Barrow Neurological Institute Pain Intensity Research Articles

Operative findings and outcome of microvascular decompression/adhesiolysis for trigeminal neuralgia in multiple sclerosis without demyelinating brain stem lesions

ObjectiveTrigeminal neuralgia (TN) in multiple sclerosis (MS) poses several challenges for treatment. Although these patients often have typical attacks, they may not be considered as candidates for microvascular decompression (MVD). Here we report on surgical findings and long term follow-up of MVD/ adhesiolysis in a series of patients with multiple sclerosis but without demyelinating brain stem lesions. MethodsFifteen patients with MS-related TN underwent MVD/ adhesiolysis. Demyelinating brain stem lesions were excluded radiologically. Outcome of the intervention was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at 3, 12, 24 months follow-up and at the last available follow-up (mean 88.2 months, range 38–146). ResultsAll 15 patients benefited from MVD/adhesiolysis and were pain free on the first day of surgery. Intraoperative findings included arterial contact in 7/15 (47 %) patients, venous contact in 9/15 (60 %), and prominent arachnoid thickening in 12/15 (80 %). The distribution of the BNI pain intensity scores showed marked improvement at all follow-up evaluations. Five patients underwent repeat MVD/adhesiolysis for pain recurrence at a mean of 43 months after the first surgery. Long term evaluation at the last available follow-up demonstrated favorable outcome in 13/15 patients (BNI I-IIIa) (87 %), while 2/15 patients had limited benefit (BNI IV). ConclusionsMS-related TN in patients without demyelinating brain stem lesions may be related either to vascular conflicts or to focal arachnoiditis at the trigeminal nerve entry zone. MVD/ adhesiolysis may be considered as a useful treatment option in this subgroup of patients with regard to long term outcome.

Teflon versus Ivalon in Microvascular Decompression for Trigeminal Neuralgia: A 2-Center 10-Year Comparison

Trigeminal neuralgia features jolts of pain along the distribution of the trigeminal nerve. If patients fail conservative management, microvascular decompression (MVD) is typically the next step in treatment. MVD consists of implanting a separating material, often Teflon, between the nerve and compressive lesions. A review found similar success and complication rates between Teflon and Ivalon, another commonly used material. The aim of this study was to analyze outcomes and complications associated with Teflon and Ivalon in MVD. We conducted a 2-center retrospective cohort study of trigeminal neuralgia treated with MVD between 2005 and 2019. Patients with no postoperative follow-up were excluded. Postoperative pain was graded using the Barrow Neurological Institute (BNI) pain intensity score. Relapse was defined as a BNI score of 4-5 during follow-up after initial pain improvement or an initial BNI score of 1-3. The study included 221 MVD procedures in 219 patients. Ivalon was implanted in 121 procedures, and Teflon was implanted in 100 procedures. Multivariate analysis found that implant type had no effect on final BNI score (P= 0.305). Relapse rates were similar at 5- and 10-year follow-up (5-year: Ivalon 10.7%, Teflon 18.0%, P= 0.112; 10-year: Ivalon 11.6%, Teflon 19.0%, P= 0.123). There was no difference in postoperative immediate facial numbness (P= 0.125). Postoperative hearing difficulty was higher in the Ivalon cohort (8.4% vs. 1.0%; P= 0.016). We found no significant difference in final BNI score or risk of relapse between Ivalon and Teflon. Complications were similar, although Ivalon was more associated with temporary postoperative hearing loss.

Endoscopic Vascular Decompression for the Treatment of Trigeminal Neuralgia: Clinical Outcomes and Technical Note.

