Recurrent Trigeminal Neuralgia Research Articles

Use of glycerol in treatment of refractory trigeminal neuralgia - A report of 2 cases

We present 2 cases of Trigeminal neuralgia (TN) refractory to medicinal therapy. The patients had pain that was unilateral along distribution of the trigeminal nerve trunk, particularly the second and third trunk. Peripheral glycerol injection is a “minimally invasive therapy” that can be considered for patients refractory to medicinal treatment. Ease of administration and repeatability favors its use in a clinical setup. Both the patients responded very well to the treatment and 6 month follow up showed no recurrence of TN. Keywords: Trigeminal neuralgia, Glycerol injection, Treatment

Results of Multiple Gamma Knife Radiosurgery Treatments for Recurrent Trigeminal Neuralgia

Results of Multiple Gamma Knife Radiosurgery Treatments for Recurrent Trigeminal Neuralgia

Trigeminal Neuralgia Recurrence Post-Stereotactic Radiosurgery Unaffected by Integral Dose

Trigeminal Neuralgia Recurrence Post-Stereotactic Radiosurgery Unaffected by Integral Dose

Trigeminal interfascicular neurolysis (nerve combing) for refractory recurrent neuralgia in multiple sclerosis.

In multiple sclerosis (MS) patients, trigeminal neuralgia (TN) represents a challenging syndrome to treat, often refractory to medical therapy and percutaneous techniques. Despite the frequent lack of a neurovascular conflict, the trigeminal nerve’s axons are often damaged, with the myelin sheath permanently degenerated, thus explaining the difficulty in treating TN in MS.The authors illustrate trigeminal interfascicular neurolysis (the combing technique) to control refractory recurrent TN in MS: the nerve is longitudinally divided along its fibers from the root entry zone, determining good pain relief.The video can be found here: https://youtu.be/o1XksPW5fMY

Surgical Treatment of Trigeminal Neuralgia Combined with Tumors of the Cerebellopontine Angle

Introduction . Trigeminal neuralgia (TN) develops because of demyelination in the entry zone of the trigeminal nerve root (TNR) into the brainstem, which is accompanied by ectopic and cross-excitation of the nerve impulses with paroxysms of facial pain. One of the causes of TN are tumors of the cerebellopontine angle (CPA), which have a direct or indirect effect on the TNR. The optimal surgical approach in such cases depends on the anatomical relationship between the TNR and the tumor and vascular structures. The aim of the study was to evaluate the relationship between the anatomical variants of the TNR and the outcomes of using various surgical methods to treat TN in CPA tumors. Materials and methods. We performed a retrospective analysis of 52 patients (38 women and 14 men aged 22–82 years) with TN and ipsilateral tumors of the CPA: 29 with apical petrous meningiomas, 11 with epidermoid tumors, 10 with vestibular schwannomas, 1 with haemangioma, and 1 with cavernoma. Results. Six variants of the anatomical relationships of the TNR to CPA tumors and the adjacent vascular structures were identified: where the TNR is completely surrounded by the tumor; where the tumor compresses and displaces the TNR; where the tumor is located inside the TNR; where the tumor, together with the blood vessel, compresses the TNR; where the tumor displaces the TNR towards the vessel; and where the tumor is not in contact with the TNR, but the TNR is compressed by the blood vessel. Displacement and deformation of the TNR by CPA tumors was found in 50 patients, and no direct contact between the TNR nerve fibers and the neoplasm was observed in 2 cases. The neurovascular conflict caused by arterial and venous vessels was identified in 16 subjects. The type of a vascular decompression technique depended on the degree of stretching and deformation of the TNR. Postoperative MRI confirmed the complete removal of CPA tumors in 51 patients, while minor epidermoid residue in the contralateral cerebellopontine angle cistern was found in only one subject. There were no fatalities after surgical interventions, and the postsurgical cranial nerve neuropathies were transient and regressed within 2–3 months. In 15 cases, hypoesthesia developed or worsened in the trigeminal nerve innervation zone, then disappeared within several weeks, and was not accompanied by a recurrence of TN. Facial sensitivity improved in 6 cases, who had not previously undergone any surgical manipulations of the TNR and its peripheral branches. Complete regression of TN in the immediate postoperative period was observed in 51 patients. A percutaneous radiofrequency trigeminal rhizotomy was performed in 1 subject with an epidermoid tumor, to eliminate the intense pain paroxysms that persisted for a week. No recurrent growth of CPA tumors or relapses of TN were observed during the subsequent follow-up period of 2–10 years. Conclusion. TN can be caused by direct compression and deformation of the TNR and brainstem by CPA tumors and vascular structures. A detailed examination of the entire length of the TNR after tumor removal is necessary to evaluate the neurovascular relationships. In cases of vascular compression of the TNR, various methods of microvascular decompression can be used to treat TN.

