Partial Sensory Rhizotomy Research Articles

Partial sensory rhizotomy in recurrent trigeminal neuralgia. Our experience and literature review

Background and objectiveTrigeminal Neuralgia (NT) is a common pathology in Neurosurgery. It can be classified as idiopathic or secondary to other pathologies, such as Multiple Sclerosis (MS). Several surgical treatments have been described, some of them being replaced by more modern techniques. Partial sensory rhizotomy (PSR), described by Dandy is a technique replaced by other techniques due to its permanent side effects. We present our experience with this technique in patients with recurrent NT. Methods and materialsA retrospective review is carried out on five patients who underwent surgery at our center from 2018 to 2023 using the PSR technique. ResultsAll the patients intervened showed significant clinical improvement, except one patient who required reintervention due to uncontrolled pain. According to the Barrow Neurological Institute (BNI) scale, 80% (4/5) of patients showed improvement from grade V to grades I/II except for one of them. This patient suffered from MS. Additionally, one patient presented a corneal ulcer after surgery due to impairment of the corneal reflex. ConclusionIn our experience, PSR is a valid treatment option in selected patients with recurrent TN. It has a low incidence of complications with an adequate surgical technique and anatomical knowledge of the region. To the best of our knowledge, we are one of the few centers in Spain to publish our results with PSR in the last ten years. We report good results in pain control withdrawing medication in 80% (4/5) of the operated patients.

La rizotomía parcial sensitiva en la neuralgia del trigémino recurrente. Nuestra experiencia y revisión de la literatura

Background and objectiveTrigeminal neuralgia (NT) is a common pathology in neurosurgery. It can be classified as idiopathic or secondary to other pathologies, such as multiple sclerosis (MS). Several surgical treatments have been described, some of them being replaced by more modern techniques. Partial sensory rhizotomy (PSR), described by Dandy, is a technique replaced by other techniques due to its permanent side effects. We present our experience with this technique in patients with recurrent NT. Methods and materialsA retrospective review is carried out on five patients who underwent surgery at our center from 2018 to 2023 using the PSR technique. ResultsAll the patients intervened showed significant clinical improvement, except one patient who required reintervention due to uncontrolled pain. According to the Barrow Neurological Institute (BNI) scale, 80% (4/5) of patients showed improvement from gradeV to gradesI/II except for one of them. This patient suffered from MS. Additionally, one patient presented a corneal ulcer after surgery due to impairment of the corneal reflex. ConclusionIn our experience, PSR is a valid treatment option in selected patients with recurrent TN. It has a low incidence of complications with an adequate surgical technique and anatomical knowledge of the region. To the best of our knowledge, we are one of the few centers in Spain to publish our results with PSR in the last ten years. In our study, we report good results in pain control withdrawing medication in 80% (4/5) of the operated patients.

Efficacy and safety of microvascular decompression with or without partial sensory rhizotomy: a comprehensive meta-analysis and systematic review in treating trigeminal neuralgia.

Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient's quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47%. We aimed to assess the efficacy and safety profile of MVD + PSR when compared to standalone MVD for TN. We searched Medline, Embase, and Web of Science following PRISMA guidelines. Eligible studies included those with ≥ 4 patients, in English, published between January 1980 and December 2023, comparing MVD vs. MVD + PSR for TN. Endpoints were pain cure, immediate post-operative pain improvement, long-term effectiveness, long-term recurrence, and complications (facial numbness, hearing loss, and intracranial bleeding). We pooled odds ratios (OR) with 95% confidence intervals with a random-effects model. I2 was used to assess heterogeneity, and sensitivity and Baujat analysis were conducted to address high heterogeneity. Eight studies were included, comprising a total of 1,338 patients, of whom 1,011 were treated with MVD and 327 with MVD + PSR. Pain cure analysis revealed a lower likelihood of pain cure in patients treated with MVD when compared to patients treated with MVD + PSR (OR = 0.30, 95% CI: 0.13 to 0.72). Immediate postoperative pain improvement assessment revealed a lower likelihood of improvement in the MVD group when compared with the MVD + PSR group (OR = 0.31, 95% CI: 0.10 to 0.95). Facial numbness assessment revealed a lower likelihood of occurrence in MVD alone when compared to MVD + PSR (OR = 0.08, 95% CI: 0.04 to 0.15). Long-term effectiveness, long-term recurrence, hearing loss, and intracranial bleeding analyses revealed no difference between both approaches. Our meta-analysis identified that MVD + PSR was superior to MVD for pain cure and immediate postoperative pain improvement for treating TN. However, MVD + PSR demonstrated a higher likelihood of facial numbness complications. Furthermore, identified that hearing loss and intracranial bleeding complications appear comparable between the two treatments, and no difference between long-term effectiveness and recurrence.

