Recurrent Trigeminal Neuralgia Research Articles

Percutaneous Microballoon Compression for Trigeminal Neuralgia Using Dyna-CT

Percutaneous microballoon compression (PMC) is a well-established technique for treatment of trigeminal neuralgia (TN). However, direct puncture of the foramen ovale (FO) is sometimes difficult and there have been well-reported complications from cannulating the FO. We describe our experiences in using Dyna-CT for cannulating the FO and determining balloon position and volume. Dyna-CT was used to perform image reconstruction in 21 cases. The optimal working projection was generated and further fluoroscopic data were used to determine the needle's relationship to the foramen during puncture. Furthermore, the balloon position and three-dimensional shape were verified by Dyna-CT during balloon compression. The balloon volume and puncture angle were further calculated. Patients' prognosis was further discussed. Dyna-CT allowed quick, safe, and easy cannulation of the FO. It provided three-dimensional images which were more elaborate than the classic 'pear-shaped' images for determining correct positioning in 21 cases. The volume of the flattened balloon ranged from 568.2 mm(3) to 891.4 mm(3) with an average of 775.9 mm(3). The angle of introducing the cannula ranged from 15.17°-35.48° rotation to the midline with an average of 26.24° and 38.47°-51.89° angulation to the Reid line with an average of 46.09°. All the patients were pain free after PMC. Four patients had resolvable masseter weakness and fine touch loss. There was no recurrence of TN during follow-up. Dyna-CT demonstrated three advantages in assisting PMC. Firstly, the FO can be better visualized irrespective of the patient's position. Secondly, needle correction or insertion can be performed much more easily because of the direct fluoroscopic control. Thirdly, the needle position, balloon position, balloon configuration and the volume of the inflated balloon are more reliably determined. The use of dyna-CT provided an assisted method to PMC with a low incidence of complications and good prognosis.

Dyna-CT-assisted percutaneous microballoon compression for trigeminal neuralgia

BackgroundPercutaneous microballoon compression (PMC) for trigeminal neuralgia (TN) is a well-established technique. However, complications from cannulating the foramen ovale (FO) have been reported because direct puncture of the FO is...

Positive neurologic phenomena with initiation of dalfampridine for multiple sclerosis

ObjectiveReview cases of positive neurologic phenomena initiated or worsened with dalfampridine in patients with multiple sclerosis. BackgroundOral, extended release dalfampridine (4-aminopyridine or 4-AP) is a potassium-channel blocker approved for the treatment of gait impairment in multiple sclerosis (MS). The enhanced conduction along demyelinated axons promoted by dalfampridine could potentially lead to development of positive neurologic phenomena. MethodsWe reviewed the medical records of patients who were started on dalfampridine for activation of positive sensory or motor symptoms. ResultsFour of 76 patients (5.3%) developed positive sensory symptoms within one month of starting dalfampridine; one additional patient had new-onset seizure. Cessation of dalfampridine was insufficient to resolve symptoms in two patients with recurrent trigeminal neuralgia. ConclusionsInitiation of dalfampridine may be associated with initiation or recurrence of positive sensory symptoms in patients with multiple sclerosis. The increased axonal conduction from potassium channel blockade may contribute to this exacerbation of positive sensory phenomena.

Recurrent Trigeminal Neuralgia at 20 Years After Surgery

Microvascular decompression (MVD) is now the most feasible method of treatment for trigeminal neuralgia (TN). The recurrence of symptoms is rarely encountered postoperatively. A female patient with typical right V3 distribution TN had been successfully treated by MVD at age 56 years by transposing the offending superior cerebellar artery, and she became completely pain-free postoperatively without sequelae. Twenty years after the first MVD, pain recurred on the right V2 distribution at age 76 years and she was operated on a second time to resolve the pain. Re-exploration surgery revealed that the trigeminal nerve was compressed mediocranially by the anterior inferior and posterior inferior cerebellar artery complex, which had not been close to the neural structure during the first surgery. The artery complex was successfully transpositioned to decompress the root exit zone (REZ) of the nerve and she became pain-free again. Although various causal factors likely contribute to recurrence of TN, the present case of recompression of a REZ occurred due to a newly developed offending artery which caused TN a long time after the first surgery.