Abstract No. 571 Computed tomography–guided percutaneous radiofrequency thermocoagulation for recurrent trigeminal neuralgia: initial experience

Abstract No. 571 Computed tomography–guided percutaneous radiofrequency thermocoagulation for recurrent trigeminal neuralgia: initial experience

Trigeminal neuralgia management after microvascular decompression surgery: two case reports

Trigeminal neuralgia (TN) involves chronic neuropathic pain, characterized by attacks of repeating short episodes of unilateral shock-like pain, which are abrupt in onset and termination. Anticonvulsants, such as carbamazepine, are the gold standard first-line drugs for pharmacological treatment. Microvascular decompression (MVD) surgery is often the course of action if pharmacological management with anticonvulsants is unsuccessful. MVD surgery is an effective therapy in approximately 83% of cases. However, persistent neuropathic pain after MVD surgery may require reintroduction of pharmacotherapy. This case report presents two patients with persistent pain after MVD requiring reintroduction of pharmacological therapy. Although MVD is successful for patients with failed pharmacological management, it is an invasive procedure and requires hospitalization of the patient. About one-third of patients suffer from recurrent TN after MVD. Often, alternative treatment protocols, including the reintroduction of medications, may be necessary to achieve improvement. This case report presents two cases of post-MVD recurrent pain. Further research is lacking on the success rates of subsequent medication therapy after MVD has proven less effective in managing TN.

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.

Factors Associated With Long-term Risk of Recurrence After Percutaneous Radiofrequency Thermocoagulation of the Gasserian Ganglion for Patients With Trigeminal Neuralgia: A Multicenter Retrospective Analysis.

This study aimed to estimate risk factors associated with recurrence after radiofrequency thermocoagulation (RFT) of the Gasserian ganglion among a large sample of patients with trigeminal neuralgia (TN) during a long-term follow-up. We performed a multicenter retrospective analysis of data from 1481 patients with TN who underwent RFT from 2005 through 2017. Recurrence-free survival (RFS) was assessed by the Kaplan-Meier method. Risk factors of all patient characteristics were determined by using univariate and multivariate Cox regression analysis. Prognostic value was determined by prognostic index (PI) with regression coefficients and receiver-operating characteristic curve model. The median of RFS was 136 months (95% confidence interval [CI]: 123.5-148.5). The rate of RFS was 85.3% (95% CI: 83.5%-87.1%) at 1 year, 74.6% (95% CI: 72.2%-77.0%) at 3 years, 68.0% (95% CI: 65.5%-70.5%) at 5 years, and 54.9% (95% CI: 51.6%-58.2%) at 10 years. Multivariate analysis showed that atypical facial pain (hazard ratio [HR]=16.914, 95% CI: 13.117-21.808, P<0.001), Barrow Neurological Institute (BNI) Class II/III facial hypesthesia before undergoing RFT (HR=2.47, 95% CI: 1.52-4.016, P<0.001)/(HR=3.288, 95% CI: 1.035-10.433, P=0.044), and history of previous microvascular decompression/RFT/neurosurgeries≥2 (HR=1.642, 95% CI: 0.941-2.863, P=0.041)/(HR=2.808, 95% CI: 1.819-4.334, P<0.001)/(HR=3.83, 95% CI: 1.802-8.146, P<0.001) were independently associated with RFS. Patients with PI>0.764 were identified as high-risk patients for TN recurrence with a median RFS of 36 months (95% CI: 23.9-48.1) compared with those with PI<0.764 (HR=6.785, 95% CI: 5.371-8.573, P<0.001). Our results indicated the patients with a higher risk for recurrence after RFT for the treatment of TN. In addition, our findings might provide support for clinical decision-making before the RFT procedure.

