Anesthesia Dolorosa Research Articles

Linear Accelerator Radiosurgery for Nonvestibular Schwannomas

Nonvestibular schwannomas are uncommon tumors of the brain often treated by surgical resection. Surgery may be associated with high morbidity. We present a series of nonvestibular schwannomas treated with linear accelerator radiosurgery during a 19-year period. This is a retrospective analysis of patients who underwent treatment of nonvestibular schwannomas at the University of Florida with linear accelerator radiosurgery between August 1989 and February 2008. Forty-nine patients underwent treatment during the study period, and 6 were lost to follow up. The mean age was 51 years (range, 17-82 years), 39% had previous surgical resection, and 67% presented with preradiosurgery cranial nerve deficits. There were 25 trigeminal, 18 jugular foramen, 2 facial, 2 oculomotor, 1 hypoglossal, and 1 high cervical schwannomas. The median tumor volume was 5.3 mL (range, 0.3-24.5 mL), treated with a median dose of 1250 cGy (range, 1000-1500 cGy). Study endpoints were actuarial local tumor control and neurological outcome. Forty-three patients were available for a median follow-up of 37 months (range, 6-210 months). Actuarial local tumor control was 97% at 1 year, 91% at 4.5 years, and 83% at 5 years. There were 4 new cranial nerve deficits (9%) including facial numbness (2 patients), anesthesia dolorosa (1 patient), and facial weakness (1 patient). Thirty-nine percent had documented clinical and/or symptomatic improvement. There were no other morbidity and no mortality with treatment. Radiosurgery for nonvestibular schwannomas offers good actuarial local tumor control and has superior morbidity compared with surgical resection. This is the largest linear accelerator radiosurgical series, and the second largest radiosurgical series reported to date.

Percutaneous glycerol rhizotomy for trigeminal neuralgia: safety and efficacy of repeat procedures

Percutaneous glycerol rhizotomy (PGR) is an established technique to treat trigeminal neuralgia. Our aim was to establish how safe and efficacious repeat glycerol rhizotomies were on a study of 179 PGRs performed in our institution. There was an overall success rate of 92.1% in improvement of facial pain. Nine patients had reduced facial sensation post-operatively. There were no cases of anaesthesia dolorosa. The mean time to repeat injection was 22.9 months (1–108 months). Of those requiring repeat glycerol rhizotomies within 6 months, 23% had multiple sclerosis. There was no evidence that the number of repeat glycerol rhizotomies affects the probability of them having a complication (p = 0.87). Glycerol rhizotomy for trigeminal neuralgia is a safe and efficacious method of pain relief, which is particularly useful in the elderly. It can be repeated many times with no increase in morbidity and most importantly, in our practice, no anaesthesia dolorosa.

Editorial: Microvascular decompression for trigeminal neuralgia

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.

Linac-stereotactic Radiosurgery (LSRS) in the Management of Trigeminal Neuralgia: Median 6 Year Follow-up in 51 Cases

Stereotactic Radiosurgery (SRS) with the Gamma Knife (GK) has been used successfully in the treatment of Trigeminal Neuralgia (TN). Results have been comparable to open surgery. There have been few reports with the use of Linac SRS (LSRS) in the management of TN. We report our updated results with LSRS in the treatment of TN. Between 2000 and 2010, 51 patients with medically refractory TN were treated with LSRS. Prior neurosurgical intervention had been performed in 39 patients. Twenty two patients had one procedure, 14 patients had two, and 5 patients had three interventions. All patients had typical TN. LSRS was given to the cranial nerve V entry root zone into the brainstem. Targeting was defined by CT and MRI Scans, and CT Cisternogram, utilizing axial and coronal images. Treatment planning was accomplished thru Radionics Treatment Planning System. The dose was 87 Gy to Dm, in one fraction using the 5 mm collimator and 6 arcs with the 20% Isodose line just touching the brainstem. This dosimetry is similar to Gamma Knife. The dose rate was 400 MU/min. Average Arc length was 130 degrees. Response to treatment was defined as excellent (no pain, off analgesics), good (no pain, with analgesics), and poor (continued pain despite analgesics). With a median follow-up of 72 months (range, 50-122 months), 62.7% (32/51) of patients have reported an excellent or good result after LSRS. One patient has sustained permanent ipsilateral facial numbness. A 2nd patient developed anesthesia dolorosa. LSRS offers comparable results to Gamma Knife SRS in the management of TN.