Trigeminal neuralgia: Assessment of neurovascular decompression by 3D fast imaging employing steady-state acquisition and 3D time of flight multiple overlapping thin slab acquisition magnetic resonance imaging

Background:Trigeminal neuralgia is most commonly caused by vascular compression at the trigeminal nerve (TN) root entry zone. Microvascular decompression (MVD) has been established as a useful treatment. Outcome depends on the correct identification of the compression site and its adequate decompression at surgery. Preoperative identification of neurovascular compression might predict which patients will benefit from MVD. Management of persistent or recurrent trigeminal neuralgia after an MVD is a baffling problem for neurosurgeons. An accurate neuroradiological evaluation of the TN padding following a failed MVD might help identify the underlying cause and plan further treatment.Case description:A 68-year-old female presented with a right-sided trigeminal neuralgia (V3) refractory to medical therapy. A high-resolution three-dimensional magnetic resonance imaging (3D MRI) study included fast imaging employing steady-state acquisition (FIESTA) and time of flight multiple overlapping thin slab acquisition (TOF MOTSA) sequences to evaluate the neurovascular anatomy in the cerebellopontine angle. An unambiguous compression of the right TN at the rostral-medial site by the superior cerebellar artery (SCA) was identified. The SCA loop compressing the TN was identical in location and configuration to that predicted in the preoperative study. After the MVD, the patient was relieved from her pain and a postoperative high-resolution 3D MRI study confirmed the appropriate placement of the Teflon implant between the TN and SCA.Conclusion:To our knowledge, this is the first report that characterizes the proper TN padding by high-resolution 3D MRI after trigeminal MVD. The present case also emphasizes the importance of performing a 3D MRI in patients with trigeminal neuralgia to anticipate the surgeon's view and predict the outcome after MVD.

Perspectives on key articles in neurosurgery

Park, Kyung-Jae MD, PhD*,‡; Kondziolka, Douglas MD*; Berkowitz, Oren RPA-C, MSPH*; Kano, Hideyuki MD, PhD*; Novotny, Josef Jr PhD*; Niranjan, Ajay MS, MCh*; Flickinger, John C. MD*; Lunsford, L. Dade MD* Neurosurgery, 2012 Feb;70(2):295-305 Study Question: What is the efficacy of repeat radiosurgery on patients with recurrent trigeminal neuralgia? Methods: Park et al. performed a retrospective study on 119 patients who were previously treated with the gamma knife for trigeminal neuralgia. Patients were treated with a median target dose for 70 Gy (dose ranging between 50 and 90 Gy). The endpoints used were pain relief according to the Barrow Neurological Institute pain score and facial sensory dysfunction. Results: The authors reported that their median follow-up was 48 months (ranging between 6 and 187 months). Their median interval for treatment was 26 months. The authors reported that 87% of their patients experienced initial pain relief. At 1 year, 3 years, and 5 years, the pain relief rates were 87.8%, 69.8%, and 44.2%, respectively. The authors found that patients who presented with recurrent facial pain in a distribution smaller than their initial presentation had a more favorable prognosis. Facial sensory dysfunction rates were 21% within 18 months; however, facial sensory dysfunction was a favorable indicator for pain relief. The authors also found that having a higher dose of radiation to the brainstem correlated with sensory dysfunction. Conclusion: Park et al. conclude that repeat radiosurgery for trigeminal neuralgia can be as effective as the initial treatment in terms of pain relief. Perspective: Radiosurgery for trigeminal neuralgia was initially reserved for patients who were not good candidates for a microvascular decompression. However, there are an increasing number of patients with trigeminal neuralgia who are treated with radiosurgery. Given that radiosurgery is not as durable as a microvascular decompression for pain relief, there are an increasing number of patients who present with recurrent pain. Park et al. report that repeat treatments can be just as effective in pain control. However, the rate of facial sensory dysfunction is higher for the second treatment. Interestingly, for repeat treatments, sensory dysfunction appears to correlate with pain relief. Despite the fact that the rate of facial numbness is higher with a second treatment, the authors also point out that rhizotomies also carry a significant risk for facial sensory changes. Finally, the time to pain relief took 1.5 months which is similar to the latency for a first treatment. This paper suggests that we can safely use repeat radiosurgery for patients with recurrent TN. Summary written by: Michael Lim

Surgical Management of Medically Refractory Trigeminal Neuralgia

The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis-related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.