Results of a Third or Fourth Radiosurgery for Trigeminal Neuralgia

Stereotactic Radiosurgery SRS is an accepted option for treatment of medically refractory trigeminal neuralgia (TN) with a median duration of pain relief of 5 years. Repeat SRS for recurrent pain has been well described with similar results. Data regarding the use of a third or fourth SRS for recurrent pain are limited. Here we report the largest series to date on the use of a third or fourth SRS for TN. Retrospective review of a single institution SRS database identified 24 cases of unilateral TN in 23 patients who were treated with 3 sessions of SRS from 1999 to 2018. 3 patients underwent a fourth SRS. Background history, treatment outcomes and toxicity, and dosimetric data were obtained by chart review and telephone interview. Pain relief was defined using the Barrow Neurological Institute (BNI) scale. Categorical variables were compared using the chi square or Fisher’s exact test. Duration of at least BNI IIIB pain relief was estimated using the Kaplan-Meier method and compared with the log-rank test. Univariate cox proportional hazards were used to evaluate for predictors of pain relief. 22 of 24 cases had sufficient follow up to determine BNI pain outcomes. 18 of the 22 cases (82%) achieved at least BNI IIIb pain relief. At a median follow up of 1.96 years, the median duration of at least BNI IIIb pain relief after third SRS was 3.90 years, with 1, 3, and 5 year pain relief rates of 59%, 51%, and 38% respectively. New or worsening facial numbness was seen in 9 cases (41%) with 1 (4.5%) being reported as bothersome. 1 case (4.5%) of corneal abrasions requiring surgery and 2 cases (9%) of dry eye without vision loss or corneal abrasions, and 0 cases of anesthesia dolorosa were reported. The median dose at third SRS was 75 Gy (range 75-85). All 3 patients treated with a fourth SRS had at least BNI IIIb pain relief with no relapse at a median follow up of 2.54 years. No cases of severe numbness or toxicity were reported after fourth SRS. No factors predicting initial response to a third SRS were identified. Patients with a successful second SRS were less likely to experience pain relapse after third SRS (HR 0.12, p = .02). Third and fourth SRS had a longer durability of pain relief than first and second SRS (p = .02). No factors predictive of numbness after third SRS were identified. Non-numbness toxicity after third SRS was associated with a higher dose to the pons surface (median 41.6 Gy vs 16.9 Gy, p < .01) and decreased distance from the isocenter to the pons surface (median 2.9 mm vs 4.6 mm, p < .01). A third or fourth SRS is an effective treatment option for recurrent TN and may be more durable than the first or second SRS. Durable relief is more likely in patients with a successful second SRS. Toxicity rates appear to increase with third SRS, and dose to the pons should be limited to decrease this risk. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

Surgical Outcomes After Microvascular Decompression With Internal Neurolysis and Partial Neurectomy for Patients With Trigeminal Neuralgia and Negative Neurovascular Compression

Abstract INTRODUCTION Microvascular decompression (MVD) is an effective and durable treatment for patients with trigeminal neuralgia (TN) due to neurovascular compression (NVC). In the absence of NVC, the traditional MVD is less effective in achieving long-term pain relief. Internal neurolysis at the root entry zone (REZ) of the trigeminal nerve has been described in the literature; however, there are few reports of long-term outcome after this procedure. Furthermore, this is the first study to combine this procedure with additional partial neurectomy. METHODS This is a retrospective review of the senior author's patients with TN who underwent retrosigmoid craniectomy for MVD with internal neurolysis and partial neurectomy. Primary indications were patients with TN and no evidence of NVC intraoperatively. A total of 9 patients were included in the analysis. Three cases were of recurrent TN. The technique was performed with an 11-blade or arachnoid knife to open the perineurium in a longitudinal fashion at the REZ. A disc dissector was used to comb the fascicles along the longitudinal course, and a partial neurectomy was performed with a microscissors to make three selective cuts into the fascicles at the REZ. Barrow Neurological Institute (BNI) facial pain and numbness scales were used as postoperative assessment. RESULTS At median follow up of 12 mo (range: 2 to 34), 8 of 9 patients (89%) had a BNI-pain score of I (no trigeminal pain, no medications). Two of nine patients (22%) had a BNI-numbness score of I (no numbness); seven (78%) had a BNI-numbness score of II (mild facial numbness that is not bothersome). CONCLUSION Internal neurolysis with partial neurectomy appears to be an effective and potentially durable treatment option for patients with TN (primary or recurrent) without NVC. Larger series with longer follow-up is indicated to further evaluate the utility of this procedure.