Clinical Outcome of Partial Sensory Rhizotomy in Negative-Exploration Trigeminal Neuralgia and Technical Nuances

Background: Microvascular decompression is considered to be a potential treatment for most trigeminal neuralgia cases with obvious neurovascular conflict. Partial sensory rhizotomy (PSR) is an alternate option in cases of negative investigation for neurovascular conflict, although its effectiveness and technical complexity are still being debated. Objective: To evaluate the therapeutic efficacy of PSR following negative-exploration trigeminal neuralgia (NETN) in terms of pain control, adverse effects from sensory fiber destruction, and patient satisfaction in the short-term or after 1 month, and in the long-term or after 12 months. In addition, technical nuances were highlighted to mitigate the negative effects of PSR. Materials and Methods: The present study enrolled 27 NETN patients, and all were operated by the same neurosurgeon. The patients underwent surgery via a keyhole retromastoid technique, with extensive exploration for any possible intraoperative neurovascular conflict. A modified PSR approach was used to operate on these negative exploration cases, and this entailed cutting fewer than 1/5 of the trigeminal sensory fibers. The short-term or within one month, and long-term or after one-year intervals were used to track all instances. The therapeutic efficacy of employing pain score and subjective sensation in terms of pain control, adverse consequences from sensory fiber destruction, and patient satisfaction were investigated. Results: Eighty-five point two percent of patients reported excellent pain control following PSR, in terms of both pain score and total pain alleviation. Despite having their trigeminal nerve fibers severed, not all of the patients experienced numbness, and 45% of patients recovered to some extent on their own within a year. Only 13% of patients had Anesthesia Dolorosa in the present trial, which could be attributable because only 1/5 of the trigeminal nerve fibers were severed. There was no relationship between pain distribution and pain alleviation efficacy before and after PSR. When PSR was effective, most patients should notice an improvement within a month of the surgery. Conclusion: For patients with negative exploration following keyhole suboccipital craniectomy, PSR proved to be therapeutic and effective in alleviating trigeminal neuralgic pain. The majority of the patients can tolerate the minor side effects from minute nerve destruction well, particularly numbness, which partially resolves on its own with time. Keywords: Negative exploration; Trigeminal neuralgia; Microvascular decompression; Partial sensory rhizotomy; Efficacy

Surgical Treatment for Trigeminal Neuralgia.

Various treatments for trigeminal neuralgia (TN) are known to yield initial satisfactory results; however, the surgical treatment has excellent long-term outcomes and a low recurrence rate. Surgical treatment addresses the challenge of vascular compression, which accounts for 85% of the causes of TN. As for surgical treatment for TN, microvascular decompression (MVD) has become the surgical treatment of choice after Peter J. Jannetta reported the results of MVD surgery in 1996. Since then, many studies have reported a success rate of over 90% for the initial surgical treatment. Most MVDs aim to separate (decompress) the culprit vessel from the trigeminal nerve. To increase the success rate of surgery, accurate indications for MVD and management of the offender vessels without complications are critical. In addition, if there is no vascular compression, partial sensory rhizotomy or internal neurolysis can be performed to improve surgical outcomes.