Clinicopathological review of patients with and without multiple sclerosis treated by partial sensory rhizotomy for medically refractory trigeminal neuralgia: A 12-year retrospective study

BackgroundTrigeminal nerve root entry zone demyelination has been implicated as a cause of trigeminal neuralgia (TN) in multiple sclerosis (MS) and patients with nerve root vascular compression. We have examined the relationship between pathology and treatment outcome in patients with and without MS, treated for intractable TN by partial sensory rhizotomy (PSR). MethodsWe reviewed the operative records, electron microscopic biopsy findings and post-operative satisfaction and pain scores of 23 MS and 47 non-MS patients who underwent PSR between 1992 and 2004. ResultsThe MS and non-MS patients had similar ages of onset of TN, duration of symptoms, age at surgery and proportions with typical and atypical symptoms. Demyelination was present in 16 MS and 23 non-MS patients (p=0.129), and a compressing vessel in 5 MS and 23 non-MS patients (p=0.039). Of those with demyelination, vascular compression was documented in 3 MS and 15 non-MS patients (p=0.008). Pain and satisfaction scores were similar in both groups. Recurrent TN was more commonly associated with a compressing vessel (p=0.019). ConclusionsTN is frequently associated with nerve root entry zone demyelination in MS and patients with nerve root vascular compression. The characteristics of the TN and response to PSR are similar in both groups. Persistent vascular compression increases the risk of recurrent TN after PSR.

Effectiveness of Repeat Glycerol Rhizotomy in Treating Recurrent Trigeminal Neuralgia

Percutaneous glycerol rhizotomy (GR) is used to treat trigeminal neuralgia (TN), with satisfactory pain relief lasting 2 to 3 years in most patients after the first intervention. The efficacy of subsequent GRs, however, has not been studied. To compare the pain relief and durability achieved by the first GR with those obtained after subsequent GRs in a retrospective cohort of TN patients. Between 1998 and 2010, 548 patients with TN underwent 708 GRs. After exclusions, 430 initial GRs (GR1) and 114 subsequent GRs (GR2+) were compared in terms of initial pain relief, durability, sensory change, and complications. Durability was assessed by determining median time to treatment failure for all GRs achieving complete pain relief without medications (n = 375: 264 failures, 111 censored). Predictors of initial pain relief were assessed by logistic regression, and predictors of failure were assessed by Cox regression analysis. After GR1, pain relief results were as follows: 285 patients (66%) were pain free without medications, 26 (6%) were pain free with medications, 66 (15%) improved, and 53 (12%) were unchanged. After GR2+, results were as follows: 90 patients (79%) were pain free without medications, 6 (5%) were pain free with medications, 7 (6%) improved, and 11 (10%) were unchanged (P = .03). Median time to treatment failure was 26 months after GR1 and 25 months after GR2+ (P = .34). On multivariate analysis, prior GR was a positive predictor of initial pain relief (odds ratio, 2.067; 95% confidence interval, 1.243-3.437; P = .005) and had no effect on durability. TN patients experienced greater pain relief and equivalent durability after GR2+ beyond the initial treatment.

Repeat Gamma Knife Radiosurgery for Trigeminal Neuralgia

Trigeminal neuralgia (TN) may recur after treatment by gamma knife stereotactic radiosurgery (GKSR). To evaluate management outcomes in patients who underwent repeat GKSR for TN. The authors reviewed their experience with repeat GKSR in 119 patients with recurrent TN. The median patient age was 74 years (range, 34-96 years). The median interval between procedures was 26 months. The median target dose for repeat GKSR was 70 Gy (range, 50-90 Gy) and the median cumulative dose was 145 Gy (range, 120-170 Gy). The median follow-up was 48 months (range, 6-187 months) after repeat GKSR. After repeat GKSR, 87% of patients achieved initial pain relief (Barrow Neurological Institute pain score I-IIIb). Pain relief was maintained in 87.8% at 1 year, 69.8% at 3 years, and 44.2% at 5 years. Facial sensory dysfunction occurred in 21% of patients within 18 months after GKSR. Longer pain relief was observed in patients who had recurrent pain in a reduced pain distribution of the face compared with the pain distribution at the time of their initial GKSR, and in those who developed additional trigeminal sensory loss after a repeat procedure. A cumulative edge of brainstem dose ≥ 44 Gy was more likely to be associated with the development of sensory loss. Repeat GKSR provides a similar rate of pain relief as the first procedure. The best responses were observed in patients who had good pain control after the first procedure and those who developed new sensory dysfunction in the affected trigeminal distribution.

