Microvascular decompression for primary trigeminal neuralgia: long-term effectiveness and prognostic factors in a series of 362 consecutive patients with clear-cut neurovascular conflicts who underwent pure decompression

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Object

The purpose of this study was to evaluate the long-term efficacy of microvascular decompression (MVD) and to identify the factors affecting outcome in patients treated for primary trigeminal neuralgia (TN). Only the cases with a clear-cut neurovascular conflict (vascular contact and/or compression of the root entry zone of the trigeminal nerve) found at surgery and treated with “pure” MVD (decompression of the root without any additional lesioning or cutting of the adjacent rootlets) were retained.

Methods

The study included 362 patients who were followed up over a period of 1 to 18 years (median follow-up 7.2 years). A Kaplan–Meier survival analysis was generated at 1 and 15 years of follow-up for all of the considered factors. According to Kaplan–Meier analysis, the success rate (defined as pain-free patients without any medication) was 91% at 1 year and estimated to be 73.38% after 15 years of follow-up.

Results

None of the following patient-related factors played any significant role in prognosis: sex, patient age at surgery, history of systemic hypertension, duration of neuralgia before surgery, or history of failed trigeminal surgery. Patients with atypical neuralgia (a baseline of permanent pain) had the same outcome as those with a typical (purely spasmodic) presentation. In addition, the side and topography of the trigeminal nerve did not play a role, whereas involvement of all three divisions of the nerve had a negative effect on outcome. Concerning anatomical factors, neither the type of the compressive vessel nor its location along or around the root was found to be significant. However, the severity of compression was important—the more severe the degree of compression, the better the outcome (p = 0.002). The authors also found that presence of focal arachnoiditis had a negative influence on outcome (p = 0.002).

Conclusions

Pure MVD can offer patients affected by a primary TN a 73.38% probability of long-term (15 years) cure of neuralgia. The presence of a clear-cut and marked vascular compression at surgery (and possibly—although not yet reliably—on preoperative magnetic resonance imaging) is the guarantee of a higher than 90% success rate.

Abbreviations used in this paper:MVD = microvascular decompression; NVC = neurovascular conflict; TN = trigeminal neuralgia.

Article Information

Address correspondence to: Marc Sindou, M.D., Ph.D., Department of Neurosurgery, Hôpital Neurologique “Pierre Wertheimer” 59, Bd Pinel, 69003 Lyon, France. email: marc.sindou@chu-lyon.fr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flow diagram of patient selection, modified from Sindou et al., 2006. Note that the morbidity rate in patients who had posterior fossa surgery for primary TN was 0.44%. CPA = cerebellopontine angle.

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    Graphs of global results of pain-free patients at 1 year (upper) and at 15 years (lower). Note that patients in whom paroxysmal pain was relieved but who continued to experience some background pain even though no medication was required were considered to have had failed surgery.

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    Kaplan–Meier curve (at 15 years of follow-up) of pain-free patients according to age at time of surgery. Outcome was better in older patients than in younger ones. This difference is not statistically significant, but does demonstrate a trend (p = 0.09).

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    Kaplan–Meier curve (at 15 years of follow-up) of pain-free patients according to preoperative duration of neuralgia. No statistical significance was found (p = 0.67).

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    Kaplan–Meier curve (at 15 years of follow-up) of pain-free patients according to degree of compression; the more severe the degree, the better the outcome (p = 0.001).

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    Kaplan–Meier curve (at 15 years of follow-up) of pain-free patients according to degree of atrophy. Curve shows a worse outcome with severe atrophy; however, the difference is not statistically significant (p = 0.36).

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    Kaplan–Meier curve (at 15 years of follow-up) of pain-free patients according to degree of arachnoiditis. Severe arachnoiditis was revealed to have a significant negative effect on outcome (in the long term only; p = 0.002).

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