PurposeMicrovascular decompression (MVD) surgery is considered as an effective method with which to treat trigeminal neuralgia (TN). However, sometimes MVD surgery fails due to incomplete decompression of the responsible vessels caused by a poor visual field. In this study, we evaluated the benefits of endoscopic visualization and the value of full endoscopic vascular decompression (EVD) by describing the surgical results of 20 patients with TN after EVD.Patients and MethodsThis was a retrospective study in a single institution of 20 patients with TN who received EVD between April 2018 and October 2019. All patients underwent EVD via the suboccipital retrosigmoid approach without microscopy at any stage. Abnormal muscle response (AMR) and brainstem auditory evoked potentials (BAEPs) were routinely monitored throughout the procedure. Follow-up was conducted by outpatient and telephone interviews. The degree of facial pain was graded using the Barrow Neurological Institute (BNI) pain intensity score; a BNI of 1 was considered as the best result while a BNI of 2 or 3 was considered as a satisfactory result. Follow-up time ranged from 8 to 24 months, with a mean of 18±4.36 months.ResultsAll 20 patients with severe preoperative pain (BNI of 5) achieved immediate relief or complete control of pain after surgery (BNI of 1 to 2). Vascular conflicts were observed during surgery in all of the patients. None of the patients experienced hearing loss, facial paralysis, intracranial infection, cerebrospinal fluid leakage, cerebral hemorrhage, or death, following the operation.ConclusionWhen carried out by surgeons with endoscopic experience, EVD can provide a clear surgical field of view and reduce the risk of surgical injury. Our findings indicate that EVD is a safe and effective surgical method for the treatment of TN.

Microvascular Decompression versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Single-Institution Experience

Microvascular decompression (MVD) is the standard surgical procedure for patients with medically refractory trigeminal neuralgia (TN). Stereotactic radiosurgery (SRS) has gained increasing popularity as a less invasive technique. We report our institution's outcome in the surgical treatment of TN (MVD vs. SRS), taking patient's age and gender into consideration. We retrospectively reviewed a prospectively collected database of patients undergoing MVD or SRS for type 1 idiopathic TN between 2004 and 2019 at the University of Iowa. Standardized data collection focused on preoperative clinical characteristics and postoperative outcomes including the Barrow Neurological Institute (BNI) Pain Intensity Score. A total of 111 patients underwent MVD and 103 patients underwent SRS for TN. Patients were younger in the MVD (median, 60 years) than SRS (median, 72 years) group. More females (58%) than males (42%) had TN. Multivariate ordinal regression analysis showed that an outcome of BNI score I-II (P= 0.365) and III (P= 0.736) can be achieved with either MVD or SRS; however, BNI score IV (P= 0.031) and V (P= 0.022) were more associated with SRS. Six percent of patients in the MVD group and 26% in the SRS group developed pain recurrence and required a second operation. Nine of 10 patients who underwent MVD after failed SRS had complete pain relief. Factoring in patients' age and gender, both MVD and SRS can achieve a favorable outcome for medically refractory TN, although BNI scores of IV and V were more common with SRS.

Internal Neurolysis with and without Microvascular Decompression for Trigeminal Neuralgia: Case Series

Microvascular decompression (MVD) has remained the first-line surgical treatment of trigeminal neuralgia when an offending vessel can be identified that is causing neurovascular compression. However, patients without neurovascular compression can either develop trigeminal neuralgia or recurrence after MVD. In addition, patients with venous and less severe arterial compression have been shown to have reduced efficacy after MVD. Internal neurolysis is a surgical technique used to separate the fascicles of the trigeminal nerve and might be a good option for patients with trigeminal neuralgia but without vascular compression. A retrospective, institutional review board-approved medical record review was performed of adult patients with trigeminal neuralgia who had undergone internal neurolysis. The search resulted in 32 patients who had been treated from 2016 to 2019. The Barrow Neurological Institute (BNI) pain intensity scale and hypesthesia scale (HS) were used to determine the outcomes. The average follow-up was 20 months (range, 3-40 months). The postoperative outcomes showed a BNI pain intensity scale score of I for 50%, with excellent control in 56%, successful control in 78%, adequate control in 94%, and poor control in 6%. Significantly more patients without previous treatment had had successful pain control (95% vs. 54%). Six patients (19%) experienced pain recurrence and were significantly more likely to experience pain recurrence compared with patients without a previous procedure (39% vs. 5%). The overall BNI-HS score postoperatively was I for 28%, II for 69%, and III for 3%. Internal neurolysis with and without MVD has shown efficacy in treating trigeminal neuralgia in carefully selected patients.

Earlier radiosurgery leads to better pain relief and less medication usage for trigeminal neuralgia patients: an international multicenter study.