Percutaneous radiofrequency thermocoagulation for the treatment of different types of trigeminal neuralgia: Evaluation of quality of life and outcomes

Radiofrequency thermocoagulation (RFT) of the gasserian ganglion is a routine and effective technique for the treatment of classical trigeminal neuralgia (CTN). In this study we compared its efficacy in patients with CTN and atypically symptomatic or mixed trigeminal neuralgia (MTN). Fifty-seven patients were treated with RFT for trigeminal neuralgia from June 2006 to February 2009. Thirty patients had CTN, and 27 had MTN. Outcomes were measured by using the visual analog pain scale (VAS) and patients' reports of quality of life (QOL), medication usage, and complications over a follow-up period of up to 3 years. Our results showed that the patients with MTN were younger, tended to have bilaterial involvement of the first division, and were unresponsive to treatment. All surgeries were completed smoothly. About 86.7% CTN patients and 48.1% MTN patients responded immediately to RFT. The VAS scores were significantly higher in the CTN group than in MTN group (P<0.05). Kaplan-Meier curves showed that 1-year, 2-year, and 3-year pain relief rates were 76.7%, 73.3%, and 73.3% in the CTN group and 46.6%, 41.4%, and 41.4% in the MTN group, respectively. The rates of pain relief for both groups leveled off at 2 years. Complications included numbness, dysesthesia, and anesthesia dolorosa. RFT did not cause any deaths and complications were low. The treatment was very effective for CTN and, to some degrees, effective for MTN. If numbness, dysesthesia, and anesthesia dolorosa are limited to the trigger area, QOL will be greatly improved.

Outcomes following single-treatment Gamma Knife surgery for trigeminal neuralgia with a minimum 3-year follow-up

Gamma Knife surgery (GKS) has been shown to be effective in treating trigeminal neuralgia (TN). Existing studies have demonstrated success rates of 69.1-85% with median follow-up intervals of 19-60 months. However, series with uniform long-term follow-up data for all patients have been lacking. In the present study the authors examined outcomes in a series of patients with TN who underwent a single GKS treatment followed by a minimum follow-up of 36 months. They used a clinical scale that simplifies the reporting of outcome data for patients with TN. Fifty-three consecutive patients with typical, intractable TN received a median maximum radiation dose of 80 Gy applied with a single 4-mm isocenter to the affected trigeminal nerve. Follow-up data were obtained by clinical examination and questionnaire. Outcome results were categorized into the following classes (in order of decreasing success): Class 1A, complete pain relief without medications; 1B, complete pain relief with either a decrease or no change in medications; 1C, > or = 50% pain relief without medications; 1D, > or = 50% pain relief with either a decrease or no change in medications; and Class 2, < 50% pain relief and/or increase in medications. Patients with Class 1A-1D outcome (equivalent to Barrow Neurological Institute Grades I-IIIb) were considered to have a good treatment outcome, whereas in patients with Class 2 outcome (equivalent to Barrow Neurological Institute Grades IV and V) treatment was considered to have failed. A good treatment outcome from initial GKS was achieved in 31 (58.5%) patients for whom the mean follow-up period was 48 months (range 36-66 months). Outcomes at last follow-up were reflected by class status: Class 1A, 32.1% of patients; 1B, 1.9%; 1C, 3.8%; 1D, 20.8%; and Class 2, 41.5%. Statistical analysis showed no difference in outcomes between patients previously treated with microvascular decompression or rhizotomy compared with patients with no previous surgical treatments. Thirty-six percent of patients reported some degree of posttreatment facial numbness. Anesthesia dolorosa did not develop in any patient. Despite a time-dependent deterioration in the success rate of GKS for medically intractable TN, the authors' study showed that > 50% of patients can be expected to have a good outcome based on their scoring system, with approximately 33% having an ideal outcome (pain free with no need for medications). Long-term data, as those presented here, are important when counseling patients on their treatment options.