Risk factors of herpes simplex virus reactivation after surgery for primary trigeminal neuralgia

The objective of this study is to investigate the risk factors of oral or facial herpes simplex virus (HSV-1) infection after primary trigeminal neuralgia (PTN). The clinical data of 33 PTN patients admitted by the same surgeon in the neurosurgery were retrospectively analyzed. Among the 33 patients, 26 patients underwent microvascular decompression (MVD), 6 patients who have not been found the clear offending vessels during the operation underwent partial sensory rhizotomy (PSR), and only one underwent adhesive band separation. Thirteen patients with postoperative oral and facial HSV-1 infection were selected as the herpes group, and the remaining 20 patients without postoperative oral and facial HSV-1 infection were selected as the non-herpes group. The differences between the two groups were compared by statistical analysis of factors such as gender, age, operation mode, operation time, and serum HSV-1 antibody titer value before surgery. Compared with the non-herpes group, there were no statistically significant differences in sex ratio (P = 0.930), age composition (P = 0.261), or disease profile (P = 0.226). Twenty-six patients underwent MVD operation, eight of whom were infected, and the difference between the two groups was statistically significant (P = 0.029). The operation time of the herpes group was 10-30min, which was significantly longer than that of the non-herpes group. The difference in operation time between the two groups was statistically significant (P = 0.023). Serum HSV-1-IgM was negative (< 0.9 COI) in all patients before surgery, but the positive rate of HSV-1-IgG (≥ 1.1 COI) was 97%, and the titer was greater than four times in 97% (32/33) of patients. The titer of IgG antibody in the herpes group was significantly lower than that in the non-herpes group, and the difference between the two groups was statistically significant (P = 0.017). The serum HSV-1-IgG in most of the PTN patients was positive. Latent HSV-1 in the trigeminal ganglion may be reactivate after PTN surgery to produce ipsilateral oral and facial herpes infection. The infection of HSV-1 reactivation after PTN surgery was positively correlated with the operation time but negatively correlated with the titer of HSV-1-IgG antibody before PTN surgery. The incidence of HSV-1 infection after PTN operation is related to different surgical procedures.

Clinical Efficacy of Combined Microvascular Decompression (Mvd) and Partial Sensory Rhizotomy (Psr) for Trigeminal Neuralgia

Objective — To analyze the effect of microvascular decompression combined with partial sensory root resection in the clinical treatment of trigeminal neuralgia. Methods — A total of 54 patients with trigeminal neuralgia admitted to our hospital from June 2018 to June 2021 were selected as the research samples, and they were divided into the reference group (n=27) and the observation group (n=27) according to the random number table method. The reference group received microvascular decompression, while the observation group received partial sensory root resection and microvascular decompression. The treatment effect and complications of the two groups were observed, and the sleep quality and pain degree of the two groups before and after treatment were compared. Results — After treatment, the effective rate of the observation group was approximately the same as that of the reference group (P > 0.05), and the complication rate of the observation group was higher than that of the reference group, but there was no statistical difference (P > 0.05). In addition, there were no significant differences in VAS and PSQI scores between the two groups before and after treatment, and the data were similar (P > 0.05). Conclusion — For the treatment of trigeminal neuralgia, microvascular decompression has a good effect, and the effect of partial sensory root resection is also good, which can be selected as appropriate.

Recurrence Rates After Microvascular Decompression in Patients With Primary Trigeminal Neuralgia and Its Influencing Factors: A Systematic Review and Meta-Analysis Based on 8,172 Surgery Patients

Background: Primary trigeminal neuralgia (PTN) is known to reoccur following microvascular decompression (MVD) surgery. However, the rates and contributing factors related to PTN recurrence remain controversial. The purpose of this study was to explore the postoperative recurrence rates and related influencing factors of patients with PTN after MVD. Additionally, recurrence rates after different treatments were compared to provide guidelines for clinicians.Methods: We conducted systematic reviews and meta-analyses in accordance with the preferred reporting items of the PRISMA guidelines. We searched nine databases, namely, the PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, VIP, and Wanfang databases, from establishment to July 13, 2020, selecting for studies about the long-term postoperative efficacy of MVD in the treatment of PTN. Factors associated with higher recurrence rates after MVD and long-term postoperative results of other treatments underwent formal meta-analysis, where odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were calculated. The dose-response model was used to inspect the associations between several factors and higher recurrence rates.Results: Seventy-four studies (8,172 patients, 32 case series studies, and 42 non-randomized controlled trials) were analyzed in our research. Overall, 956 out of 8,172 patients relapsed, and the pooled recurrence rate was 0.096 (0.080–0.113). Influencing factors of relatively higher recurrence rates included atypical trigeminal neuralgia symptoms, lack of nerve groove, non-arterial compression, patients who were 50–60 years old, and longer disease duration. Dose–response analysis showed that the recurrence rate had a significant trend with the published year and the follow-up time. Simultaneously, the recurrence rate of MVD treatment was much lower than that of conventional drug treatment, gamma knife surgery, percutaneous balloon compression, and radiofrequency thermocoagulation. When the surgical technique was improved or combined with partial sensory rhizotomy (PSR), the postoperative recurrence rates were significantly reduced.Conclusions: Even for PTN patients who have a successful operation, ~10% of them will still relapse. This research identifies several factors that can affect the recurrence rate. Compared with other operations, MVD has a relatively lower recurrence rate. Our analysis suggests that improved surgical techniques and combining PSR and MVD will yield better results.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020159276.