Trigeminal neuralgia (TN) is a chronic pain condition that is difficult to control with conservative management. Furthermore, disabling medication-related side effects are common. This study examined how stereotactic radiosurgery (SRS) affects pain outcomes and medication dependence based on the latency period between diagnosis and radiosurgery. The authors conducted a retrospective analysis of patients with type I TN at 12 Gamma Knife treatment centers. SRS was the primary surgical intervention in all patients. Patient demographics, disease characteristics, treatment plans, medication histories, and outcomes were reviewed. Overall, 404 patients were included. The mean patient age at SRS was 70 years, and 60% of the population was female. The most common indication for SRS was pain refractory to medications (81%). The median maximum radiation dose was 80 Gy (range 50-95 Gy), and the mean follow-up duration was 32 months. The mean number of medications between baseline (pre-SRS) and the last follow-up decreased from 1.98 to 0.90 (p < 0.0001), respectively, and this significant reduction was observed across all medication categories. Patients who received SRS within 4 years of their initial diagnosis achieved significantly faster pain relief than those who underwent treatment after 4 years (median 21 vs 30 days, p = 0.041). The 90-day pain relief rate for those who received SRS ≤ 4 years after their diagnosis was 83.8% compared with 73.7% in patients who received SRS > 4 years after their diagnosis. The maximum radiation dose was the strongest predictor of a durable pain response (OR 1.091, p = 0.003). Early intervention (OR 1.785, p = 0.007) and higher maximum radiation dose (OR 1.150, p < 0.0001) were also significant predictors of being pain free (a Barrow Neurological Institute pain intensity score of I-IIIA) at the last follow-up visit. New sensory symptoms of any kind were seen in 98 patients (24.3%) after SRS. Higher maximum radiation dose trended toward predicting new sensory deficits but was nonsignificant (p = 0.075). TN patients managed with SRS within 4 years of diagnosis experienced a shorter interval to pain relief with low risk. SRS also yielded significant decreases in adjunct medication utilization. Radiosurgery should be considered earlier in the course of treatment for TN.

Outcomes of Treatment for Elderly Patients With Trigeminal Neuralgia: Percutaneous Balloon Compression Versus Microvascular Decompression.

The study aimed to evaluate the surgical outcomes of percutaneous balloon compression (PBC) and microvascular decompression (MVD) in the treatment of elderly patients with trigeminal neuralgia (TN). A total of 30 patients who underwent PBC surgery (PBC group) and 30 patients who received MVD surgery (MVD group) were included. The treatment efficacy, Barrow Neurological Institute (BNI) pain intensity score, inflammatory response, the rates of complication and recurrence were analyzed respectively. The total efficacy was 93.33% in the PBC group and 90.00% in the MVD group (P > 0.05), respectively. The pain relief rate was 90.00% and 86.67% after PBC and MVD surgery, respectively (P > 0.05). The levels of IL-1β, TNF-α, and IL-6 were significantly decreased at post-operative 3 days and 5 days compared with pre-operation in the 2 groups (P < 0.05). The post-operative complication rates regarding masticatory muscle weakness and facial numbness in the PBC group were higher than MVD group (P < 0.05). Nevertheless, the incidences of herpes simplex and keratohelcosis were similar between the 2 groups (P > 0.05). The recurrence rates were also similar between the 3 groups (P > 0.05). Percutaneous balloon compression and MVD are effective in the treatment for elderly TN, which can effectively improve the post-operative cure rate of pain prognosis and reduce the inflammatory response. However, PBC is a minimally invasive, safe and effective method for patients in poor general condition and refused treatment with craniotomy.

A Retrospective Review of the Outcomes and Utility of Percutaneous Radiofrequency Rhizotomy for Trigeminal Neuralgia Using Anatomic Landmark Guidance in Asleep Patients

Radiofrequency rhizotomy is a percutaneous procedure for trigeminal neuralgia frequently performed with intermittent awakening, although the utility and accuracy of this procedure in continuously sedated patients have not yet been evaluated. To evaluate pain relief in patients with trigeminal neuralgia undergoing radiofrequency rhizotomy under continuous sedation. Patients from 2012 to 2017 who underwent radiofrequency rhizotomy for trigeminal neuralgia were evaluated retrospectively. Barrow Neurological Institute Pain Intensity scores were assigned to determine relapse at 1 mo, 1 yr, 3 yr, and 5 yr. Descriptive relapse rates for patients with multiple sclerosis and those undergoing repeat procedures are also reported. A total of 90.8% of procedures reported Barrow Neurological Institute I-III score at 1 mo (P<.0001), 66.3% at 1 yr (P=.0012), and 71.1% at 3 yr (P=.0003). Duration to relapse was 3.0 and 6.0 at 1 and 3 yr, respectively. Procedures in patients with multiple sclerosis reported 100% relief at 1 mo and 87.5% relief at 1 yr (P=.0099). The presence of numbness and postoperative medication changes were not associated with pain relief (P=.0063, P=.1338). The use of continuous sedation in radiofrequency rhizotomy for trigeminal neuralgia provides pain relief comparable to the recorded literature rate for procedures with intermittent awakening.

