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  • Author or Editor: Kim J. Burchiel x
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Jonathan P. Miller, Feridun Acar and Kim J. Burchiel

Object

Trigeminal neuralgia (TN) presents a diagnostic challenge because of the variety of symptoms, findings during microvascular decompression (MVD), and postsurgical outcomes observed among patients who suffer from this disorder. Recently, a new paradigm for classification of TN was proposed, based on the quality of pain. This study represents the first clinical analysis of this paradigm.

Methods

The authors analyzed 144 consecutive cases involving patients who underwent MVD for TN. Preoperative symptoms were classified into 1 of 2 categories based on the preponderance of shocklike (Type 1 TN) or constant (Type 2 TN) pain. Analysis of clinical characteristics, neurovascular pathology, and postoperative outcome was performed.

Results

Compared with Type 2 TN, Type 1 TN patients were older, were more likely to have right-sided symptoms, and reported a shorter duration of symptoms prior to evaluation. Previous treatment by percutaneous or radiosurgical procedures was not a predictor of symptoms, surgical findings, or outcome (p = 0.48). Type 1 TN was significantly more likely to be associated with arterial compression. Venous or no compression was more common among Type 2 TN patients (p < 0.01). Type 1 TN patients were also more likely to be pain-free immediately after surgery, and less likely to have a recurrence of pain within 2 years (p < 0.05). Although a subset of patients progressed from Type 1 to Type 2 TN over time, their pathological and prognostic profiles nevertheless resembled those of Type 1 TN.

Conclusions

Type 1 and Type 2 TN represent distinct clinical, pathological, and prognostic entities. Classification of patients according to this paradigm should be helpful to determine how best to treat patients with this disorder.

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Jonathan P. Miller, Feridun Acar and Kim J. Burchiel

Object

Hardware infection is a common occurrence after the implantation of neurostimulation and intrathecal drug delivery devices. The authors investigated whether the application of a neomycin/polymyxin solution directly into the surgical wound decreases the incidence of perioperative infection.

Methods

Data from all stereotactic and functional hardware procedures performed at the Oregon Health & Science University over a 5-year period were reviewed. All patients received systemic antibiotic prophylaxis. For the last 18 months of the 5-year period, wounds were additionally injected with a solution consisting of 40 mg neomycin and 200,000 U polymyxin B sulfate diluted in 10 ml normal saline. The primary outcome measure was infection of the hardware requiring explantation.

Results

Six hundred fourteen patients underwent hardware implantation. Among 455 patients receiving only intravenous antibiotics, the infection rate was 5.7%. Only 2 (1.2%) of 159 patients receiving both intravenous and local antibiotics had an infection. The wounds in both of these patients were compromised postoperatively: 1 patient had entered a swimming pool, and the other had undergone a general surgery procedure that exposed the hardware. If these patients are excluded from analysis, the effective infection rate using a combined intravenous and local antibiotic prophylaxis is 0%. There were no complications due to toxicity.

Conclusions

The combination of local neomycin/polymyxin with systemic antibiotic therapy can lead to a significantly lower rate of postoperative infection than when systemic antibiotics are used alone.

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Jonathan P. Miller, Feridun Acar, Bronwyn E. Hamilton and Kim J. Burchiel

Object

Neurovascular compression (NVC) of the trigeminal nerve is associated with trigeminal neuralgia (TN), but also occurs in many patients without facial pain. This study is designed to identify anatomical characteristics of NVC associated with TN.

Methods

Thirty patients with Type 1 TN (intermittent shocklike pain) and 15 patients without facial pain underwent imaging for analysis of 30 trigeminal nerves ipsilateral to TN symptoms, 30 contralateral to TN symptoms, and 30 in asymptomatic patients. Patients underwent 3-T MR imaging including balanced fast-field echo and MR angiography. Images were fused and reconstructed into virtual cisternoscopy images that were evaluated to determine the presence and degree of NVC. Reconstructed coronal images were used to measure nerve diameter and crosssectional area.

Results

The incidence of arterial NVC in asymptomatic nerves, nerves contralateral to TN symptoms, and nerves ipsilateral to TN symptoms was 17%, 43%, and 57%, respectively. The difference between symptomatic and asymptomatic nerves was significant regarding the presence of NVC, nerve distortion, and the site of compression (p < 0.001, Fisher exact test). The most significant predictors of TN were compression of the proximal nerve (odds ratio 10.4) and nerve indentation or displacement (odds ratio 4.3). There was a tendency for the development of increasingly severe nerve compression with more advanced patient age across all groups. Decreased nerve size was observed in patients with TN but did not correlate with the presence or extent of NVC.

Conclusions

Trigeminal NVC occurs in asymptomatic patients but is more severe and more proximal in patients with TN. This information may help identify patients who are likely to benefit from microvascular decompression.

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Jonathan P. Miller, Stephen T. Magill, Feridun Acar and Kim J. Burchiel

Object

Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia (TN). However, many patients do not experience complete pain relief, and relapse can occur even after an initial excellent result. This study was designed to identify characteristics associated with improved long-term outcome after MVD.

Methods

One hundred seventy-nine consecutive patients who had undergone MVD for TN at the authors' institution were contacted, and 95 were enrolled in the study. Patients provided information about preoperative pain characteristics including preponderance of shock-like (Type 1 TN) or constant (Type 2 TN) pain, preoperative duration, trigger points, anticonvulsant therapy response, memorable onset, and pain-free intervals. Three groups were defined based on outcome: 1) excellent, pain relief without medication; 2) good, mild or intermittent pain controlled with low-dose medication; and 3) poor, severe persistent pain or need for additional surgical treatment.

Results

Type of TN pain (Type 1 TN vs Type 2 TN) was the only significant predictor of outcome after MVD. Results were excellent, good, and poor for Type 1 TN versus Type 2 TN patients in 60 versus 25%, 24 versus 39%, and 16 versus 36%, respectively. Among patients with each TN type, there was a significant trend toward better outcome with greater proportional contribution of Type 1 TN (lancinating) symptoms (p < 0.05).

Conclusions

Pain relief after MVD is strongly correlated with the lancinating pain component, and therefore type of TN pain is the best predictor of long-term outcome after MVD. Application of this information should be helpful in the selection of TN patients likely to benefit from MVD.