Unusual recurrence of trigeminal neuralgia after microvascular decompression by muscle interposal

SummaryBackgroundPatients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. However, re-operation should be considered in selected patients.Case ReportA 48-year-old woman presented with recurrent trigeminal neuralgia (TN) 3 years following microvascular decompression (MVD). The patient underwent brain magnetic resonance angiography (MRA), which did not reveal neurovascular compression; therefore surgical re-exploration was carried out. During the operation, the fifth cranial nerve was seen without impingement from any blood vessels; however, a very firm tissue was observed and identified as the muscle fragment from the previous MVD procedure. The fifth cranial nerve was carefully separated from the muscle. Thereafter, the right SCA was dissected out from the muscle and suspended by a periosteum tape sutured to the nearby dura.ConclusionsOur findings, along with similar cases reported in the literature, support the development of new inert materials and alternative surgical strategies that can limit TN recurrence.

Gamma Knife surgery for recurrent or residual trigeminal neuralgia after a failed initial procedure

The purpose of this study was to assess outcomes of Gamma Knife surgery (GKS) as a second treatment for recurrent or residual trigeminal neuralgia (TN) after failure of 3 initial procedures: microvascular decompression (MVD), GKS, and percutaneous radiofrequency rhizotomy (PRR). Between 1999 and 2008, 65 patients (31 men [48%] and 34 women [52%]) with recurrent TN were treated with GKS. All 65 patients had undergone previous medical procedures that failed to achieve sufficient pain relief: 27 patients (42%) had undergone MVD, 8 (12%) had undergone PRR, and 30 (46%) had undergone GKS as the initial treatment. The entry zone of the trigeminal nerve was targeted using a 4-mm collimator and treated with 35-90 Gy. The isocenter was positioned so that the brainstem surface was usually irradiated at an isodose no greater than 20% (59 patients) to 30% (6 patients). The median duration of TN symptoms in these patients was 39 months (range 1-192 months). At the clinical evaluation, 42 patients (65%) with idiopathic TN reported successful pain control at a median follow-up point of 64 months (range 18-132 months). Of these patients, 33 (51%) were no longer using medication. At the 1-, 2-, and 3-year follow-up examinations, 74%, 71%, and 66% of patients experienced successful pain control, respectively. There was no significant difference in pain relief in the initial MVD group compared with the initial GKS and initial PRR groups (74% vs 59% and 50%, respectively; p = 0.342). Recurrence of pain was noted in 23 patients. Twelve of these 23 patients underwent another GKS, resulting in pain control in 8 patients (67%); 8 other patients underwent MVD, resulting in pain relief in 7 patients (87.5%). The median time from GKS to pain recurrence was 7 months (range 3-48 months). There was no significant difference in new facial numbness among the 3 groups (p = 0.24); however, in the initial GKS group, facial numbness was significantly associated with freedom from pain (p = 0.0012). There was a significant correlation between the total radiation dose and facial numbness. The cutoff value for facial numbness ranged from 115 to 120 Gy (p = 0.037). Gamma Knife surgery as a second treatment achieved acceptable levels of pain control in 65% of patients with residual or recurrent TN after long-term follow-up. Initial treatment was not a factor that affected pain control, but salvage surgery may be considered separately for each group.

Outcome Predictors After Gamma Knife Radiosurgery for Recurrent Trigeminal Neuralgia

Trigeminal neuralgia (TN) that recurs after surgery can be difficult to manage. To define management outcomes in patients who underwent gamma knife stereotactic radiosurgery (GKSR) after failing 1 or more previous surgical procedures. We retrospectively reviewed outcomes after GKSR in 193 patients with TN after failed surgery. The median patient age was 70 years (range, 26-93 years). Seventy-five patients had a single operation (microvascular decompression, n=40; glycerol rhizotomy, n=24; radiofrequency rhizotomy, n=11). One hundred eighteen patients underwent multiple operations before GKSR. Patients were evaluated up to 14 years after GKSR. After GKSR, 85% of patients achieved pain relief or improvement (Barrow Neurological Institute grade I-IIIb). Pain recurrence was observed in 73 of 168 patients 6 to 144 months after GKSR (median, 6 years). Factors associated with better long-term pain relief included no relief from the surgical procedure preceding GKSR, pain in a single branch, typical TN, and a single previous failed surgical procedure. Eighteen patients (9.3%) developed new or increased trigeminal sensory dysfunction, and 1 developed deafferentation pain. Patients who developed sensory loss after GKSR had better long-term pain control (Barrow Neurological Institute grade I-IIIb: 86% at 5 years). GKSR proved to be safe and moderately effective in the management of TN that recurs after surgery. Development of sensory loss may predict better long-term pain control. The best candidates for GKSR were patients with recurrence after a single failed previous operation and those with typical TN in a single trigeminal nerve distribution.