Trigeminal Neuralgia: Indications of Gasserian Ganglion Gompression with Balloon Catheter in the Modern Era

Many therapies are available for trigeminal neuralgia (TN), from medical therapy to invasive, mininvasive and non-invasive methods. There is no a unique indication concerning the choice of treatment; we report our indications for gasserian ganglion compression with balloon by percutaneous approach. Out of 421 patients affected by TN treated with various methods from 2004 through to 2014, we present 46 patients treated by gasserian ganglion compression with balloon catheter. Patients selected for this procedure were only those refractory to medical therapy and refractory to the other available therapies (radiofrequency, microvascular decompression, radiosurgery, glycerolization, peripheral alcoholizations): balloon compression was performed as third line therapy. After the procedure, twenty-eight patients were classified as BNI pain intensity score grade 1, seven other as grade 2, three other as grade 3, six were classified as BNI grade 4, and in one patient no improvement of pain occurred (BNI grade 5). After an average period of follow up of 8,6 years, four cases of pain recurrence occurred. Because balloon compression is an ablative and non-selective procedure and all three trigeminal divisions are damaged to achieve stable pain remission, the procedure was performed only in patients affected by recurrent TN refractory to the other available methods.

Personalized needle modification for CT-guided percutaneous infrazygomatic radiofrequency ablation of the maxillary nerve through the foramen rotundum in order to treat V2 trigeminal neuralgia.

Background: The computed tomography (CT)-guided radiofrequency ablation (RFA) of the maxillary nerve (V2) via foramen rotundum (FR) approach has been reported to offer the highest rates of pain relief in V2 trigeminal neuralgia (TN). However, the access to FR may be obstructed by the greater wing of the sphenoid bone.Objectives: We report on an optimized CT-guided percutaneous infrazygomatic of maxillary nerve through the foramen rotundum (FR) to treat V2 trigeminal neuralgia (TN) using personalized RFA needles based on patient’s individual CT-image parameters.Patients and methods: 176 patients with isolated V2 TN were included. If the entry of the percutaneous needle into the FR canal was blocked by the greater wing of the sphenoid bone, straight RFA needles was bent at the tip with an angle α (the angle between the straight line from the external opening of FR to the skin entry point and the long axis of the FR canal). The maxillary nerve RFA was performed after confirmation with electrophysiological tests. Pain relief in the V2 territory and TN recurrence rate were followed for up to 60 months.Results: Fifty-two patients (29.55%) required needle bending. The maxillary nerve thermal RFA resulted in analgesia in the V2 territory without affecting the V1 or V3 zone. TN recurrence rate at 6, 12, 24, 36, 48 and 60 months was 2.55%, 7.64%, 17.20%, 24.41%, 30.28% and 33.77%, respectively.Conclusion: The personalized needle modification technique for maxillary nerve RFA through FR is safe and effective to treat V2 TN.

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.

Repeat microvascular decompression for patients with persistent or recurrent trigeminal neuralgia: Prognostic factors and long-term outcomes.

Patients with persistent or recurrent trigeminal neuralgia (TN) after microvascular decompression (MVD) are frequently difficult to manage. This study aimed to analyze the safety and efficiency of repeat MVD, with the main focus on prognostic factors and long-term outcomes.We performed a retrospective study of 41 TN patients (19 men, 22 women) who underwent repeat MVD due to persistent or recurrent pain from January 2008 to January 2016. These patients were followed up from 12 to 96 months (mean, 42 ± 17.3 months). Univariate analysis by Spearman's rank correlation coefficient was used for analysis of prognostic factors.During the repeat MVD, compression of the trigeminal nerve was noted by an artery in 15 patients (36.6%), vein in 6 patients (14.6%), Teflon in 8 patients (19.5%), and no compression in 12 patients (29.3%). Twenty-one patients (51.2%) had already undergone 1 or more previous ablative procedures, either before the first MVD or between the surgeries. The complete pain relief rates of repeat MVD were 87.8% immediately after surgery and 75% at last follow-up. Thirteen patients (31.7%) had new or increased facial numbness after repeat surgery. Univariate analysis revealed 2 prognostic factors, negative finding during reoperation (P = .021) and no pain relief after the initial surgery (P = .038), that showed a negative influence on success rates after repeat MVD.Repeat MVD can still achieve an excellent outcome in patients with persistent or recurrent pain. However, the risk of facial numbness is increased. Surgeons should be selective in performing repeat MVD, priority should be given to patients who have a pain-free interval after initial MVD or show demonstrable compression on imaging studies.

