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Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: technique and expectations

Douglas Kondziolka and L. Dade Lunsford

Object

In the management of trigeminal neuralgia (TN), physicians seek rapid and long-lasting pain relief, together with preservation of trigeminal nerve function. Percutaneous retrogasserian glycerol rhizotomy (PRGR) offers distinct advantages over other available procedures. The aim of this report was to provide details of the PRGR procedure and its expected outcome.

Methods

The authors reviewed their experience with PRGR in 1174 patients to evaluate the procedural technique, results, and complications. Although it is clear that TN is not a static disorder but one characterized by remissions and recurrences, long-lasting pain relief was noted in 77% of patients, with 55% discontinuing all medications and 22% requiring some drug usage.

Conclusions

The authors discuss the role of PRGR in their practice, along with other procedures such as microvascular decompression and gamma knife surgery, for idiopathic or multiple sclerosis–related TN. They conclude that PRGR had distinct advantages over other procedures, which include eliminating the need for intraoperative confirmatory sensory testing, and a lower risk of facial sensory loss.

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

Kunal P. Raygor, Anthony T. Lee, Noah Nichols, Doris D. Wang, Mariann M. Ward, Nicholas M. Barbaro, and Edward F. Chang

: Chang, Raygor, Barbaro. Reviewed submitted version of manuscript: Chang, Raygor, Barbaro. Statistical analysis: Raygor. Administrative/technical/material support: Ward. Study supervision: Chang, Barbaro. References 1 Klun B . Microvascular decompression and partial sensory rhizotomy in the treatment of trigeminal neuralgia: personal experience with 220 patients . Neurosurgery . 1992 ; 30 ( 1 ): 49 – 52 . 1371184 10.1227/00006123-199201000-00009 2 Raygor KP , Lee A , Chang EF . Treatment of idiopathic trigeminal neuralgia in the elderly . In: Sagher O

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Percutaneous balloon compression of the trigeminal nerve for treatment of trigeminal neuralgia

Jeffrey A. Brown, Christopher J. Chittum, David Sabol, and Jan J. Gouda

The technique of percutaneous balloon compression for treatment of trigeminal neuralgia is demonstrated by using embedded audiovisual kernels. A text-based description with linked images is also provided to accomodate varying computer hardware capabilities. A new needle system for guiding the balloon catheter to the entrance of Meckel's cave and a balloon pressure monitoring system for the procedure is described and demonstrated. Results from a series of 141 consecutive patients treated during the period between 1983 and 1995 indicate an initial success rate of 92%. Fifty-seven percent of patients have postoperative numbness, which is described as mild to moderate by 94% of them. Sixteen percent have ipsilateral masseter-pterygoid weakness after compression. The overall recurrence rate is 26%. A Kaplan-Meier survival curve indicates that 60% of patients are pain free 8 years after surgery without recurrence requiring reoperation. The recurrence rate does not significantly differ from patients with first division pain to patients without first division involvement. An absent corneal reflex has not occurred, nor has anesthesia dolorosa. Balloon compression injures the myelinated fibers that mediate the “trigger” to the lancinating pain of trigeminal neuralgia. Because the corneal reflex is mediated by unmyelinated fibers, selective, monitored compression of myelinated fibers should preserve the corneal reflex when first division pain is present.

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Role of the neurologist in the evaluation and treatment of patients with trigeminal neuralgia

Jeffrey Cohen

The neurologist, although not usually the first healthcare provider to evaluate a patient with trigeminal neuralgia (TN), is often involved in confirming the diagnosis and managing the patient's pain with medications. The neurologist has several other important roles for patients with TN: assessing and reducing the individual's pain, patient and family education, and encouraging referral to a neurosurgeon for pain-reducing procedures when appropriate. In general, surgical procedures for TN should be considered when the patient does not attain pain relief after adequate trials of two or three medications, or when pain relief is attained but the patient requires medication dosing at levels that result in significant drug toxicity. There is emerging evidence that surgical procedures for TN are more effective if performed earlier in the course of the patient's pain.