Efficacy and Safety of Percutaneous Ozone Injection Around Gasserian Ganglion for the Treatment of Trigeminal Neuralgia: A Multicenter Retrospective Study.

BackgroundOzone injection around Gasserian ganglion (OIAGG) has been reported to be an effective treatment for trigeminal neuralgia (TN); however, there remain areas for improvement. To overcome one of these limitations, a multicenter examination of application would be extremely helpful.ObjectiveThe goal of this report was to assess the efficacy of OIAGG for refractory TN across multiple centers and to explore factors predictive of successful treatment.DesignA multicenter, retrospective study.SettingThe study was conducted across 3 pain centers across China.Patients and MethodsA total of 103 subjects from 3 pain centers were enrolled in the study. An ozone-oxygen mixture gas at a concentration of 30 µg/mL was injected into the area around the Gasserian ganglion performed under C-arm X-ray guidance. Primary outcome measures included a pain assessment using a visual analog scale (VAS) and the Barrow Neurological Institute (BNI) pain intensity scale. Clinical assessment of patients for these outcome measures was performed at pretreatment, post-treatment, 6 months, 1 year and 2 years after the OIAGG.ResultsSuccessful pain relief was defined as a score within BNI grades I–IIIa. The pain relief rates at post-treatment, 6 months, 1 year and 2 years after the procedure were 88.35%, 86.87%, 84.46% and 83.30%, respectively. The VAS at each observation time point was significantly different from the preoperative levels (P<0.05). Logistic regression analysis showed that previous nerve damage had a significant effect on the treatment results. No significant complications or side effects were found during or after treatment.ConclusionThis multicenter research confirms our previous single center results that OIAGG is both effective and safe for patients with TN.

Results of a third Gamma Knife radiosurgery for trigeminal neuralgia.

Gamma Knife radiosurgery (GKRS) is a commonly used procedure for medically refractory trigeminal neuralgia (TN), with repeat GKRS routinely done in cases of pain relapse. The results of a third GKRS in cases of further pain relapse have not been well described. In this study, the authors report the largest series of patients treated with a third GKRS for TN to date. Retrospective review of institutional electronic medical records and a GKRS database was performed to identify patients who had been treated with a third GKRS at the authors' institution in the period from 2010 to 2018. Telephone interviews were used to collect long-term follow-up data. Pain outcomes were measured using the Barrow Neurological Institute (BNI) pain intensity scale, with a score ≤ IIIb indicating successful treatment. Twenty-two nerves in 21 patients had sufficient follow-up to determine BNI pain score outcomes. Eighteen of 22 cases had a successful third GKRS, with a median durability of pain relief of 3.88 years. There was no significant difference in the durability of pain relief after a third GKRS compared with those of institutional historical controls of prior series of first and second GKRS procedures. Ten cases had new or worsening facial numbness, with 1 case being bothersome. Four cases of toxicity other than facial numbness were reported, including 1 case of corneal abrasions and possible neurotrophic keratopathy. No cases of anesthesia dolorosa were reported. No factors predicting treatment success or the durability of pain relief were identified. Nonnumbness toxicity was more common in those with a proximally placed shot at the third GKRS. A third GKRS is an effective treatment option for TN patients who have pain relapse after repeat GKRS. Pain outcomes of a third GKRS are similar to those following a first or second GKRS. Toxicity is tolerable in patients with a distally placed shot at the third GKRS.