Efficacy and Safety of Repeated Percutaneous Radiofrequency Thermocoagulation for Recurrent Trigeminal Neuralgia.

Background: Percutaneous radiofrequency thermocoagulation (PRT) is used to treat trigeminal neuralgia (TN) with a satisfactory pain relief but a high recurrence rate.Objective: To explore the efficacy and safety of repeated PRT for recurrent TN as compared to patients who received the first PRT.Methods: Between January 2013 to May 2013, 31 patients with recurrent TN who have been treated with PRT previously were recruited and underwent repeated PRT (group A), and compared with 41 TN patients received the first initial PRT (group B). Visual Analog Scale (VAS) score was assessed preoperatively and postoperatively after 2 years of follow-up, and compared in terms of initial pain relief, complications, and recurrence rate between the two groups.Results: In group A, 27 patients (87.0%) were pain free immediately, and 30 patients (96.8%) experienced pain relief at 48 h, whereas that was 37 patients (90.0%) and 40 patients (97.6%) in group B (p ≧ 0.05). Patients in group A who remained an “excellent” or “good” pain relief condition (VAS score ≦ 1) were 96.8% at 6 months, 83.9% at 1 year, 74.2% at 2 years, whereas the percentage in group B was 97.6, 85.4, and 73.2% (p ≧ 0.05).Conclusion: For patients with recurrent TN after PRT, repeated PRT might be considered as a useful treatment option when other treatments fail. In addition, the frequency and severity of adverse events for repeated PRT were similar as compared to initial PRT.

Prospective Comparison of Redo Microvascular Decompression and Percutaneous Balloon Compression as Primary Surgery for Recurrent Trigeminal Neuralgia.

ObjectiveTo prospectively compare facial pain outcomes for patients having either a repeat microvascular decompression (MVD) or percutaneous balloon compression (PBC) as their surgery for trigeminal neuralgia (TN) recurrence. MethodsProspective cohort study of 110 patients with TN recurrence who had either redo MVD (n=68) or PBC (n=42) from July 2010 until September 2016. The mean follow-up was 45.6 months. ResultsAfter redo MVD, 65 patients (95.6%) experienced immediate relief of pain. After PBC, 34 patients (81%) were immediately relieved of their neuralgia. After 1 month, the clinical effect of redo MVD was better than PBC (p<0.01). Patients who had redo MVD more commonly were pain free off medications (93.4% at 1 year, 78.2% at 4 years) compared with the PBC patients (85.1% at 1 year, 59.3% at 4 years). However, mean length of stay was longer (p>0.05). Patients after PBC who occurred developed herpes simplex (35.7%), facial numbness (76.2%), and annoying dysesthesia (21.4%) more frequently compared with patients after redo MVD who occurred developed herpes simplex (14.7%), facial numbness (8.8%), and hypoesthesia (5.9%) (p<0.05). The symptoms recurred respectively in 15 patients (22.1%) and 19 patients (45.2%) after redo MVD and PBC within the entire 6-year follow-up period. ConclusionFor the patients with TN recurrence, redo MVD was a more effective procedure than PBC. The cure rate and immediate relief of pain were better, and the incidence of complications was lower.

Posterior Fossa Re-Exploration for Recurrent Trigeminal Neuralgia: Operative Findings and Surgical Techniques.

