Barrow Neurological Institute Pain Intensity Research Articles

Efficacy and safety of Dyna CT-assisted percutaneous balloon compression in the treatment of tumor-related trigeminal neuralgia: A single-center retrospective analysis

BackgroundPercutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia (TN). Patients with tumor-related TN are typically treated by tumor resection. However, when craniotomy is not feasible, PBC may serve as a simple and effective method for pain relief. Currently, there is limited literature on the use of this technique in treating patients with tumor-related TN. In this study, we aim to evaluate the efficacy and safety of Dyna CT-assisted PBC in the treatment of tumor-related TN. MethodsFrom January 2018 to December 2023, a total of 19 patients with tumor-related TN underwent Dyna CT-assisted PBC at our institution. The modified Barrow Neurological Institute Pain Intensity Grading Scale and sensory reduction scores were employed to assess treatment outcomes. A retrospective analysis was conducted on the clinical characteristics, surgical efficacy, postoperative complications, and follow-up results of all patients. ResultsImmediate and complete pain relief was observed in 18 patients following PBC, with one patient experiencing delayed recovery. Follow-up periods ranged from 4 to 62 months, revealing only 4 patients with pain recurrence at the last follow-up, and tumor-related TN patients with involvement of Meckel's cave were more prone to recurrence. No severe complications occurred throughout the follow-up period. Although facial numbness was reported in all 15 patients, jaw weakness in 8 patients, and postoperative headache in 7 patients, these symptoms resolved within a short period. There were no statistically significant differences in postoperative facial numbness and jaw weakness between tumor-related TN patients with or without Meckel's cave involvement. However, patients with Meckel's cave involvement were more likely to experience postoperative headaches. Patient satisfaction scores indicated a significant improvement in postoperative quality of life. ConclusionFor patients with tumor-related TN, when craniotomy is not feasible, Dyna CT-assisted PBC proves to be a safe and effective alternative treatment. Additionally, we observed varying postoperative clinical outcomes based on the different sites of tumor compression on the trigeminal nerve. Patients with tumor-related TN not involving Meckel's cave exhibited more enduring clinical efficacy compared to those with Meckel's cave involvement.

Ultrasound-Guided Occipital Nerve Block in the Management of Refractory Headache and Its Outcomes: A Prospective Study

Abstract Purpose Headache severely impacts health and lifestyle, causing distress and leading to accommodative changes in affected individuals. Treatment options available for refractory headache range from a conservative approach to advanced forms. The purpose of our study was to evaluate the effectiveness of ultrasound-guided occipital nerve block (ONB) in the management of refractory headaches using visual analog scale (VAS) score and Barrow Neurological Institute Pain Intensity Score (BNIPIS). Methods A study sample of 30 eligible patients with refractory headaches including occipital neuralgia, migraine, tension headache, cluster headache, and vascular headaches aged between 18 and 65 years were included in our study. VAS and BNIPIS were noted for each patient before and after the procedure. ONB was given around the target nerve under aseptic precaution. Two milliliters of 0.5% bupivacaine was used as an injection solution for all patients. Results The mean VAS score in acute pain at pre-treatment and post-treatment after 24 hours and 3 months was found as 7.53, 1.53, and 3.20, whereas in chronic pain the score was 8.13, 3.07, and 5.87, respectively. Pre-treatment pain levels in acute and chronic subjects in BNIPIS IV and V category shifted to category I and II after 24 hours (postinjection) that later were recorded II and III, respectively, after 3 months. Conclusion Standard treatment guidelines are given by the international headache association for the management of headaches. The use of ONB is well advocated and practiced for a long time. In our study, we found that the use of greater occipital nerve block reduced pain levels affecting VAS and BNIPIS, which was more effective in acute cases than in chronic cases.

Surgical Strategy for Petroclival Meningioma-Related Trigeminal Neuralgia: The Role of Porus Trigeminus Opening