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Recurrent or refractory trigeminal neuralgia after microvascular decompression, radiofrequency ablation, or radiosurgery

Rene O. Sanchez-Mejia, Mary Limbo, Jason S. Cheng, Joaquin Camara, Mariann M. Ward, and Nicholas M. Barbaro

Object

Trigeminal neuralgia (TN) is characterized by paroxysmal lancinating pain in the trigeminal nerve distribution. When TN is refractory to medical management, patients are referred for microvascular decompression (MVD), radiofrequency ablation, or radiosurgery. After the initial treatment, patients may have refractory or recurrent symptoms requiring retreatment. The purpose of this study was to determine what factors are associated with the need for retreatment and which modality is most effective.

Methods

To define this population further, the authors evaluated a cohort of patients who required retreatment for TN. The mean follow-up periods were 51 months from the first treatment and 23 months from the last one, and these were comparable among treatment groups.

Conclusions

Trigeminal neuralgia can recur after neurosurgical treatment. In this study the authors demonstrate that the number of patients requiring retreatment is not negligible. Lower retreatment rates were seen in patients who initially underwent radiosurgery, compared with those in whom MVD or radiofrequency ablation were performed. Radiosurgery was more likely to be the final treatment for recurrent TN regardless of the initial treatment. After retreatment, the majority of patients attained complete or very good pain relief. Pain relief after retreatment correlates with postoperative facial numbness.

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Comparison of posterior fossa exploration and stereotactic radiosurgery in patients with previously nonsurgically treated idiopathic trigeminal neuralgia

Bruce E. Pollock

Object

Stereotactic radiosurgery (SRS) is commonly performed in patients with trigeminal neuralgia, and numerous investigators have found that facial pain outcomes after this procedure are better for patients in whom prior surgery did not fail. Researchers in some centers claim that the results of SRS are equivalent to posterior fossa exploration (PFE). The goal in this study was to verify that claim.

Methods

Information was retrieved from a prospectively maintained database of patients less than 70 years old with idiopathic trigeminal neuralgia who underwent PFE (55 patients) or SRS (28 patients) as their initial surgery between 1999 and 2004. Of the two groups, patients who underwent radiosurgery were older (60.5 compared with 50.7 years, p < 0.001). Microvascular decompression was performed in 49 patients (89%) and partial nerve section was performed in six (11%) in the PFE group. The mean maximum dose for SRS was 89.1 Gy. At a mean follow-up duration of 25.5 months, patients who had undergone PFE were more commonly pain free without medications (75% at 1 year, 72% at 3 years) compared with the patients treated with SRS (59% at 1 and 3 years; p = 0.01). Additional surgery was performed in 10 patients (18%) after PFE, compared with eight patients (29%) after SRS (p = 0.4). Eight patients (15%) had either new facial numbness (six cases) or dysesthesias (two cases) after PFE, whereas 12 (43%) had either new facial numbness (eight cases) or dysesthesias (four cases) after SRS. No correlation was noted between the development of facial numbness and facial pain outcome after PFE (p = 0.37), whereas patients in whom trigeminal dysfunction developed after radiosurgery were more frequently free of pain (p = 0.02).

Conclusions

The results support PFE as a more effective primary surgery than SRS in patients with idiopathic trigeminal neuralgia. Moreover, injury to the trigeminal nerve during PFE is not required to achieve excellent facial pain outcomes.

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Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis

Jason S. Cheng, Rene O. Sanchez-Mejia, Mary Limbo, Mariann M. Ward, and Nicholas M. Barbaro

Object

Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief.

Methods

Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V).

Conclusions

Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.

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Percutaneous balloon compression for the treatment of trigeminal neuralgia: results in 56 patients based on balloon compression pressure monitoring

Jeffrey A. Brown and Julie G. Pilitsis

Object

Percutaneous balloon compression is an effective and technically simple method for treating trigeminal neuralgia (TN). Nevertheless, dysesthesias (10–20%) and masseter muscle weakness (66%) following the procedure have been noted. The purpose of this study was to evaluate the results of testing TN with percutaneousballoon compression aided by intraluminal pressure monitoring.

