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Editorial: Proposed Surgical Trigeminal Neuralgia Score checklist

Alexander A. Khalessi and Steven Giannotta

The authors merit congratulations for their ambitious efforts to assess the quality of surgical literature regarding the management of trigeminal neuralgia (TN). 1 In the presented literature review and in the Surgical Trigeminal Neuralgia Score (STNS)–based evaluation of study rigor they attempt to 1) provide a checklist to guide future journal editorial decisions; 2) standardize patient-centered outcome measures in the TN literature; and 3) guide clinical practitioners in the application of study results to patient care situations. The authors

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Role of patient history and physical examination in the diagnosis of trigeminal neuralgia

Kenneth F. Casey

The diagnosis of facial pain has been a source of confusion for neuroscientists and primary care givers alike. The profusion of various subtypes, differential syndromes, and confusing nomenclature is silent testimony to this dilemma. The author presents a simple scheme with which to arrive at the diagnosis. The use of the patient's history, confirmed by the physical examination, can be supplemented with some of the tests described herein.

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Trigeminal neuralgia

Peter J. Jannetta

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CyberKnife radiosurgical rhizotomy for the treatment of atypical trigeminal nerve pain

Chirag G. Patil, Anand Veeravagu, Regina S. Bower, Gordon Li, Steven D. Chang, Michael Lim, and John R. Adler Jr.

treatment of atypical TN. Furthermore, frameless CyberKnife SRS appears to be a safe and effective treatment modality for atypical TN. Acknowledgments Dr. Patil and Dr. Veeravagu contributed equally to the preparation of the manuscript. This study was funded in part by the Vickie and Gary Reed Research Fund. References 1 Barker FG II , Jannetta PJ , Bissonette DJ , Larkins MV , Jho HD : The long-term outcome of microvascular decompression for trigeminal neuralgia . N Engl J Med 334 : 1077 – 1083 , 1996 10.1056/NEJM199604253341701 2

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Stereotactic radiosurgery for functional disorders

Gerhard M. Friehs, Michael C. Park, Marc A. Goldman, Vasilios A. Zerris, Georg Norén, and Prakash Sampath

online database of the National Library of Medicine was conducted using the following search term combinations: radiosurgery OR Gamma Knife; tremor; Parkinson disease; thalamotomy; pallidotomy; pain; trigeminal neuralgia; epilepsy; and psychiatric disease. We selected articles pertinent to this report and added historical papers. Publications were categorized into 4 groups: movement disorders, pain, epilepsy, and psychiatric disease. Our experience and that of authors from numerous treatment centers is discussed in a critical manner. We have also included personal

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Microvascular decompression of cranial nerves: lessons learned after 4400 operations

Mark R. McLaughlin, Peter J. Jannetta, Brent L. Clyde, Brian R. Subach, Christopher H. Comey, and Daniel K. Resnick

Object

Microvascular decompression has become an accepted surgical technique for the treatment of trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and other cranial nerve rhizopathies. The senior author (P.J.J.) began performing this procedure in 1969 and has performed more than 4400 operations. The purpose of this article is to review some of the nuances of the technical aspects of this procedure.

Methods

A review of 4415 operations shows that numerous modifications to the technique of microvascular decompression have occurred during the last 29 years. Of the 2420 operations performed for trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia before 1990, cerebellar injury occurred in 21 cases (0.87%), hearing loss in 48 (1.98%), and cerebrospinal fluid (CSF) leakage in 59 cases (2.44%). Of the 1995 operations performed since 1990, cerebellar injuries declined to nine cases (0.45%), hearing loss to 16 (0.8%), and CSF leakage to 37 (1.85%) (p < 0.01, test for equality of distributions). The authors describe slight variations made to maximize surgical exposure and minimize potential complications in each of the six principal steps of this operation. These modifications have led to decreasing complication rates in recent years.

Conclusions

Using the techniques described in this report, microvascular decompression is an extremely safe and effective treatment for many cranial nerve rhizopathies.