Long-term outcomes of percutaneous retrogasserian glycerol rhizotomy in 3370 patients with trigeminal neuralgia

To assess the long-term outcomes of percutaneous retrogasserian glycerol rhizotomy (PRGR) in patients with medically unresponsive idiopathic trigeminal neuralgia. A total of 3370 patients undergoing PRGR between 1983 and 2003 in our hospital were followed up for 13.1 years (range 3-23 years), and the outcomes were investigated. Of the 3370 patients, 99.58% had complete initial pain relief. A total of 2750 patients were followed up when 112 died of unrelated causes and 508 were lost to follow up. Of the 2750 patients, 962 (35%) had pain recurrence at various intervals: 0.3% in 1 year; 21% in 1 to 5 years; 7% in 5 to 10 years; 4% in 10 to 15 years and 3% in 15 to 23 years. The major complication was facial numbness, among which hypesthesia outweighed hypalgesia. Most patients recovered within half a year, although 109 patients (3.96%) developed permanent mild hypesthesia. There was no anesthesia dolorosa or surgery related mortality in this series. PRGR is a minimally invasive and simple procedure yielding a favorable outcome for trigeminal neuralgia. The major complications of this procedure are reversible within various time intervals. It may serve as a first-line surgical modality for patients unresponsive to pharmacotherapy.

Relief of Trigeminal Anesthesia Dolorosa with Cervical Cord Stimulation: A Case Report

Relief of Trigeminal Anesthesia Dolorosa with Cervical Cord Stimulation: A Case Report

Gamma Knife Radiosurgery (GKRS) in the Management of Trigeminal Neuralgia: Long-term Follow-up Report of 511 Cases

Gamma knife radiosurgery (GKRS) has been used successfully in the treatment of trigeminal neuralgia (TN). Results have compared favorably to surgical procedures with respect to pain relief and complications. We report our updated long-term results with GKRS in the treatment of TN. Between 1991 and 2007, 511 patients with medically-refractory typical TN were treated with GKRS, and have not been lost to follow-up. Prior neurosurgical intervention had been performed in 30.1% of the patients (158/511), with a total of 356 procedures. All patients had typical TN. The GKRS was given to the cranial nerve V entry root zone into the brainstem. Targeting was defined by CT and MRI scans, and inversion recovery MRI, utilizing axial, coronal, and sagittal images. Treatment planning was accomplished through the Leksell Treatment Planning System. The prescribed doses ranged from 70 to 90 Gy prescribed to Dm, in one shot using the 4 mm collimator, with the 20% isodose line just touching the brainstem. Response to treatment was defined as excellent (no pain, off analgesics), good (no pain, with analgesics), and poor (continued pain despite analgesics). Response to treatment was recorded in interviews conducted by a gamma knife nurse. With a median follow-up of 10 years (range, 5–16 years), 54.2% (277/511) of patients reported an excellent result, and 23.1% (118/511) a good result after GKRS. There was a dose response, with 55.7% (68/122) of patients reporting an excellent or good response after 70 Gy, compared to 82.4% (183/222) at 80 Gy, and 86.2% (144/167) at 90 Gy (p < 0.01). Temporary ipsilateral facial numbness occurred in 18.8% (96/511), and permanent facial numbness in 5.1% (26/511). Loss of corneal reflex occurred in 1.4% (7/511), and painful dysesthesias in 2.7% (14/511). There have been 2 cases of anesthesia dolorosa. There was a dose-response in facial numbness, with temporary numbness occurring in 6.5% (8/122) at 70 Gy, 17.1% (38/222) at 80 Gy, and 29.3% (49/167) at 90 Gy (p < 0.01). Permanent numbness occurred in 2.5% (3/122) at 70 Gy, 3.2% (7/222) at 80 Gy, and 9.0% (15/167) at 90 Gy (p < 0.01). The GKRS offers favorable results, both in pain relief and complications, compared to surgery in the management of medically refractory TN. In view of these long-term good pain relief and low complication risks, GKRS should be considered as a primary initial treatment option in medically-refractory TN. The optimal dose with maximum pain relief and minimal complications, appears to be 80 Gy.