Value of Partial Sensory Rhizotomy in the Microsurgical Treatment of Trigeminal Neuralgia Through Retrosigmoid Approach.

PurposeMicrovascular decompression (MVD) is the most effective surgical procedure for the treatment of refractory primary trigeminal neuralgia (TN), but due to the presence of non-neurovascular compression (NVC), the application of MVD is limited. In some cases, partial sensory rhizotomy (PSR) is required. The purpose of this study was to compare the outcome of MVD and MVD+PSR in the treatment of primary TN and to evaluate the application value of PSR in the treatment of TN.Patients and MethodsWe retrospectively analyzed the postoperative outcomes of patients who received MVD or MVD+PSR for the first time from the same surgeon in the neurosurgery department of China-Japan Friendship Hospital from March 2009 to December 2017. A total of 105 patients were included in the data analysis, including 40 in the MVD group and 65 in the MVD+PSR group.ResultsThe MVD group had an effectiveness rate of 60% and a recurrence rate of 31.4% after an average follow-up of 49.4 months. The MVD+PSR group had an average effectiveness rate of 69.2% and a recurrence rate of 28.6% after an average follow-up of 71.4 months. There was no statistically significant intergroup difference in long-term effectiveness (p=0.333) or recurrence rates (p=0.819). The incidence of facial numbness was significantly higher in the MVD+PSR group than in the MVD group (83.1% vs 7.5%; p<0.001). However, facial numbness had no significant effect on the patients’ daily life.ConclusionMVD+PSR and MVD have the same effectiveness in the treatment of primary TN. MVD+PSR is associated with a higher incidence of facial numbness than MVD, but the difference does not affect the patients’ daily life. PSR should have a place in the treatment of TN by posterior fossa microsurgery.

Personal experience with microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia.

BackgroundTrigeminal neuralgia (TN) is a severe, paroxysmal pain in the distribution of the fifth cranial nerve. Microvascular decompression (MVD) is the most widely used surgical treatment for TN. We undertook this study to analyze the effects of and complications of MVD and to refine the surgical procedure for treating TN.MethodsA total of 88 patients underwent for TN underwent surgery at our hospital. Among them, 77 patients underwent MVD alone, and 11 underwent partial sensory rhizotomy (PSR) with or without MVD. The medical records of these patients were retrospectively analyzed for patient characteristics, clinical results, offending vessels, and complications if any.ResultsThe mean follow-up duration was 43.2 months (range, 3–216 months). The most common site of pain was V2+V3 territory (n=27), followed by V2 (n=25) and V3 (n=23). The most common offending vessels were the superior cerebellar artery and anterior inferior cerebellar artery in that order. The overall rate of postoperative complications was 46.1%; however, most complications were transient. There were two cases of permanent partial hearing disturbance. In the MVD alone group, the cure rate was 67.5%, and the improvement rate was 26.0%. Among 11 patients who underwent PSR with or without MVD, the cure rate was 50.0%, and the improvement rate was 30.0%.Conclusion The clinical results of MVD were satisfactory. Although the outcomes of PSR were not as favorable as those of pure MVD in this study, PSR can be considered in cases where there is no significant vascular compressive lesion or uncertainty of the causative vessel at the surgery.