ObjectivePetroclival (PC) meningiomas invade Meckel's cave through the porus trigeminus, leading to secondary trigeminal neuralgia (TN). Microsurgery and stereotactic radiosurgery (SRS) are the typical treatment options. This study investigated symptom control, outcomes, and surgical strategies for PC meningioma-induced TN. MethodsWe retrospectively analyzed 28 TN patients with PC meningiomas who underwent microsurgical nerve decompression between January 2021 and February 2023. In all patients undergoing a transpetrosal approach, the porus trigeminus was opened to enable the removal of the entire tumor within Meckel’s cave. Clinical outcomes were assessed using the Barrow Neurological Institute (BNI) pain intensity scale. Risk factors for poor TN outcomes and poor facial numbness were analyzed. ResultsAmong 28 patients, 21 (75%) underwent the transpetrosal approach, 5 (17.9%) underwent the retrosigmoid approach, and 2 (7.1%) underwent the Dolenc approach. Following microsurgery, 23 patients (82.1%) experienced TN relief without further medication (BNI I or II). TN recurrence occurred in 2 patients (7.1%), and 3 patients (10.7%) did not achieve TN relief. Cavernous sinus invasion was significantly correlated with poor TN outcomes (p=0.047). A history of previous SRS (p=0.011) and upper clivus type tumor (p=0.018) were significantly associated with poor facial numbness. ConclusionsMicrosurgical nerve decompression is effective in improving BNI scores in patients with TN associated with PC meningiomas. Considering the results of our study, the opening of the porus trigeminus can be considered as a suggested procedure in the treatment of PC meningiomas, especially in cases accompanied by TN.

Efficacy andsafety ofpercutaneous balloon compression forbilateral trigeminal neuralgia: a retrospective study.

Percutaneous balloon compression (PBC) of the Gasserian ganglion is steadily gaining traction within the trigeminal neuralgia (TN) community. Bilateral trigeminal neuralgia (BTN) is a rare condition, and its treatment remains challenging. As far as we know, there are currently no research reports on the treatment outcomes of PBC for BTN.The purpose of this study is to meticulously evaluate the efficacy and safety of PBC for BTN in our medical institution. In this retrospective study, we collected and analyzed the medical records of all patients with BTN who underwent the PBC procedure at the Department of Neurosurgery at Hebei General Hospital from July 2017 to July 2023. After undergoing PBC therapy, all patients were promptly assessed for treatment efficacy based on the modified Barrow Neurological Institute (BNI) pain intensity grading scale. All 37 patients with BTN experienced significant pain relief (BNI I-IIIb) immediately following unilateral PBC treatment. Among these patients, 25 reported relief from pain on the non-operative side, which was effectively managed with medication. Out of the 12 patients who did not experience improvement in contralateral symptoms, 11 received contralateral PBC. Out of the 48 treated sides, 47 sides (97.9%) achieved excellent pain control following a single PBC procedure. The follow-up times ranged from 2 to 62months. At the 1-year follow-up, 94.6% of the patients maintained excellent therapeutic outcomes.Three recurrent patients underwent repeated unilateral PBC, and all of them maintained excellent pain control postoperatively. At the last follow-up, satisfaction was at 91.7% (measured using the Likert scale), with no severe complications occurring. The results indicate that PBC is an effective and relatively safe method for treating BTN, offering a valuable option for pain control in these rare cases of TN.

Transposition versus interposition method in microvascular decompression for trigeminal neuralgia: midterm analysis of both techniques in a single-center study.

Operative interposition of material between the trigeminal nerve and offending artery for surgical treatment of drug-resistant trigeminal neuralgia (TGN), following the Jannetta method, has been proven to be the most successful invasive treatment. Reexplorations of patients with recurrence of TGN have revealed nerve root irritations and scarring due to interposed material. To prevent these complications, modifications of microvascular decompression (MVD) aim at transposing the vessel away from the trigeminal nerve, without attachment of additional material to the nerve root. Given that both techniques (interposition and transposition) have been performed in the authors' institution, they decided to analyze them for the short- and midterm outcomes. All patients who had undergone MVD for drug-resistant TGN in the authors' institution between 2008 and 2022 were analyzed retrospectively. Outcome at discharge and follow-up was evaluated using the Barrow Neurological Institute pain intensity score. Additionally, complications and pain recurrence were assessed. A total of 114 patients were operated on using transposition and 110 patients were treated using interposition. For transposition 102 patients were followed up for a median of 31.5 months, and for interposition 100 patients were followed up for a median of 95 months. At discharge 92.1% versus 94.5% of patients in the transposition and interposition groups, respectively, experienced a good outcome (Barrow Neurological Institute pain intensity scores I-III). At follow-up, 83.3% versus 85% of patients in the transposition and interposition groups, respectively, continued to demonstrate a good outcome. In 4.9% of patients in the transposition group and in 6% of patients in the interposition group, recurrence of pain occurred. Complications occurred in 24.6% of patients in the transposition and in 27.3% of those in the interposition group. The most frequent complications were facial hypesthesia (10.5% vs 11.8%, transposition vs interposition), followed by CSF leaks (2.6% vs 8.2%). Transposition for MVD is an elegant way of solving vessel-nerve conflicts at the cerebellopontine angle. Similar to interposition, transposition shows positive short- and midterm outcomes for patients experiencing drug-resistant TGN. However, the main objective of transposition, which is improved prevention of recurrence and reduction of complications at the trigeminal nerve, could not be confirmed in this study.