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Retrosigmoid approach for resection of cerebellopontine angle meningioma and decompression of the trigeminal nerve

Lee A. Tan, Carter S. Gerard, Sumeet K. Ahuja, and Roham Moftakhar

Cerebellopontine angle (CPA) lesions account for up to 10% of all intracranial tumors. The most common CPA lesions are vestibular schwannomas (70–80%), meningiomas (10–15%) and epidermoid cysts (5%). CPA tumors are estimated to be the secondary cause for up to 9.9% patients with trigeminal neuralgia. We demonstrate a case of medically refractory trigeminal neuralgia caused by a CPA meningioma that was successfully treated via retrosigmoid approach. The patient had immediate and dramatic symptomatic improvement after surgery. Detailed surgical techniques of retrosigmoid craniotomy and tumor dissection are presented in high definition video with narration.

The video can be found here: http://youtu.be/55j9QCQEsH8.

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A prospective 15-year follow up of 154 consecutive patients with trigeminal neuralgia treated by percutaneous stereotactic radiofrequency thermal rhizotomy.

Commentary

Chad J. Morgan and John M. Tew Jr.

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Technique of microvascular decompression

Technical note

Peter J. Jannetta, Mark R. Mclaughlin, and Kenneth F. Casey

Vascular compression of the trigeminal nerve in the cerebellopontine angle is now generally accepted as the primary source or “trigger” causing trigeminal neuralgia. A clear clinicopathological association exists in the neurovascular relationship. In general, pain in the third division of the trigeminal nerve is caused by rostral compression, pain in the second division is caused by medial or more distant compression, and pain in the first division is caused by caudal compression.

This discussion of the surgical technique includes details on patient position, placement of the incision and craniectomy, microsurgical exposure of the supralateral cerebellopontine angle, visualization of the trigeminal nerve and vascular pathological features, microvascular decompression, and wound closure. Nuances of the technique are best learned in the company of a surgeon who has a longer experience with this procedure.

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Selective ablation of nociceptive neurons for elimination of hyperalgesia and neurogenic inflammation

Gabriel C. Tender, Stuart Walbridge, Zoltan Olah, Laszlo Karai, Michael Iadarola, Edward H. Oldfield, and Russell R. Lonser

Object

Neuropathic pain is mediated by nociceptive neurons that selectively express the vanilloid receptor 1 (VR1). Resiniferatoxin (RTX) is an excitotoxic VR1 agonist that causes destruction of VR1-positive neurons. To determine whether RTX can be used to ablate VR1-positive neurons selectively and to eliminate hyperalgesia and neurogenic inflammation without affecting tactile sensation and motor function, the authors infused it unilaterally into the trigeminal ganglia in Rhesus monkeys.

Methods

Either RTX (three animals) or vehicle (one animal) was directly infused (20 μl) into the right trigeminal ganglion in Rhesus monkeys. Animals were tested postoperatively at 1, 4, and 7 weeks thereafter for touch and pain perception in the trigeminal distribution (application of saline and capsaicin to the cornea). The number of eye blinks, eye wipes, and duration of squinting were recorded. Neurogenic inflammation was tested using capsaicin cream. Animals were killed 4 (one monkey) and 12 (three monkeys) weeks postinfusion. Histological and immunohistochemical analyses were performed.

Throughout the duration of the study, response to high-intensity pain stimulation (capsaicin) was selectively and significantly reduced (p < 0.001, RTX-treated compared with vehicle-treated eye [mean ± standard deviation]): blinks, 25.7 ± 4.4 compared with 106.6 ± 20.8; eye wipes, 1.4 ± 0.8 compared with 19.3 ± 2.5; and squinting, 1.4 ± 0.6 seconds compared with 11.4 ± 1.6 seconds. Normal response to sensation was maintained. Animals showed no neurological deficit or sign of toxicity. Neurogenic inflammation was blocked on the RTX-treated side. Immunohistochemical analysis of the RTX-treated ganglia showed selective elimination of VR1-positive neurons.

Conclusions

Nociceptive neurons can be selectively ablated by intraganglionic RTX infusion, resulting in the elimination of high-intensity pain perception and neurogenic inflammation while maintaining normal sensation and motor function. Analysis of these findings indicated that intraganglionic RTX infusion may provide a new treatment for pain syndromes such as trigeminal neuralgia as well as others.