Microvascular Decompression Alone without Rhizotomy Is an Effective Way of Treating Glossopharyngeal Neuralgia: Clinical Analysis of 46 Cases

Background: Microvascular decompression (MVD) has been the right choice for glossopharyngeal neuralgia (GPN) patients. However, whether glossopharyngeal/vagal nerve root rhizotomy should be combined with MVD is still controversial. Objective: To evaluate whether glossopharyngeal/vagal nerve root rhizotomy during MVD is necessary for the treatment of GPN. Methods: We performed a retrospective study of 46 GPN patients who underwent MVD surgery alone in our hospital, and their patient demographics, clinical presentations, and intraoperative findings are shown. The immediate and long-term follow-up outcomes were investigated to show the treatment’s efficiency and safety; the outcome was also compared with our previous study. The relevant literature was reviewed to show complications for GPN patients undergoing glossopharyngeal/vagal nerve root rhizotomy with MVD. Results: The most common offending vessel was the posterior inferior cerebellar artery (60.9%). 100% of the patients were pain-free (score of I on the Barrow Neurological Institute pain intensity [BNI-P] scale) immediately after MVD surgery, while 1 patient relapsed with occasional pain 12 months after the operation (score of III on the BNI-P scale). Poor wound healing and hearing loss were found in 1 case each. No complications related to the glossopharyngeal nerve/vagal nerve were reported. Some surgical techniques, such as thorough exploration of the CN IX–X rootlets, full freeing from arachnoid adhesions, and usage of a moist gelatin sponge, can improve the success rate of the operation. Conclusions: MVD alone without rhizotomy is an effective and safe method for patients with GPN.

The Long-Term Outcomes and Predictors of Microvascular Decompression with or without Partial Sensory Rhizotomy for Trigeminal Neuralgia.

PurposeMicrovascular decompression (MVD) and MVD combined with partial sensory rhizotomy (PSR) are effective surgical treatments for idiopathic trigeminal neuralgia (TN). The aim of this study was to compare the long-term outcomes of both MVD and MVD+PSR for the treatment of TN and to identify the factors that may influence the long-term outcomes after MVD or MVD+PSR.Patients and MethodsFrom March 2009 to December 2017, 99 patients with idiopathic TN who underwent MVD or MVD+PSR in our hospital (40 MVD, 59 MVD+PSR) were included in the study. The indications for MVD+PSR were as follows: vessels only contacted the nerve root, absence of arterial conflict, or failing to completely decompress from the arteries or veins. All patients were treated by one neurosurgeon and were followed up for at least 1 year. The outcomes were assessed with the Barrow Neurological Institute (BNI) Pain Intensity Scale.ResultsThe average follow-up duration was 63.0 months (range, 13.2–118.8 months). Patients in the MVD group were younger than those in the MVD+PSR group (55.1 years and 60.5 years, respectively, P=0.012). A total of 62.5% of the patients in the MVD group and 69.5% of the patients in the MVD+PSR group had favorable long-term outcomes. The Kaplan-Meier survival analysis showed no significant difference in long-term outcomes between the two groups (P=0.202). No factors were associated with long-term outcomes after MVD. For MVD+PSR, a long duration of the disease (odds ratio (OR) 6.967, P=0.016) was associated with unfavorable long-term outcomes, whereas pure arterial compression (OR 0.131, P=0.013) was associated with favorable long-term outcomes.ConclusionFor patients who are not suitable to undergo pure MVD, MVD+PSR can be used as an effective alternative. For MVD+PSR, patients with a long duration of symptoms may have poor long-term outcomes, while patients with pure arterial compression may have favorable long-term outcomes.

Multisession radiosurgery for intracranial meningioma treatment: study protocol of a single arm, monocenter, prospective trial

BackgroundSingle session radiosurgery represents a widely accepted treatment for intracranial meningiomas. However, this approach could involve a high risk of treatment-related complications when applied to large volume lesions. In these cases and for those not suitable for surgical resection, radiosurgery in multisession setting could represents a viable option. The literature results are reassuring in terms of correlated adverse events as well as in terms of tumor control. However, no prospective long-term results are available. In this scenario, we design a prospective monocentric phase II study, in order to verify the safety of a multisession radiosurgery schedule delivering 25 Gy in 5 daily fractions.MethodsPatients diagnosed with large and/or near to critical structures, intracranial meningiomas have been treated by means of multisession radiosurgery in both exclusive and postoperative settings. The primary study aim is safety that has been being prospectively scored based on international scales, including NCI Common Toxicity criteria, version 4.03, Barrow Neurological Institute pain intensity score, Barrow Neurological Institute facial numbness score and House-Brackmann Facial Nerve Grading System for qualitative analysis. Secondary aim is treatment efficacy in terms of local control that has been being assessed on volumetric analysis.DiscussionThis is the first prospective phase II trial on multisession radiosurgery for large and/or near to critical structures intracranial meningiomas. If positive results will be found, this study could represent the starting point for a phase III trial exploring the role of multisession radiosurgery in the exclusive and postoperative radiation therapy treatment of intracranial meningiomas.Trial registrationTrial registration: clinicaltrials.gov platform (Multisession Radiosurgery in Large Meningiomas –MuRaLM- identifier NCT02974127). Registered: November 28, 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02974127?term=radiosurgery&cond=Intracranial+Meningioma&draw=2&rank=1

Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia.