Cyberknife Stereotactic Radiosurgery for Trigeminal Neuralgia: A Single-Institution Retrospective Analysis of Clinical Outcomes

Abstract Introduction: CyberKnife stereotactic radiosurgery (CKSRS) is recognized as a highly efficient intervention for refractory trigeminal neuralgia (TN). Our study aims to evaluate the clinical outcomes of CKSRS in treating medically refractory TN. By assessing these results, we aim to understand CKSRS efficacy and its potential as an alternative for nonresponsive patients to traditional medical treatments. Methods: In a retrospective study carried out at my institution, 25 patients with refractory TN were treated between 2018 and 2020. Clinical outcomes, including pain control and hypoesthesia/numbness, were assessed at 6, 12, and 24 months after CKSRS. The study employed the Barrow Neurological Institute pain intensity and facial numbness scores acquired through a telephone questionnaire to assess pain relief and the onset of facial hypoesthesia, thus establishing the effectiveness of the treatment. Results: There were 14 male and 11 female patients. Among all the patients, 44% experienced relief from pain and were not on any medication for pain, whereas 52% reported occasional pain that did not require medication at the end of the study period. The adverse effect of CKSRS, facial numbness, was observed in 58% of patients as mild facial numbness and in 44% as bothersome facial numbness. Moreover, a higher dose of CKSRS administered to the trigeminal nerve was associated with statistically significant pain control (P < 0.05). Conclusion: The study concludes that CKSRS is a safe and effective treatment option for refractory TN. It is worth noting that the occurrence or progression of facial hypoesthesia posttreatment was identified as a predictor of prolonged pain relief.

Microvascular decompression for trigeminal neuralgia: an experience of 84 operated cases

AimWe retrospectively analyse and review the results of microvascular decompression performed for trigeminal neuralgia. We also discuss the surgical nuances, complication avoidance and compare our results with other reported studies.Materials and methodsThis is a retrospective study in which the data of eighty-four patients who underwent microvascular decompression for trigeminal neuralgia in the last ten years from 2013 till May 2023 at our institute (Neuron hospital and SSG Hospital, Vadodara, India) was reviewed. The preoperative pain characteristics, radiology reports and the degree and duration of post-operative pain relief and neurologic outcome was assessed. MRI was done preoperatively in all the cases to rule out a secondary cause for trigeminal neuralgia. All the cases of secondary trigeminal neuralgia were excluded from the study. A favourable outcome was defined as a post-operative Barrow Neurological Institute pain intensity score of 1.ResultsEighty patients had excellent immediate postoperative pain relief without any need for medications. None of these patients have developed any recurrence of pain till date. Four operated patients did not experience any pain relief after surgery.ConclusionMicrovascular decompression for trigeminal neuralgia is a safe and effective procedure which treats the root cause of the disease and hence provides good long term pain relief.

Microsurgical posterior fossa re-exploration for recurrent trigeminal neuralgia after previous microvascular decompression: common grounds—scarring, deformation, and the “piston effect”

ObjectiveMicrovascular decompression (MVD) is a well-accepted treatment modality for trigeminal neuralgia (TN) with high initial success rates. The causes for recurrence of TN after previously successful MVD have not been fully clarified, and its treatment is still a matter of debate. Here, we present the surgical findings and the clinical outcome of patients with recurrent TN after MVD who underwent posterior fossa re-exploration.MethodsMicrosurgical posterior fossa re-exploration was performed in 26 patients with recurrent TN (mean age 59.1 years) who underwent MVD over a period of 10 years. The trigeminal nerve was exposed, and possible factors for recurrent TN were identified. Arachnoid scars and Teflon granulomas were dissected meticulously without manipulating the trigeminal nerve. Outcome of posterior fossa re-exploration was graded according to the Barrow Neurological Institute (BNI) pain intensity score. Follow-up was analyzed postoperatively at 3, 12, and 24 months and at the latest available time point for long-term outcome.ResultsThe mean duration of recurrent TN after the first MVD was 20 months. Pain relief was achieved in all patients with recurrent TN on the first postoperative day. Intraoperative findings were as follows: arachnoid scar tissue in 22/26 (84.6%) patients, arterial compression in 1/26 (3.8%), venous contact in 8/26 (30.8%), Teflon granuloma in 14/26 (53.8%), compression by an electrode in Meckel’s cave used for treatment of neuropathic pain in 1/26 (3.8%), evidence of pulsations transmitted to the trigeminal nerve through the Teflon inserted previously/scar tissue (“piston effect”) in 15/26 (57.7%), and combination of findings in 18/26 (69.2%). At long-term follow-up (mean 79.5 months; range, 29–184 months), 21/26 (80.8%) patients had favorable outcome (BNI I-IIIa). New hypaesthesia secondary to microsurgical posterior fossa re-exploration occurred in 5/26 (19.2%) patients.ConclusionsPosterior fossa re-exploration avoiding manipulation to the trigeminal nerve, such as pinching or combing, may be a useful treatment option for recurrent TN after previously successful MVD providing pain relief in the majority of patients with a low rate of new hypaesthesia.