The Use of MRI in Preoperative Decision-Making for Trigeminal Neuralgia: A Single-Center Study

Few studies have examined associations between vascular compression and postoperative pain relief in patients undergoing microvascular decompression (MVD) for treatment of medically refractory type 1 trigeminal neuralgia (TN). The authors sought to examine for associations between vascular compression and postoperative pain relief to determine the utility of preoperative magnetic resonance imaging (MRI) in surgical decision-making for TN. The charts of 59 patients who underwent 60 MVDs for TN between 2007 and 2017 at a single academic institution were reviewed. Patient demographics, the presence of compressing vessel on preoperative MRI and intraoperatively, complications, follow-up time, performance of a partial sensory rhizotomy, and pain resolution at most recent follow-up were recorded. Sensitivity and specificity of MRI for detecting vascular compression were calculated and associations between preoperative and intraoperative evidence of vascular compression with postoperative pain relief were examined. Sensitivity and specificity of preoperative MRI determined through blinded reads by the senior author were 65.3% (95% confidence interval, 13.5-32.0) and 90.9% (95% confidence interval, 86.1-100.0), respectively. Overall, 76.3% of patients were pain free at most recent follow-up. Preoperative MRI and intraoperative evidence of vascular compression were not associated with postoperative pain relief at most recent follow-up (P= 0.47 and 0.43, respectively). The findings of lower sensitivity and poor interrater reliability of MRI, as well as a lack of association between compressive vessel and postoperative pain relief reported in this study, suggest the decision to pursue MVD for TN should be based more heavily on classic symptomatic presentation over preoperative evidence of vascular compression.

The efficiency of micro-vascular decompression versus micro-vascular decompression with partial sensory rhizotomy for classical trigeminal neuralgia – a retrospective analysis of 58 patients

The efficiency of micro-vascular decompression versus micro-vascular decompression with partial sensory rhizotomy for classical trigeminal neuralgia – a retrospective analysis of 58 patients

Internal neurolysis: ‘nerve combing’ for trigeminal neuralgia without neurovascular conflict – early UK outcomes

Introduction Internal neurolysis (INL) is a surgical procedure where trigeminal nerve fibres are separated between the pons and porus trigeminus to relieve trigeminal neuralgia (TN). We report pain and functional outcomes to evaluate its safety and efficacy. Materials and methods Prospective cohort of all patients undergoing retrosigmoid craniotomy and INL between 2015 and 2017 at University Hospital Southampton. Patients with type I (6) or type II (2) refractory TN and no clear neurovascular conflict were offered INL as an alternative to partial sensory rhizotomy. Barrow Pain Intensity Scale (BNI) and Brief Pain Inventory Facial scores (BPI-Facial) were assessed. Minimum follow-up was 2 years'. Results Eight patients (7F:1M) underwent INL. Two had MS. Pre-operatively, all had severe pain (BNI grade V) and the median BPI-Facial score was 115 (range 79–123).. There were no unexpected complications. On last follow-up, six (75%) had no pain (BNI grade I), while two (25%) had recurred (at 5 and 27 months). Median BPI-Facial score for all patients on the last follow-up was 20 (range 18–91) reflecting dramatically improved quality of life and activities. Conclusions INL is a potentially safe and effective treatment for refractory TN. Long-term efficacy is unknown, but early results are promising.

Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery.

Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly. A prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up. One hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I-IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control. In this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient's unique condition and wishes.

Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why

BackgroundDuring the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call “trigeminal root massage” (TRM). Methods52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. ResultsAll 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. ConclusionsThe described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don’t find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as “nerve combing”. Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.

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.

Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why.

During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call "trigeminal root massage" (TRM). 52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don't find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as "nerve combing". Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.

Factors That May Affect Delayed Relief Of Trigeminal Neuralgia After Microneurosurgery And The Long-Term Outcomes Associated With Delayed Relief.