Microvascular decompression (MVD) is considered the first choice for the surgical treatment of trigeminal neuralgia (TN). However, recurrence after MVD is still a problem and a challenge for neurosurgeons. In this study, we share our experience in the posterior fossa re-exploration of the recurrent cases. From January 2014 to January 2015, 15 recurrent TN patients who received fossa re-exploration were retrospectively studied. Surgeries were performed by retrosigmoid suboccipital approach. Brainstem auditory evoked potentials (BAEP) were monitored throughout the operation. Intraoperative findings and surgical techniques were recorded. Postoperative outcomes and complications were analyzed. Among the 15 patients, Teflon adhesion was found in 14. Teflon felt displacement was found in 4 patients, and additional Teflon felt was used to interpose. New offending vessels were found in 5 patients. Three of them were small arteries and the other 2 were petrosal veins. After dissected, small pieces of wet gelatin sponge and Teflon felt were implanted respectively to ensure complete decompression. The remaining 6 patients had no vascular compression except severe adhesion, and nerve combing was performed. After surgery, 12 achieved complete pain relief, 2 gained partial pain relief, and 1 failed. Six patients experienced facial numbness postoperatively. There was no hearing impairment or other complications. During the mean 26-month follow-up, no recurrence occurred and all of 6 cases with facial numbness after surgery improved. Teflon adhesion is a significant cause of recurrent TN. Wet gelatin-assisted method is good for Teflon interposition. If no vascular compression is found during re-exploration, trigeminal nerve combing can be used. Intraoperative BAEP monitoring is helpful to reduce the incidence of hearing loss.

Revision Microvascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm: Factors Associated with Surgical Failure.

Objective To investigate risk factors for symptom recurrence in patients requiring a revision microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS). Design Retrospective review of a prospectively maintained database. Participants Seventeen consecutive patients undergoing revision MVD at our institution between January 1993 and September 2017. Main Outcome Measures The incidence and causes for revision MVDs were recorded. Response to revision MVD for TN was tracked using the Barrow Neurological Institute (BNI) grading scale. Response to revision MVD for HFS was graded as "no improvement," "some relief," or "complete resolution" of symptoms. Results Revision MVD rate for the senior author across all MVDs performed in this period was 1.9% for TN and 9.3% for HFS. Initial MVD failure was primarily caused by active inflammation and/or scarring and adhesions in 5/17 patients, malposition/slippage of Teflon in 3/17 patients, and insufficient Teflon in 1/17 patients. Without other factors, a new site of neurovascular conflict was identified in 4/17 patients, while the same site of neurovascular conflict was found in 3/17 patients. No cause could be identified in 1/17 patients. Scarring was found primarily in the TN group and was associated with symptom persistence. Conclusion Revision MVD for recurrent TN and HFS is an effective procedure offering the prospect of a complete cure. Proper Teflon use is crucial for surgical success. Scarring after initial MVD is a negative prognostic factor requiring destructive treatment consideration. Although morbidity rates were slightly increased with revision versus original MVDs, the complications were non-disabling and resolved over time.

Quantitative analysis of the safety and efficacy of microvascular decompression for patients with trigeminal neuralgia above and below 65 years of age

For medically-refractory trigeminal neuralgia (TN), microvascular decompression (MVD) is the first-line treatment, and has demonstrated the greatest efficacy and durability. However, due to potential surgical complications, a bias may exist against performing MVD in elderly patients. We sought to determine through a quantitative analysis whether MVD in the elderly is a safe and effective procedure for TN. We completed a Pubmed/SCOPUS literature search up to 12/2016 for eligible studies on MVD for TN. Only research articles with age stratification of results were included. In this quantitative analysis, we analyzed the data for the six articles identified in the literature comparing MVD for a group of patients ≥65 years with an elderly group <65 years. A total of 1483 were included. 455 patients were ≥65 years (mean 70.8 years, range 65–89 years) and 1028 patients were <65 years (mean 53.4 years, range 19–64 years). Composite mean follow-up time was 51.6 months for the elderly group, and 55.1 months for the young group. Following MVD, each group had 1 mortality (p = 0.43). There were 21 serious morbidities in the elderly group (4.62%) and 32 in the young group (3.11%) (p = 0.11). In addition, 15 patients (1.46%) in the elderly group and 24 patients (1.62%) in the young group experienced a cerebrospinal fluid leak (p = 0.23). TN recurrence rates 9.23% in the young group and 13.33% in the elderly group (p = 0.070). In conclusion, for properly-selected surgical candidates, MVD should not be ruled out on the basis of age ≥65 years.