Frameless Linear Accelerator (LINAC) Based Radiosurgery (SRS) vs. Framed Gamma Knife SRS for Idiopathic Trigeminal Neuralgia (TN)

Stereotactic radiosurgery (SRS) is an effective treatment for idiopathic trigeminal neuralgia (TN). Conventional treatment is done through frame-based solution due to small target and high radiation dose. More recently, LINAC based frameless SRS technique has been established as a patient friendly alternative. Herein we compared our single institution experience of LINAC based frameless SRS vs frame-based gamma knife SRS for TN. The hypothesis is LINAC based frameless SRS can provide equivalent dosimetric and clinical outcome as compared frame-based gamma knife treatment. Patients with idiopathic TN who received SRS treatment (LINAC based frameless treatment or Gamma knife framed treatment) at our institution from 2015-2022 were included. A minimum follow up of 1 year was required. Patient data was extracted from electronic medical records and radiation treatment planning system. Pain intensity was evaluated utilizing a modified 0-4 Barrow Neurological Institute (BNI) pain intensity score, and then dichotomized where BNI score 0-2 represented response to treatment and BNI score 3-4 represented no response. Statistical analysis was conducted with a linear regression model accounting for race, gender, prior pain, pain distribution including laterality and branch involvement, medication regimen at time of treatment, previous radiation treatment, and prior procedures. Response was then compared between both modalities overall and within each sub-group with chi-square testing and linear regression. A total of 81 patients were identified, 14 patients were excluded due to lack of adequate follow-up, leaving 67 for analysis. 12 (17.9%) were male and, 55 (82.1%) were female. All patients were managed with medication prior to SRS treatment. 5 (7.5%) had rhizotomy and 13 (19.4) had microvascular decompression, and 8 (11.9%) had previous gamma-knife radiosurgery prior to SRS treatment at our institution. Of the 67 patients, 23 (34.3%) received frame-based gamma knife SRS, 44(65.7%) received frameless LINAC treatment. 58 (86.6%) radiation naïve patients received 90 Gy in 1 fraction, while out of the 9 who had previously had intracranial radiation treatment 7 (10.4%) received 70 Gy and 2 (3%) received 80 Gy all prescribed to 100% isodose line. All patients were treated with 4 mm cone. There was no significant difference in brainstem dose between these two techniques. Between LINAC-based or Gamma Knife modalities rate of pain control (77.3 % vs 82.6 %, respectively, p = 0.61) as well as toxicity in facial numbness (31.8% vs 21.7%, respectively, p = 0.38) showed no statistical difference. There was no statistically significant signal (p > 0.05) detected within the subgroups analyzed. The linear regression model also showed no significant difference. LINAC based frameless SRS provides comparable dosimetry and pain control for TN as compared to frame-based gamma knife treatment. It is a patient friendly solution for patients with TN.