Glossopharyngeal neuralgia (GN) is a rare pain condition in which patients experience paroxysmal, lancinating throat pain. Multiple surgical approaches have been used to treat this condition, including microvascular decompression (MVD), and sectioning of cranial nerve (CN) IX and the upper rootlets of CN X, or a combination of the two. The aim of this study was to examine the long-term quality of life and pain-free survival after MVD and sectioning of the CN X/IX complex. A combined retrospective chart review and a quality-of-life telephone survey were performed to collect demographic and long-term outcome data. Quality of life was assessed by means of a questionnaire based on a combination of the Barrow Neurological Institute pain intensity scoring criteria and the Brief Pain Inventory-Facial. Kaplan-Meier analysis was performed to determine pain-free survival. Of 18 patients with GN, 17 underwent sectioning of the CN IX/X complex alone or sectioning and MVD depending on the presence of a compressing vessel. Eleven of 17 patients had compression of CN IX/X by the posterior inferior cerebellar artery, 1 had compression by a vertebral artery, and 5 had no compression. One patient (6%) experienced no immediate pain relief. Fifteen (88%) of 17 patients were pain free at the last follow-up (mean 9.33 years, range 5.16-13 years). One patient (6%) experienced throat pain relapse at 3 months. The median pain-free survival was 7.5 years ± 10.6 months. Nine of 18 patients were contacted by telephone. Of the 17 patients who underwent sectioning of the CN IX/X complex, 13 (77%) patients had short-term complaints: dysphagia (n = 4), hoarseness (n = 4), ipsilateral hearing loss (n = 4), ipsilateral taste loss (n = 2), and dizziness (n = 2) at 2 weeks. Nine patients had persistent side effects at latest follow-up. Eight of 9 telephone respondents reported that they would have the surgery over again. Sectioning of the CN IX/X complex with or without MVD of the glossopharyngeal nerve is a safe and effective surgical therapy for GN with initial pain freedom in 94% of patients and an excellent long-term pain relief (mean 7.5 years).

Microvascular Decompression for Trigeminal Neuralgia in Patients with Multiple Sclerosis: Predictors of Treatment Success

Microvascular decompression (MVD) is highly effective in managing the neuropathic facial pain of trigeminal neuralgia (TN). Its utility in patients with TN and concurrent multiple sclerosis (MS) has been a subject of debate. The goal of this study was to identify demographic and perioperative variables associated with favorable outcome after MVD over the past 20 years in patients from our institution. A retrospective analysis of our cohort of 33 patients diagnosed with MS and TN who underwent MVD between 1997 and 2017 to treat neuropathic facial pain was performed. Perioperative variables included MS disease burden, findings on preoperative magnetic resonance imaging (MRI), TN pain severity, and the presence of intraoperative neurovascular compression. MS disease burden was quantified using the Expanded Disability Status Scale. Preoperative and postoperative pain severity was quantified using the Barrow Neurological Institute (BNI) pain severity scale. A total of 33 patients with TN and MS were treated with MVD at our institution (out of the 632 total MVDs performed) between 1997 and 2017. Twenty-two patients (67%) maintained a reduction in pain at a mean follow-up of 53.5 months. Higher preoperative BNI pain intensity score was associated with unfavorable outcome after MVD (P= 0.006). No associations were identified between MS disease burden, presence of neurovascular compression or pontine demyelinating plaques on MRI, or intraoperative findings of neurovascular compression and treatment outcomes. MVD is a reasonable treatment option for patients with TN and MS, although the rate of freedom from pain is lower than that for the general TN population. Preoperative pain severity may be a predictor of treatment success.

Combined pulsed and thermal radiofrequency versus thermal radiofrequency alone in the treatment of recurrent trigeminal neuralgia after microvascular decompression: A double blinded comparative study.