Subarachnoid bleeding into the superior cerebellopontine cistern after radiofrequency trigeminal rhizotomy: case report

Sir, We would like to report an unusual case of a patient suffering from trigeminal neuralgia, who underwent percutaneous radiofrequency trigeminal rhizotomy (RF-TR), and complicated with subarachnoidal bleeding in the superior cerebellopontine cistern. A 68-year-old woman had been suffering from medically intractable trigeminal neuralgia. She had a 6-year history of trigeminal neuralgia at the ophthalmic and maxillary branches of the left trigeminal nerve. Cranial magnetic resonance imaging scans revealed no structural or vascular abnormality. Routine preoperative analyses, including coagulation studies, were normal. The patient underwent RF-TR under intravenously administered sedation and analgesia. The localization was confirmed within the nerve by electrical stimulation at 0.5 V (100 Hz, 0.2 m); and a lesion was made at a temperature of 70°C for 60 s. After the procedure, the patient’s pain resolved completely. However, 12 h after the procedure, sudden onset of severe headache, vomiting and neck stiffness occurred. The initial cranial computed tomography (CT) scan was normal. Lumbar puncture examination revealed bloody cerebrospinal fluid (CSF); the lymphocyte and monocyte proportions were normal. The control cranial CT scan showed subarachnoidal bleeding in the left superior cerebellopontine cistern (Fig. 1). The patient underwent conservative treatment, and neck stiffness and headache improved. She was discharged 7 days after the procedure. Trigeminal RF-TR is an effective and commonly performed procedure for control of medically refractory pain. Surgical procedures, such RF-TR, microvascular decompression, etc, may lead to serious complications. Anesthesia dolorosa, painful dysesthesia, absence of corneal reflex, corneal keratitis, masseter paralysis, septic-aseptic meningitis, cranial nerve palsy (cranial nerves III, IV, VI, VII, and VIII), blindness, carotid puncture, and carotidcavernous fistulae are all potential complications of the RFTR procedure [2]. Thus, all surgeons should be aware of these risks and not consider any of these methods as easy and safe. Meckel’s cave and root entry zone, which are the focus of these intervention methods, are at the same time the areas where multiple anatomic variations and vital structures are located [3]. Meckel’s cave opens through a porus into the cerebellopontine cistern. Meckel’s segment of the trigeminal nerve, which begins at the porus and extends to the trigeminal ganglion, is differentiated from the cavernous segment in the wall of the cavernous sinus. Meckel’s segment is narrower adjacent to the porus and fans out as it approaches the posterior edge of the gasserian ganglion, which is embedded in the dura just anterior to the anterior edge of Meckel’s cave. The superior petrosal sinus extends medially through the upper edge of the porus of Meckel’s cave and above the trigeminal nerve to join the cavernous sinus [1]. Some superior petrosal veins may join the sinus on the medial side of the trigeminal nerve. The SCA A. Savas Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey

A case study illustrating traps, pitfalls and concerns for the hypnodontist

AbstractThis case study is about hypnosis for intractable pain in the case of a patient who had trigeminal neuralgia, which through medical intervention had become anaesthesia dolorosa. The study will address the demand characteristics set up by the patient. Inherent in the demands were pitfalls and traps that ultimately resulted in a pyrrhic victory. This case illustrates the need to know the limits for the hypnodontist: of their jurisdictionally permitted scope of practice; their own abilities; whose goals are being met by the intervention; and what outcomes define success for the patient and the hypnodontist. Copyright © 2009 British Society of Experimental &amp; Clinical Hypnosis. Published by John Wiley &amp; Sons, Ltd.