Efficacy and safety of combined thermocoagulation radiofrequency and pulse radiofrequency in the treatment of trigeminal neuralgia

Aims: The aim of this study was to evaluate the efficacy and safety of radiofrequency thermocoagulation (RFT) combined with pulsed radiofrequency (PRF) of the Gasserian ganglion in patients with V2/V3 trigeminal neuralgia (TN).
 Methods: We evaluated 27 patients with V2/3 TN who had undergone combined RFT and PRF of the Gasserian ganglion. Patients were treated with PRF (42°C, 45 V, 20 ms, 120 s), RFT (65°C, 60 s), RFT (70°C, 60 s), and PRF (42°C, 45 V, 20 ms, 120 s), consecutively. Visual analogue scale (VAS) and Barrow Neurological Institute Pain Intensity Scale (BNI) scores were evaluated before and after (1st month, 6th month, and 12th month) the procedure. A BNI score of 1-3 was considered as an effective treatment, while a BNI score of 4 or 5 indicated unsuccessful treatment.
 Results: VAS scores were significantly lower than the baseline values in all post-treatment evaluation visits (1st month, 6th month, 12th month) during the 12-month follow-up period (p0.05).
 Conclusion: Combined RFT and PRF to the Gasserian ganglion is a safe and effective therapeutic approach in the treatment of TN. However, its efficacy partially decreases after one year.

Retrospective comparison of percutaneous balloon compression and radiofrequency-thermocoagulation in the management of trigeminal neuralgia

PurposeTo compare percutaneous balloon compression (PBC) and radiofrequency thermocoagulation (RFTC) for the treatment of trigeminal neuralgia.MethodsThis was a retrospective single-center analysis of data from 230 patients with trigeminal neuralgia who underwent 202 PBC (46%) and 234 RFTC (54%) from 2002 to 2019. Comparison of demographic data and trigeminal neuralgia characteristics between procedures as well as assessment of 1) initial pain relief by an improved Barrow Neurological Institute (BNI) pain intensity scale of I–III; 2) recurrence-free survival of patients with a follow-up of at least 6 months by Kaplan-Meier analysis; 3) risk factors for failed initial pain relief and recurrence-free survival by regression analysis; and 4) complications and adverse events.ResultsInitial pain relief was achieved in 353 (84.2%) procedures and showed no significant difference between PBC (83.7%) and RFTC (84.9%). Patients who suffered from multiple sclerosis (odds ratio 5.34) or had a higher preoperative BNI (odds ratio 2.01) showed a higher risk of not becoming pain free. Recurrence-free survival in 283 procedures was longer for PBC (44%) with 481 days compared to RFTC (56%) with 421 days (p=0.036) but without statistical significance. The only factors that showed a significant influence on longer recurrence-free survival rates were a postoperative BNI ≤ II (P=<0.0001) and a BNI facial numbness score ≥ 3 (p = 0.009). The complication rate of 22.2% as well as zero mortality showed no difference between the two procedures (p=0.162).ConclusionBoth percutaneous interventions led to a comparable initial pain relief and recurrence-free survival with a low and comparable probability of complications. An individualized approach, considering the advantages and disadvantages of each intervention, should guide the decision-making process. Prospective comparative trials are urgently needed.

A Comparative Review of the Outcome Following MVD and PBC in Patients with Trigeminal Neuralgia.

This study aims to systematically review the treatment outcomes of percutaneous balloon compression (PBC) and microvascular decompression (MVD) in patients with trigeminal neuralgia. A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was performed using PubMed, Embase, and Cochrane Central Registry of Controlled Trials databases. Only those articles with more than 5 years' follow-up length were included in this investigation. To uniformly assess the postoperative outcome, we defined pain relief as totally pain free, while the postoperative hospitalization and last follow-up period were defined as early and long term, respectively. The facial numbness was quantified with Barrow Neurological Institute Pain Intensity Score (BNI). After database searching and screening, 7,797 cases were finally included according to the criteria. The early pain relief rates were 94.1% (1,551/1,649) and 89.9% (4,962/5,482) following PBC and MVD (odds ratio [OR] = 0.603; p < 0.05), while the long-term rates were 58.1% (921/1,566) and 74.9% (4,549/6,074; OR = 2.089; p < 0.05), respectively. Although a significant higher facial numbness occurred in the PBC group in the early stage, it was mostly diminished 5 years later compared with the MVD group. At long-term follow-up, hypoacusis and facial palsy occurred more often in the MVD group (p < 0.05). Both MVD and PBC provide a satisfactory outcome for the patients in the long term. As a simple, safe, and reliable technique, PBC should be considered as a viable alternative.