Repeat Gamma Knife Radiosurgery for Trigeminal Neuralgia

Repeat gamma knife stereotactic radiosurgery (GKRS) for recurrent or persistent trigeminal neuralgia induces an additional response but at the expense of an increased incidence of facial numbness. The present series summarized the results of a repeat treatment series at Wake Forest University Baptist Medical Center, including a multivariate analysis of the data to identify the prognostic factors for treatment success and toxicity. Between January 1999 and December 2007, 37 patients underwent a second GKRS application because of treatment failure after a first GKRS treatment. The mean initial dose in the series was 87.3 Gy (range, 80-90). The mean retreatment dose was 84.4 Gy (range, 60-90). The dosimetric variables recorded included the dorsal root entry zone dose, pons surface dose, and dose to the distal nerve. Of the 37 patients, 81% achieved a >50% pain relief response to repeat GKRS, and 57% experienced some form of trigeminal dysfunction after repeat GKRS. Two patients (5%) experienced clinically significant toxicity: one with bothersome numbness and one with corneal dryness requiring tarsorraphy. A dorsal root entry zone dose at repeat treatment of >26.6 Gy predicted for treatment success (61% vs. 32%, p = .0716). A cumulative dorsal root entry zone dose of >84.3 Gy (72% vs. 44%, p = .091) and a cumulative pons surface dose of >108.5 Gy (78% vs. 44%, p = .018) predicted for post-GKRS numbness. The presence of any post-GKRS numbness predicted for a >50% decrease in pain intensity (100% vs. 60%, p = .0015). Repeat GKRS is a viable treatment option for recurrent trigeminal neuralgia, although the patient assumes a greater risk of nerve dysfunction to achieve maximal pain relief.

Treatment of recurrent trigeminal neuralgia due to Teflon granuloma

Recurrent trigeminal neuralgia after microvascular decompression (MVD) may be due to insufficient decompression, dislocation of the implant to pad the neurovascular contact, or the development of granuloma. Here, we report on our experience with Teflon granuloma including its treatment and histopathological examination. In a series of 200 patients with trigeminal neuralgia MVD was performed with Teflon felt according to Jannetta’s technique. In three patients with recurrent facial pain Teflon granuloma was found to be the cause for recurrence. In each instance, the granuloma was removed for histopathological examination. Mean age at the first procedure was 62.3 years and at the second procedure 66.3 years. Recurrence of pain occurred between 1 and 8.5 years after the first procedure. MRI scans demonstrated local gadolineum enhancement in the cerebellopontine angle, and CT scans showed local calcification. Intraoperatively dense fibrous tissue was found at the site of the Teflon granuloma. Histopathological examination revealed foreign body granuloma with multinuclear giant cells, collagen-rich hyalinized scar tissue, focal hemosiderin depositions, and microcalcifications. The Teflon granuloma was completely removed, and a new Teflon felt was used for re-decompression. Patients were free of pain after the second procedure at a mean of 40.3 months of follow-up. Teflon granuloma is a rare cause for recurrent facial pain after MVD. Small bleeding into the Teflon felt at surgery might trigger its development. A feasible treatment option is surgical re-exploration, nerve preserving removal of the granuloma, and repeat MVD.

Effect of Various Surgical Modalities in Recurrent or Persistent Trigeminal Neuralgia

Background/Aims: In recurrent or persistent idiopathic trigeminal neuralgia (TN) after initial operation, additional surgical procedures may be required. There are numerous articles reporting the outcomes of additional surgical treatment and it is unclear how best to treat patients with recurrent or persistent TN. We evaluated the subsequent therapeutic options for recurrent or persistent TN. Methods: The study was a retrospective study. The authors reviewed 29 patients (15 female/14 male) who underwent retreatments for recurrent or persistent symptoms after an initial operation. Results: The mean follow-up duration was 56.4 months (range 12–78.7) from final treatment. Patients underwent a mean of 2.3 retreatments with a mean period of 26 months (range 1–72) between treatments. Final treatments were as follows: microvascular decompression (MVD) in 12 patients, percutaneous rhizotomy in 10, and radiosurgery in 7. Of the 29 patients, after final treatments, 9 patients (31%) achieved excellent results and 15 (52%) good results. Failure results were seen in 17% of patients with recurrent TN. Conclusion: In this study the authors demonstrate that percutaneous rhizotomy is recommended for most patients with recurrent pain after MVD, and MVD can be effective in patients with a history of failed percutaneous procedures. Radiosurgery can be utilized to treat those that have not responded to other surgical modalities.