Radiofrequency Treatment of the Thoracic Paravertebral Nerve Combined with Glucocorticoid for Refractory Neuropathic Pain Following Breast Cancer Surgery

Background: Neuropathic pain following breast cancer surgery can have a profoundly negative impact on the physical and psychosocial functioning of patients. Radiofrequency treatment has been used as therapy for chronic pain, which also has a problem under debate of its neurodestructive nature. Although the efficacy and safety of using glucocorticoids in nerve block treatment are controversial, they have been used to treat neuropathic pain for many years and have been used to alleviate acute and continued postoperative pain. Neither radiofrequency combined with glucocorticoids nor radiofrequency treatment of the thoracic paravertebral nerve for neuropathic pain following breast cancer surgery has been reported. Objective: To describe the efficacy of thoracic paravertebral nerve radiofrequency treatment combined with glucocorticoids for refractory neuropathic pain following breast cancer surgery. Design: A series of 3 patients, who following breast cancer surgery with neuropathic pain that did not respond to conservative treatment, were selected. They received radiofrequency treatment of the thoracic paravertebral nerve combined with betamethasone. If pain remained after this treatment at a dermatome of a different level or at the same level, the same treatment was administered after at least 2 months had passed. Results: A total of 21 treatments were administered to the 3 patients. After these treatments, all 3 patients experienced pain relief and their quality of life improved as evaluated by the SF36. Hypoesthesia worsened slightly after treatment. However, anesthesia dolorosa and transient burning pain in the corresponding dermatome, which seemed to be related to neuro-injury after radiofrequency treatment, were not seen. Conclusion: This case series suggests that it is possible that radiofrequency treatment of the thoracic paravertebral nerve combined with glucocorticoid may help in pain relief and improve the quality of life of patients with refractory neuropathic pain following breast cancer surgery. Key words: Radiofrequency, neuropathic pain, glucocorticoid, breast cancer surgery, thoracic paravertebral nerve, postmastectomy pain

Traitement des douleurs trigéminales neuropathiques par stimulation corticale

The neurosurgical procedures currently available for the treatment of trigeminal neuralgia can induce trigeminal neuropathic pain. Severe forms of trigeminal neuropathic pain correspond to the classical facial anesthesia dolorosa, whose treatment is known to be very difficult. Chronic stimulation of the ventral posterolateral nucleus (VPL) of the thalamus was, in the past, the only neurosurgical therapy available to treat this complication. The long-term results have been disappointing, which opened the field to the development of other techniques, including stimulation of the motor cortex for which there is now sufficient experience showing long-term results that are satisfactory in more than 70% of patients. Meanwhile, some authors have proposed directly stimulating the nerve branches concerned, such as the supraorbital nerve, or discussing indications for thalamic stimulation. In this chapter, only the cortical stimulation procedure will be developed.

Pulsed Radiofrequency Treatment of the Supraorbital and Supratrochlear Nerve in a Case of Trigeminal Neuralgia -A case report-

Pharmacological management is the first choice for treatment of the trigeminal neuralgia patients; however, if this mode of treatment fails a minimally invasive procedure should be performed. One of the most commonly used procedures is conventional radiofrequency lesioning of the Gasserian ganglion. Despite its popularity and success rate, this technique has disadvantages such as diminished corneal reflex, masseter weakness, numbness and anesthesia dolorosa. As a result, many studies have been conducted in an attempt to find a better method of treating trigeminal neuralgia. We report here a case of a trigeminal neuralgia patient that was treated with pulsed radiofrequency lesioning of the supraorbital and supratrochlear nerve due to pain in the frontal head that was refractory to the pharmacological treatments. Following the procedure, the Visual Analogue Scale score for pain decreased to 1−2/10 and the pain relief persisted for 7 months. These results indicate that pulsed radiofrequency treatment of the peripheral nerve may be useful for trigeminal neuralgia patients that do not respond to pharmacological treatments.