Robot-assisted percutaneous balloon compression for trigeminal neuralgia- preliminary experiences

ObjectivesThis study aims to discuss the availability of robot-assisted percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) and share our preliminary experiences.MethodsPatients with TN who underwent robot-assisted PBC from June to September 2022 were enrolled. We designed a fixing plug for robot-assisted PBC, three-dimensional structured light registration was used, puncture trajectory was the line connects the medial third of inner and outer aperture of foramen ovale. Numerical Rating Scale (NRS), Barrow Neurological Institute (BNI) pain and numbness intensity score were used to evaluate the facial pain and numbness.ResultsEventually, nine patients were enrolled, the structured light registrations were successfully finished in all patients with a mean registration error of 0.68 mm. All the punctures of foramen ovales were successfully done one-time. Of note, the balloons were all got pear-shaped followed by 150 to 180 s compression. Though, postoperatively, all the patients complained of facial numbness and four patients suffered from transient masseter weakness, all patients got fully or mostly pain relief. It should be noted that is the numbness and weakness gradually relieved during follow-up.ConclusionThree-dimensional structured light registration and robot assisted PBC is an effective choice for patients with TN. Extension line between the medial third of the inner and outer aperture of foramen ovale might be a safe and effective puncture trajectory to this procedure.

Percutaneous Rhizotomy of the Gasserian Ganglion in Patients With Mass Lesion-Associated Trigeminal Neuralgia: A Case Series.

Patients with trigeminal neuralgia (TN) secondary to mass lesions are typically treated by directly addressing the underlying pathology. In cases of TN not alleviated by treatment of the pathology, percutaneous balloon compression (PBC) and glycerol rhizotomy (Gly) are simple and effective ways to alleviate pain. However, there is limited literature on the use of these techniques for patients with TN caused by mass lesions. To describe the use of PBC/Gly to treat mass lesion-related TN. We report a retrospective, single-institution, descriptive case series of patients who presented with TN secondary to tumor or mass-like inflammatory lesion from 1999 to 2021. Patients with primary, idiopathic, or multiple sclerosis-related TN were excluded. Outcomes included Barrow Neurological Institute (BNI) pain intensity and hypesthesia scores, pain persistence, and postoperative complications. A total of 459 procedures were identified, of which 16 patients met the inclusion criterion (14 PBC and 2 Gly). Of the 15 patients with tumors, 12 had TN pain despite prior tumor-targeted radiation. Short-term (<3 months) BNI pain intensity improvement occurred in 15 (93.8%) patients. The mean follow-up was 54.4 months. Thirteen (81.3%) patients were pain-free (Barrow Neurological Institute pain intensity scale: IIIa-50%; I-25.0%; II-6.3%) for a mean of 23.8 (range 1-137) months. Ten patients (62.5%) had pain relief for ≥6 months from first procedure. New facial numbness developed immediately postprocedure in 8 (50%) patients. Transient, partial abducens nerve palsy occurred in 1 patient. PBC/Gly is an effective option for medically refractory TN in patients with mass-associated TN and is a viable option for repeat treatment.

443 Bilateral Facial Pain With Simultaneous Onset in Trigeminal Neuralgia

INTRODUCTION: Bilateral TN (BTN) represents a non-negligible disease burden. BTN is often sequential in nature, meaning pain develops on one side before developing on the contralateral side. The few cases of simultaneous onset BTN are often indiscriminately considered or not specified from sequential onset BTN cases. METHODS: A retrospective analysis was conducted to identify patients with simultaneous onset of bilateral TN. Demographic characteristics and comorbidities were assessed. Treatment plans and modalities were recorded, and procedural outcomes and treatment durability was assessed by determining median time pain recurrence in patients with at least 30 days of follow-up. Pharmacotherapy treatment and Barrow Neurological Institute pain intensity scores were compared at last follow-up with index treatment. RESULTS: Between 1996 and 2021, 17 out of 1723 patients with trigeminal neuralgia presented with simultaneous onset of bilateral trigeminal orofacial pain which underwent bilateral surgical intervention. Patients were followed for 3 to 148 months, during which 63 procedures were performed: 20 glycerin rhizotomies, 25 glycerin-radiofrequency rhizotomies, and 18 microvascular decompressions. 16 of 17 patients experienced pain recurrence after undergoing treatment: 12 with bilateral pain and 4 with unilateral recurrence. Glycerin-radiofrequency rhizotomy provided the greatest recurrence free interval (median = 15.4 months) compared to glycerin rhizotomy (median = 0.9 months; p = 0.02) and microvascular decompression (median = 7.8 months; p = 0.25). Over the course of treatment, the number of pharmacotherapy agents increased from 2 to 3 (p = 0.05). Overall facial pain scores improved from a median of 6 to 4 bilaterally. CONCLUSIONS: Patients with simultaneous bilateral trigeminal neuralgia represent a rare disease population who tend to have early pain recurrence after surgical treatment. Nevertheless, many experience overall pain improvement with re-treatment.

