance imaging (MRI), it seems logical to discuss the first-line MVD, as this reference technique addresses the cause of classical trigeminal neuralgia and has a high probability level of good evolution on the long term. Radiosurgery can also be offered as an alternative because of its less invasiveness and morbidity (in particular, a very low rate of hypoesthesia compared to percutaneous techniques). A patient with an altered general condition or recurrence after MVD (without MRI residual vascular compression) may be referred for surgery or radiosurgery. Depending on the technique chosen, the patient should be informed that pain relief will often be “at the cost” of a hypoesthesia more or less pronounced. Between these two extreme and relatively easy cases, all intermediate situations are possible. In the absence of a randomized controlled study evaluating the different surgical techniques, the American Academy of Neurology and the European Federation of Neurological Societies admit that formal recommendations on surgical treatment cannot be made. However, these Scientific Societies indicate that (1) patients with an MVD have a longer pain-free period than other surgical techniques, at the cost of significant morbidity, reduced in teams with high activity in neuralgia and (2) radiosurgery is the technique with the least complication.