The operative findings in re-do microvascular decompression for recurrent trigeminal neuralgia

Background. Re-do microvascular decompression (MVD) of the trigeminal nerve occasionally becomes necessary following recurrence of symptoms after a previous MVD. The indications include failure or contraindication of less invasive treatment options such as medication or trigeminal nerve lesioning and when supported by vascular compression on brain MRI scans.Purpose. To report on our findings following re-do MVD in the National Hospital for Neurology and Neurosurgery, Queen Square London from July 1995 to July 2008.Methods. Case note review of all patients who underwent re-do MVD for the above reasons in the senior author's series in the above institution and stated period. The parameters of study interest were pre-operative MRI features, operative findings, and complete pain-free period with regards to the first and re-do MVD.Results. Data analysis showed that 6 underwent a re-do MVD. Neurovascular conflict was confirmed in 5 cases (83.3%) involving the superior cerebellar artery and anterior inferior cerebellar artery in 2 cases each (33.3%) and ectatic basilar artery in 1 case (16.6%). Arachnoid adhesions around the previous teflon felt were also found in 5 cases (83.3%) mostly in association with other findings. Neo-arachnoid cyst formation in the corresponding cerebello-pontine angle, was an unexpected finding in 2 cases (33.3%), though of uncertain significance.Conclusion. Redo MVD should be considered as a safe and effective treatment option in recurrent trigeminal neuralgia, which fails to respond to non-surgical means.

Dorsal Root Entry Zone Dose Predicts Efficacy and Toxicity for Patients Receiving a Second Radiosurgical Treatment for Recurrent Trigeminal Neuralgia

Repeat gamma knife radiosurgery (GKRS) for recurrent trigeminal neuralgia has been reported in the literature as a means to induce an additional response after persistent or relapsed pain. However, previous series are marked by limited numbers and a variety of treatment philosophies, making it difficult to determine factors predictive of treatment outcome. In the present study, we aimed to identify prognostic factors for treatment success and toxicity.

Revision surgery of the posterior fossa cranial nerves disease

To report the clinical manifestations and the revision surgery principles of recurrent diseases of the posterior fossa nerves after primary surgery. Between 2000 to 2007, fourteen patients with recurrent diseases of the posterior fossa nerves in Shandong provincial hospital were recruited in this study, all of whom were subjected to revision surgery. The clinical manifestations and surgical findings were retrospectively reviewed. Of the five patients with recurrent trigeminal neuralgia primarily, two underwent microvascular decompression (MVD); the remaining three firstly received the II and III branches partial sensory rhizotomy and, subsequently, the pain reoccurred in the I branch distribution area. The remnant sensor fibre was resected in the reoperation by which the sufferings were controlled completely in four of these patients during 2 to 11 years of follow-up. In five patients with hemifacial spasm underwent re-exploration, there appeared obvious fibrosis, conglutination, and the formation of new vessels around the facial nerve, with which the result of reoperation for this disorder was unsatisfied. In four glossopharyngeal neuralgia patients, reanastomosis of the glossopharyngeal nerve were found in two patients, adhesion between the glossopharyngeal nerve and the vagus nerve was found in one patient, but occurred in none of the another one. In the revision surgery, the regeneration of nerve fibre and two adjacent branches of vagus nerve fibre were resected, with no occurrence during 2 to 5 years of follow-up. The pathological changes found in revision were severe adhesion between cerebellum, meninges, terylene slim and structures around. Also, the formation of new vessels, cerebellum malacia, and bleeding could be found in the procedures. The cause of recurrent of trigeminal neuralgia and hemifacial spasm are unclear. Recurrent glossopharyngeal neuralgia may attribute to the nerve fibers reanastomosis, adhesion or the communicating branches with vagus nerve. With respect to the treatment of the recurrence of trigeminal neuralgia, glossopharyngeal neuralgia after primary surgery, the effectiveness of nerve fibre resection is definite, whereas, the result of revision surgery for hemifacial spasm is poor.

Quality of Life in Patients Treated with Repeat Gamma Knife Radiosurgery for Recurrent or Refractory Trigeminal Neuralgia

Quality of Life in Patients Treated with Repeat Gamma Knife Radiosurgery for Recurrent or Refractory Trigeminal Neuralgia