Clinical outcomes after Gamma Knife surgery for idiopathic trigeminal neuralgia: review of 76 consecutive cases

Stereotactic radiosurgery is an increasingly used, and the least invasive, surgical option for patients with trigeminal neuralgia (TN). In this study, the authors performed a retrospective evaluation of the safety and efficacy of this method for idiopathic TN. The authors reviewed data from 76 patients with idiopathic TN who underwent Gamma Knife surgery (GKS). The mean age of the patients was 64 years (range 27-83 years). All patients had typical features of TN. Thirty patients (39.5%) had previously undergone surgery. The intervention consisted of GKS on the retrogasserian cisternal portion of the fifth cranial nerve. The mean maximum GKS dose used was 85.1 Gy (range 75-90 Gy). Patients were followed-up from 6 to 42 months (mean 20.3 months) after GKS. Complete pain relief was achieved in 83.1% of the patients within 1 year, 70.9% within 2 years, and 62.5% within 3 years. Patients who underwent previous surgery demonstrated a lower rate of pain relief (p < 0.05). Twenty patients (26.3%) reported pain recurrence between 6 and 42 months after treatment. New or worsened persistent trigeminal dysfunction developed after GKS in 16 patients (21%); 8 of these patients described some facial numbness/not bothersome, and 8 reported some facial numbness/somewhat bothersome. None of the patients developed troublesome dysesthesia or anesthesia dolorosa. Gamma Knife surgery for idiopathic TN proved to be safe and effective and was associated with a particularly low rate of complications.

A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia

The aim of this study was to analyze 1 surgeon's 4-year experience with microvascular decompression ([MVD], 36 patients) and Gamma Knife surgery ([GKS], 44 patients) in 80 consecutive patients with trigeminal neuralgia (TN). The authors conducted a prospective cohort study from March 1999 to December 2003 with an independent clinical assessment of the results and serial patient satisfaction surveys. All patients completed a 2004 patient satisfaction survey (0.5-5 years postoperative), and 70% of surviving patients completed the same survey in 2007 (3.9-8.5 years postoperative). Follow-up was undertaken in 100% of the patients (mean 3.4 +/- 2.14 years, range 0.17-8.5 years). Respective initial and latest follow-up raw pain-free rates were 100 and 80.6% for MVD and 77.3 and 45.5% for GKS. The median time to the maximal benefit after GKS was 4 weeks (range 1 week-6 months). Respective initial, 2-, and 5-year actuarial pain-free rates were 100, 88, and 80% for MVD and 78, 50, and 33% for GKS (p = 0.0002). The relative risk of losing a pain-free status by 5 years posttreatment was 3.35 for patients in the GKS group compared with the MVD group. Initial and 5-year actuarial rates for >or= 50% pain relief after GKS were 100 and 80%, respectively. The respective rates of permanent mild and severe sensory loss were 5.6 and 0% for patients in the MVD group, as opposed to 6.8 and 2.3% for patients in the GKS group. Anesthesia dolorosa did not occur during the study. Both procedures enjoyed a high degree of early patient satisfaction (95-100%). Microvascular decompression maintained the same rate of patient satisfaction, but satisfaction with GKS decreased to 75% as pain control waned. Twenty-three patients (29%) died of causes unrelated to the TN or the surgical intervention during the follow-up, and their pain status was known at the time of death. Statistically significant intergroup differences for the MVD versus GKS cohorts were age (median 54 years, range 36-70 years vs median 74 years, range 48-92 years, respectively), preoperative symptom duration (median 2.58 years, range 0.33-15 years vs median 7.5, range 0.6-40 years, respectively), and the presence of major comorbidities (2.8 vs 58.3%, respectively). In this nonrandomized prospective cohort trial of selected patients with potentially relevant intergroup differences, MVD was significantly superior to GKS in achieving and maintaining a pain-free status in those with TN and provided similar early and superior longer-term patient satisfaction rates compared with those for GKS. The complications of wound cerebrospinal fluid leakage, hearing loss, and persistent diplopia (1 case each in the MVD group) were not seen after GKS.