838 Gamma Knife Stereotactic Radiosurgery Retreatment of Trigeminal Neuralgia: Prognostic Factors and Clinical Outcomes

INTRODUCTION: Trigeminal neuralgia(TN) is a debilitating nerve disorder affecting approximately 4.5 per 100,000 people annually. While medical management is the first line of treatment, Gamma Knife Stereotactic Radiosurgery(GKSRS) may be used. Long-term outcomes after GKSRS retreatment are not well elucidated. METHODS: Of the 168 patients treated since 2012 at our institution, 149 had adequate follow-up data, and 53(40.4%) received 2 treatments. The Barrow Neurological Institute (BNI) pain intensity score was used to grade pain. Pain relief was defined as post-GKSRS BNI score of I-III. Treatment failure was defined as post-GKSRS score of IV-V without pain-relief. Pain-recurrence was defined as a post-GKSRS score of IV-V after achieving pain-relief. Univariable analyses were performed to examine the effects of multiple factors on outcomes. RESULTS: Median follow-up was 15(1-63) months; 136(90%) and 49(83.0%) patients achieved pain-relief after T1 and T2 respectively. Median time to pain-relief was 3 months and 1 month after T1 and T2 respectively. Median freedom from pain-recurrence was 24.0 months and 13.7 months following T1 and T2 respectively; 44 (30.0%) and 6 (12.2%) patients developed pain-recurrence following T1 and T2 respectively. High KPS score, V1+V2 pain distribution, and absence of mastication deficits reduced the risk of T1 treatment failure by 21%, 58%, and 54% respectively(p&lt;0.05). Patients with lower BNI scores after T1 had a 39% reduced risk of T2 failure(p&lt;0.001); 2(1.3%) and 4(6.8%) patients developed facial and/or mastication deficits following T1 and T2 respectively. Neither isocenter location nor dose affected outcomes. CONCLUSIONS: GKSRS remains an effective treatment for patients with refractory TN. Our data show that patients who fail or recur after T1 may still receive symptomatic relief following T2 with minimal toxicity. Abstract not yet presented, but accepted for presentation at ASTRO 2022

Internal neurolysis versus intraoperative glycerin rhizotomy for trigeminal neuralgia.

Internal neurolysis (IN) and intraoperative glycerin rhizotomy (ioGR) are emerging surgical options for patients with trigeminal neuralgia without neurovascular contact. The objective of this study was to compare the neurological outcomes of patients who underwent IN with those of patients who underwent ioGR. The authors retrospectively reviewed all patients who underwent IN or ioGR for trigeminal neuralgia at our institution. Patient demographic characteristics and immediate postoperative outcomes, as well as long-term neurological outcomes, were compared. Of 1044 patients who underwent open surgical treatment for trigeminal neuralgia, 56 patients underwent IN and 91 underwent ioGR. Of these 147 patients, 37 had no evidence of intraoperative neurovascular conflict. All patients who underwent IN and 96.7% of patients who underwent ioGR had immediate postoperative pain relief. At last follow-up, patients who underwent IN had lower Barrow Neurological Institute (BNI) pain intensity scores (p = 0.05), better BNI facial numbness scores (p < 0.01), and a greater degree of pain improvement (p = 0.05) compared with those who underwent ioGR. Patients who underwent IN also had significantly lower rates of symptomatic pain recurrence (p < 0.01) at last follow-up over an average of 9.5 months. IN appears to provide patients with a greater degree of pain relief, lower rates of facial numbness, and lower rates of pain recurrence compared with ioGR. Future prospective studies will better characterize long-term pain recurrence and outcomes.