Recurrent trigeminal neuralgia (RTN) is a common clinical problem and pain recurs in many patients after microvascular decompression (MVD). We evaluated the effect of adding pulsed radiofrequency to radiofrequency thermocoagulation at 60°C compared to radiofrequency thermocoagulation at 70°C alone in the treatment of recurrent trigeminal neuralgia after microvascular decompression. 40 patients with recurrent trigeminal neuralgia after microvascular decompression were randomly divided into two equal groups. Group A: received prolonged duration of pulsed radiofrequency followed by less destructive thermocoagulation, while group B: received sole thermocoagulation. Then patients followed up for 2years to evaluate the success rate by the Barrow Neurological Institute Pain Intensity (BNI) Scale, complications, and the need to medical treatment. The success rate was 100% in both groups at discharge (BNI<III). It was 83.3% and 78.7% after 6months, 77.8% and 68.4% after 12month, 72.2% and 68.4% after 18months and 66.7% and 63.1% after 24months in group A and B, respectively (p>.05). In group A 88.9% of patients stopped tegretol treatment after the procedure compared to 84.2% in group B (p=.32). 88.9% compared to 89.5% % in group A and B, respectively, did not use tricyclic antidepressant (p=.61). The overall complications in group A was 5.61%, while it was 36.8% in group B (p=.025). Combined pulsed and thermal radiofrequency can significantly reduce the incidence of the side effects/complications with similar success rate than using thermal radiofrequency alone in treatment of recurrent trigeminal neuralgia after microvascular decompression.

The long-term clinical outcomes of microvascular decompression for treatment of trigeminal neuralgia compressed by the vertebra-basilar artery: a case series review

BackgroundMicrovascular decompression (MVD) is a type of neurosurgery used to treat trigeminal neuralgia (TN) caused by the vertebrobasilar contact/compression. The surgery is not risk-free, however; it may cause recurrent facial pain or other side-effects. The objective of this study was to assess the long-term pain relief and the complications of MVD surgery for the vertebrobasilar compression treatment.MethodsTwenty-three patients with TN compressed by the vertebra-basilar artery (VBA) were treated with MVD. Teflon felt was placed between the brain stem and the offending artery to mobilize the artery towards the skull base and the clivus. The Barrow Neurological Institute (BNI) Pain Intensity Scale score was used to assess pre- and post-surgical pains.ResultsOf 23 patients with pre-operative BNI IV to V, 19 patients (83%) were pain-free after surgery. Four patients experienced transient partial pain relief with BNI II–III, and 3 of them (13%) were completely pain-free within 3 months. The success rate was 96%. Three patients (13%) had pain recurrences, and one received a second MVD surgery for pain relief during the period of follow-up. Four patients suffered from TN hypesthesia, and only 2 patients (8.6%) had permanent facial hypesthesia, while one patient (4.3%) developed a gradual hearing loss after surgery.ConclusionsWhile our success rate of immediate pain relief after surgery was comparable with some reports, the percentage of patients who had pain recurrences was lower, and cases who had permanent facial hypesthesia or developed a gradual hearing loss were fewer after MVD surgery. Our rate of transient complications was higher, and the postoperative pain relief seemed unusually delayed. Our study indicates that MVD is an effective, reliable, and safe neurosurgery for treatment of TN compressed by the VBA albeit our small sample size. Failure of treatment and recurrence of the disease as well as complications could be minimized by preventing displacement of the Teflon implant and extraneous Teflon touching the trigeminal nerves.

Predictive value of magnetic resonance imaging for identifying neurovascular compressions in trigeminal neuralgia

IntroductionMicrovascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery. MethodsThis observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression. ResultsPreoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48).After a mean follow-up of 29 months (range, 6-100 months), 81% of the patients reported pain control with or without medication (BNI score I–III). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score I), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favourable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P=.01) after MVD. ConclusionsDRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD.

Radiofrequency Thermoablation of the Gasserian Ganglion Versus the Peripheral Branches of the Trigeminal Nerve for Treatment of Trigeminal Neuralgia: A Randomized, Control Trial