Methods

In this study the authors review the results and complications associated with percutaneous balloon compression by using intraluminal pressure monitoring data obtained in 65 procedures performed in 56 consecutive patients over 4 years. The mean patient age was 71 years (range 37–92 years), and the mean follow-up duration was 17 months (range 3–38 months). The mean intraluminal compression pressure was (1160 ± 62 mm Hg), and the mean duration of compression was 1.15 ± 0.27 minutes. The trigeminal depressor response was observed in 60 (92%) of 65 procedures, and initial pain relief occurred in 92% of patients. The recurrence rate in patients who had initial relief was 16% (nine of 56). The mean time until recurrence in patients who experienced pain relief after surgery was 13 months (range 3–23 months). Mild numbness immediately after surgery was observed in 83% of patients. At the most recent evaluation, 17% of patients reported persistent, nontroublesome numbness and none had moderate or severe numbness. Minor dysesthesia was present in two patients (4%). Mild masseter muscle weakness occurred in 24% of patients and resolved within a maximum period of 1 year. No patient experienced anesthesia dolorosa, corneal keratitis, or other cranial nerve deficits. These morbidity rates are lower than the incidence reported in the literature when pressure monitoring is not used.

Conclusions

These data show that by monitoring compression pressure and limiting the duration of compression, it is possible to reduce the incidence of dysesthesias, severe numbness, and masseter weakness after surgery without increasing the rate of recurrent pain in patients with classic TN.

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Assessment of pain control, quality of life, and predictors of success after gamma knife surgery for the treatment of trigeminal neuralgia

Ajay Jawahar, Rishi Wadhwa, Caglar Berk, Gloria Caldito, Allyson Delaune, Federico Ampil, Brian Willis, Donald Smith, and Anil Nanda

Object

There are various surgical treatment alternatives for trigeminal neuralgia (TN), but there is no single scale that can be used uniformly to assess and compare one type of intervention with the others. In this study the objectives were to determine factors associated with pain control, pain-free survival, residual pain, and recurrence after gamma knife surgery (GKS) treatment for TN, and to correlate the patients' self-reported quality of life (QOL) and satisfaction with the aforementioned factors.

Methods

Between the years 2000 and 2004, the authors treated 81 patients with medically refractory TN by using GKS. Fifty-two patients responded to a questionnaire regarding pain control, activities of daily living, QOL, and patient satisfaction.

The median follow-up duration was 16.5 months. Twenty-two patients (42.3%) had complete pain relief, 14 (26.9%) had partial but satisfactory pain relief, and in 16 patients (30.8%) the treatment failed. Seven patients (13.5%) reported a recurrence during the follow-up period, and 25 (48.1%) reported a significant (> 50%) decrease in their pain within the 1st month posttreatment. The mean decrease in the total dose of pain medication was 75%. Patients' self-reported QOL scores improved 90% and the overall patient satisfaction score was 80%.

Conclusions

The authors found that GKS is a minimally invasive and effective procedure that yields a favorable outcome for patients with recurrent or refractory TN. It may also be offered as a first-line surgical modality for any patients with TN who are unsuited or unwilling to undergo microvascular decompression.

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Stereotactic radiosurgery for trigeminal neuralgia secondary to tumor: a single-institution retrospective series

Jennifer C. Hall, Timothy H. Ung, Tamra-Lee McCleary, Cynthia Chuang, Iris C. Gibbs, Scott G. Soltys, Melanie Hayden Gephart, Gordon Li, Erqi L. Pollom, Steven D. Chang, and Antonio Meola

, Pollom, Chang. Study supervision: Meola, Ung. Supplemental Information Previous Presentations An abstract for this paper was accepted for presentation as a poster to the annual meeting for the American Society for Radiation Oncology (ASTRO), October 23–26, 2022, in San Antonio, Texas. References 1 Maarbjerg S , Di Stefano G , Bendtsen L , Cruccu G . Trigeminal neuralgia—diagnosis and treatment . Cephalalgia . 2017 ; 37 ( 7 ): 648 – 657 . 10.1177/0333102416687280 2 Barker FG II , Jannetta PJ , Babu RP , Pomonis S