ObjectiveMicrovascular decompression (MVD) combined with partial sensory rhizotomy (PSR) with the retrosigmoid approach has become the most effective surgical treatment for trigeminal neuralgia (TN). There is variability in the pain relief processes observed in postoperative patients. The purpose of this study was to investigate delayed relief (DR) and its predictors after MVD and/or PSR for the treatment of TN and study the long-term effects associated with DR.MethodsPatients with primary TN who underwent MVD and/or PSR by the same surgeon at the China-Japan Friendship Hospital from March 2009 to December 2017 were included in the study, and all patients were followed for at least 1 year after the operation. DR was defined as follows: no changes in the Barrow Neurological Institute (BNI) score on the third day after surgery and a BNI score of I-II in the absence of any medication after a period of pain. Preoperative, intraoperative and postoperative differences were compared between the DR and non-DR groups, and the relationships between the various factors and DR was analyzed.ResultsA total of 105 patients, including 20 patients with DR (19%), 78 patients with non-DR (74%), and 7 patients without relief, were included in this study. The follow-up period ranged from 13 months to 118 months (average, 5.39 years/65 months). The duration of postoperative pain in the DR group was 3–365 days, with an average of 108 days. Statistical analysis found that no factor predicted the occurrence of DR, and the occurrence of postoperative DR did not affect the long-term effects observed in patients.ConclusionDR did not affect the long-term effects after MVD and/or PSR. Therefore, it is recommended that patients should be monitored for approximately 3 months after MVD and/or PSR and then evaluated for surgical effects. No reoperations should be performed immediately.

Gamma Knife Radiosurgery in Recurrent Trigeminal Neuralgia after Other Procedures

Objectives Trigeminal neuralgia (TN) is undurable paroxysmal pain in the distribution of the fifth cranial nerve. Invasive treatment modalities for TN include microvascular decompression (MVD) and percutaneous procedures, such as, radiofrequency rhizotomy (RFR). Gamma Knife radiosurgery (GKRS) is a considerable option for patients with pain recurrence after an initial procedure. This study was undertaken to analyze the effects of gamma knife radiosurgery in recurrent TN after other procedures. Methods Eleven recurrent TN patients after other procedures underwent GKRS in our hospital from September 2004 to August 2016. Seven patients had previously undergone MVD alone, two underwent MVD with partial sensory rhizotomy (PSR), and two underwent RFR. Mean patient age was 60.5 years. We retrospectively analyzed patient's characteristics, clinical results, sites, and divisions of pain. Outcomes were evaluated using the Visual Analog Scales (VAS) score. Results Right sides were more prevalent than left sides (7:4). The most common distribution of pain was V1 + V2 division (n = 5) following V2 + V3 (n = 3), V2 (n = 2), and V1 + V2 + V3 (n = 1) division. Median GKRS dose was 80 Gy and the mean interval between the prior treatment and GKRS was 74.45 months. The final outcomes of subsequent GKRS were satisfactory in most cases, and at 12 months postoperatively ten patients (90.0%) had a VAS score of ≤ 3. Conclusions In this study, the clinical result of GKRS was satisfactory. Invasive procedures, such as, MVD, RFR are initially effective in TN patients, but GKRS provides a safe and satisfactory treatment modality for those who recurred after prior invasive treatments.

Long-term pain relief at five years after medical, repeat surgical procedures or no management for recurrence of trigeminal neuralgia after microvascular decompression: analysis of a historical cohort

Background: Management strategies for the recurrence of trigeminal neuralgia after microvascular decompression include repeat procedures, medical management or no further therapy. No consensus exists as to which strategy is best for pain relief. The aim of this study was to determine the characteristics of patients with recurrences after microvascular decompression in the cohort, and to compare long-term pain relief between different management strategies.Materials and methods: A historical cohort of patients who underwent microvascular decompression at a neurosurgical institution between 1982–2002, followed up by postal survey at five years, was included. Characteristics of patients who experienced a recurrence were compared to those who were recurrence free, and pain relief was compared between each management strategy.Results: From 169 responders who were included in the study, 28 (16.6%) experienced a recurrence after MVD. No characteristics were significantly different between patients who experienced a recurrence and those who did not. Repeat procedures, including repeat microvascular decompression, partial sensory rhizotomy or radiofrequency thermocoagulation, yielded the highest proportion of pain relief after recurrence (p = 0.031), with 63.6% of patients pain-free at five-years. There was no evidence to suggest that the choice of repeat procedure influenced the likelihood of pain relief after recurrence. No further treatment yielded 57.1% pain-free, whereas medical therapy had the lowest proportion of pain-free patients, at 10.0%.Conclusion: A variety of options are available to patients for recurrence of TN after microvascular decompression with repeat procedures yielding the greatest likelihood of long-term pain relief in this historical cohort. The choice of management should consider the mechanism of recurrence, the benefits and risks of each option and the severity of the pain. Regardless of the management strategy selected, careful phenotyping of patients before and after surgery is paramount.