Background: Trigeminal neuralgia is the most painful condition of facial pain leading to impairment of routine activities. Although radiofrequency thermoablation (RFT) of the Gasserian ganglion is widely used for the treatment of idiopathic trigeminal neuralgia in patients having ineffective pain relief with medical therapy, the incidence of complications like hypoesthesia, neuroparalytic keratitis, and masticatory muscles weakness is high. Recent case reports have shown the effectiveness of RFT of the peripheral branches of the trigeminal nerve for relief of refractory chronic facial pain conditions including trigeminal neuralgia. Objectives: This study was conducted to compare the efficacy and safety of RFT of the peripheral branches of the trigeminal nerve with RFT of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia. Study Design: Prospective, randomized, observer-blinded, clinical trial. Setting: Tertiary care hospital and medical education and research institute. Methods: A total of 40 adult patients of idiopathic trigeminal neuralgia were randomly allocated into 2 groups. The control group received RFT of the Gasserian ganglion while the study group received RFT of the peripheral branches of trigeminal nerve. The procedures were performed in the operation room under all aseptic precautions with fluoroscopic guidance. Post-procedure, the patients were assessed for loss of sensation along the nerve distribution and the adequacy of pain relief on the Numerical Rating Scale (NRS). The patients were followed up for 3 month to assess the quality of pain relief by the NRS and the Barrow Neurological Institute (BNI) pain intensity scale. Improvement in pain was considered excellent if patients had complete pain relief without any medication, good if there was significant reduction in pain (&gt; 50%) with or without medication, and poor if there was less than 50% reduction in pain with medications. Patients were also assessed for numbness and any other side effects. Patients’ satisfaction with the procedure was recorded. Results: Nineteen patients in the control group and 18 in study group had effective pain relief of up to 3 months. Their pain scores were comparable at all time intervals, though the number of patients receiving supplementary medications was more in study group at 2 months (P = 0.015). The patients showed overall satisfaction score of 8.5 (8-9) and 8 (7-9) in control and study groups respectively. The average procedure duration was 30 (30-38) minutes in the control group and 28 (25-40) minutes in the study group. Most of the patients in both groups had mild numbness after the procedure. One patient in the control group had lower eyelid swelling and another had mild weakness of the masseter muscle, which resolved few days later. No major complication was reported in the study group except for 1 patient who reported local ecchymosis. Limitations: The main limitation of the study is that the patients and the investigator performing the procedure were not blinded, though the person who assessed the patient during follow-up was blinded to the group assignment. Another limitation is that we could not follow up with the patients after 3 months due to time constraints. Conclusion: We found that radiofrequency thermoablation of the peripheral branches of the trigeminal nerve is an effective and safe procedure for the management of idiopathic trigeminal neuralgia. Key words: Idiopathic trigeminal neuralgia, radiofrequency thermoablation, Gasserian ganglion, peripheral nerve branches, pain, trigeminal nerve

Retrosigmoid approach for glycerin rhizotomy in the treatment of trigeminal neuralgia without overt arterial compression: updated case series.

Trigeminal neuralgia (TN) is a neuropathic pain disorder characterized by severe, lancinating facial pain that is commonly treated with neuropathic medication, percutaneous rhizotomy, and/or microvascular decompression (MVD). Patients who are not found to have distinct arterial compression during MVD present a management challenge. In 2013, the authors reported on a small case series of such patients in whom glycerin was injected intraoperatively into the cisternal segment of the trigeminal nerve. The objective of the authors' present study was to report their updated experience with this technique to further validate this novel approach. The authors performed a retrospective analysis of data obtained in patients in whom glycerin was directly injected into the inferior third of the cisternal portion of the trigeminal nerve. Seventy-four patients, including 14 patients from the authors' prior study, were identified, and demographic information, intraoperative findings, postoperative course, and complications were recorded. Fisher's exact test, unpaired t-tests, and Kaplan-Meier survival curves using Mantel log-rank test were used to compare the 74 patients with a cohort of 476 patients who received standard MVD by the same surgeon. The 74 patients who underwent MVD and glycerin injection had an average follow-up of 19.1 ± 18.0 months, and the male/female ratio was 1:2.9. In 33 patients (44.6%), a previous intervention for TN had failed. On average, patients had an improvement in the Barrow Neurological Institute Pain Intensity score from 4.1 ± 0.4 before surgery to 2.1 ± 1.2 after surgery. Pain improvement after the surgery was documented in 95.9% of patients. Thirteen patients (17.6%) developed burning pain following surgery. Five patients developed complications (6.7%), including incisional infection, facial palsy, CSF leak, and hearing deficit, all of which were minor. Intraoperative injection of glycerin into the trigeminal nerve is a generally safe and potentially effective treatment for TN when no distinct site of arterial compression is identified during surgery or when decompression of the nerve is deemed to be inadequate.