Electrical Stimulation Decreases Neuralgic Pain After Trigeminal Deafferentation

Trigeminal nerve activity mediates head pain after cranial injuries, and also contributes to idiopathic syndromes such as cluster headache and trigeminal neuralgia. Nevertheless, chronic facial pain sometimes develops after lesion of the trigeminal nerve. Here we report on a patient who developed dysaesthesia and stabbing pain in her face after the trigeminal ganglion was destroyed. Transcutaneous electrical stimulation within the distribution of trigeminal deafferentation alleviated the anaesthesia dolorosa and neuralgic jabs, suggesting that sensory afferents that bypassed the trigeminal ganglion mediated therapeutic effects.

Percutaneous Balloon Compression for the Treatment of Recurrent Trigeminal Neuralgia: Long-Term Outcome in 29 Patients

Objective: To analyze the long-term clinical outcomes and complication rates associated with percutaneous balloon compression (PBC) of the trigeminal ganglion in patients with recurrent trigeminal neuralgia (TN) who were treated surgically with procedures other than PBC. Methods: In this retrospective study, the authors reviewed the results of 29 patients who underwent 41 PBC procedures for recurrent TN between 1998 and 2006. Results: The overall mean length of follow-up was 49 months (range 1–101). Pain relief was immediate in 24 (83%) patients. There was no pain relief in 5 patients (17%). 2 patients were lost to follow-up. 12 (54.5%) of 22 patients remained pain-free during a mean follow-up period of 65 months (range 40–101). The other 10 patients (45.5%) who had immediate pain relief experienced recurrent pain, with a mean time to recurrence of 7.3 months (17 days to 38 months). PBC was repeated in 11 patients, and was performed a third time in 2 patients. Morbidities included minor dysesthesia (2 patients), masseter weakness (2 patients), corneal anesthesia (1 patient), anesthesia dolorosa (1 patient), and subarachnoid hemorrhage (1 patient with history of multiple myeloma). Conclusion: PBC is a useful treatment for patients with recurrent TN who have already been treated surgically. Long-term relief of pain in this subset of TN patients is achieved nearly half of the time with side-effect profiles similar to those reported in published data.

Repeat posterior fossa exploration for patients with persistent or recurrent idiopathic trigeminal neuralgia

Patients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. The outcomes and risks of repeat posterior fossa exploration (PFE) for these patients are not clearly understood. From September 2000 to November 2006, 29 patients (14 men, 15 women) underwent repeat PFE. The mean number of surgeries per patient at the time of repeat PFE was 3.2 (range 1-6). The mean follow-up duration after surgery was 33.7 months. Compression of the trigeminal nerve was noted in 24 patients (83%) by an artery (13 patients, 45%), vein (4 patients, 14%), or Teflon (7 patients, 24%). Four patients (14%) who underwent operations elsewhere had incorrect cranial nerves decompressed at their first surgery. Only MVD was performed in 18 patients (62%) and a partial nerve section (PNS) was performed in 11 patients (38%). An excellent facial pain outcome (no pain, no medications required) was achieved and maintained for 80% and 75% of patients at 1 and 3 years after surgery, respectively. Patients with Burchiel Type 1 TN were pain free without medications (91% at 1 year and 85% at 3 years) more frequently than patients with Burchiel Type 2 TN (27% at both 1 and 3 years; hazard ratio = 5.4, 95% confidence interval 1.4-21.1, p = 0.02). Fifteen patients (52%) had new or increased facial numbness. Two patients (7%) developed anesthesia dolorosa; both had undergone PNS. Two patients (7%) had hearing loss after surgery. Repeat PFE for patients with idiopathic TN has facial pain outcomes that are comparable with both percutaneous needle-based techniques and stereotactic radiosurgery. Patients with persistent or recurrent TN should be considered for repeat PFE, especially if other less invasive surgeries have not relieved their facial pain.

Microvascular decompression for trigeminal neuralgia

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.