Long-Term Results of Gamma Knife Radiosurgery for Trigeminal Neuralgia

Although the short- to medium-term efficacy of Gamma Knife therapy for drug-resistant essential trigeminal neuralgia has been reported, long-term evaluations are limited. We evaluated patient data obtained at least 10years post-treatment and examined the significance of this treatment using new end points. Among 249 consecutive patients with essential trigeminal neuralgia who were treated with Gamma Knife radiosurgery (retrogasserian target/4-mm single isocenter/90Gy at 100%) at our institution between January 2003 and October 2011, 103 patients who were followed up for at least 10years (mean, 174 [120-219] months) after treatment and whose data were amenable to accurate evaluation, were included in this retrospective study. Herein, we used the Barrow Neurological Institute (BNI) pain intensity scale as a clinical evaluation method for pain and the BNI numbness scale to evaluate complications (namely facial dysesthesia). The initial and final follow-up pain attack cessation (BNI pain intensity score I-IIIa) rate was 82.5% (85 of 103) and 58.2% (60 of 103), respectively. Furthermore, sensory impairment (BNI numbness score≥II) at the last follow-up was observed in 24.3% (25 of 103) of the cases, while very bothersome status (BNI numbness score IV) was observed in 2.9% of the cases. Gamma Knife radiosurgery for essential trigeminal neuralgia showed good therapeutic effects during long-term follow-up. Serious complications of significant concern in the short- to mid-term follow-up, resolved spontaneously. Therefore, the indications for treatment should be expanded to include patients who strongly desire Gamma Knife therapy.

Classical trigeminal neuralgia recurrence after vascular decom - pression: analysis of the causes and features of the clinical picture

Introduction. Pain syndrome recurrence in patients with classical trigeminal neuralgia (CTN) after surgical treatment is an important and relevant issue, despite the advances in the diagnosis of the disease, progress in approaches to patient selection, and proven surgical tactics. The aim of the study is to evaluate the affecting factors for redo surgery in patients with CTN recurrence. Materials and methods. 257 patients with CTN recurrence operated on at the FSAI N.N. Burdenko National Medical Research Center for Neurosurgery of the Ministry of Health of the Russian Federation for the period from 2012 to 2017 were involved in the prospective nonrandomized study. Intraoperative findings and pain structure in postoperative period were evaluated in patients after revision surgery. Burchiel classification, DN4 Questionnarie, and Barrow Neurological Institute Pain Intensity Score (BNI-PS) were used. Results. CTN recurrence in the early and late post-operative periods was registered in 33 patients, which accounted for 13% of the total number of patients in the study group. 58% of them underwent secondary surgical intervention. The efficacy of redo surgery was noted in 79% of patients with complete regression of pain. Patients with CTN and neuropathy combination were admitted to alternative methods (neuromodulation, radiosurgery, radiofrequency ablation). In patients who received stimulation of the branches of the trigeminal nerve after vascular decompression, pain regression was observed in 100% of cases. Patient distribution after combined treatment was 78% for BNI-PS score I and 22% for BNI-PS score 2-3, respectively. Conclusion. In patients with “pure” CTN recurrence, redo surgery presents an effective method of treatment. In patients with CTN and neuropathy combination, repeat vascular decompression is effective only in terms of paroxysmal pain. Thus, multidisciplinary approach is needed – combining adjunctive methods of treatment in neurology, neurosurgery, pain management, and radiotherapy.

Magnetic resonance imaging-guided surgical strategies for treating trigeminal neuralgia without vascular compression

ObjectiveTo describe the surgical strategy, curative effect and postoperative complications of trigeminal neuralgia (TN) without vascular compression using head magnetic resonance imaging (MRI). MethodsWe retrospectively enrolled 184 patients with TN who were admitted to the Department of Neurosurgery of Zhoukou Central Hospital from January 2018 to March 2021 and had complete clinical data. Preoperative MRI reveled that 35 patients (19.0%) had no vascular compression. Among them, 16 (45.7%) had simple venous compression during surgery, 9 (25.7%) had venous compression and arachnoid adhesion during surgery, 5 (14.3%) had arachnoid adhesion during surgery, 3 (8.6%) had no venous compression or arachnoid adhesion during surgery, and 2 (5.7%) had simple artery compression during surgery. During the operation, the corresponding surgical strategies for the various types of venous compression were developed. Postoperative efficacy was assessed using the Barrow Neurological Institute pain intensity and facial numbness scores. ResultsAccording to the four types of compression identified during the operation, which did not reveal obvious vascular compression on preoperative head MRI, appropriate decompression methods were found to effectively relieve or eliminate pain (97.1%), and the postoperative effect was relatively satisfactory. There was no recurrence after 1–2 years of follow-up. After operation, two patients (5.7%) experienced occasional pain, one patient (2.9%) reported minor pain, and two patients (5.7%) reported numbness on the affected side of the face. Furthermore, one patient had aseptic meningitis (2.9%) and one patient (2.9%) had transient tinnitus or hearing loss on the affected side. ConclusionFor patients with (TN) without vascular compression on head MRI prior to surgery, different surgical strategies can be implemented based on microvascular decompression and adequate trigeminal nerve decompression findings. Our results showed that these strategies could achieve satisfactory postoperative results without increasing postoperative complications.