Repeat posterior fossa exploration for patients with persistent or recurrent idiopathic trigeminal neuralgia

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Object

Patients 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. The outcomes and risks of repeat posterior fossa exploration (PFE) for these patients are not clearly understood.

Methods

From September 2000 to November 2006, 29 patients (14 men, 15 women) underwent repeat PFE. The mean number of surgeries per patient at the time of repeat PFE was 3.2 (range 1–6). The mean follow-up duration after surgery was 33.7 months.

Results

Compression of the trigeminal nerve was noted in 24 patients (83%) by an artery (13 patients, 45%), vein (4 patients, 14%), or Teflon (7 patients, 24%). Four patients (14%) who underwent operations elsewhere had incorrect cranial nerves decompressed at their first surgery. Only MVD was performed in 18 patients (62%) and a partial nerve section (PNS) was performed in 11 patients (38%). An excellent facial pain outcome (no pain, no medications required) was achieved and maintained for 80% and 75% of patients at 1 and 3 years after surgery, respectively. Patients with Burchiel Type 1 TN were pain free without medications (91% at 1 year and 85% at 3 years) more frequently than patients with Burchiel Type 2 TN (27% at both 1 and 3 years; hazard ratio = 5.4, 95% confidence interval 1.4–21.1, p = 0.02). Fifteen patients (52%) had new or increased facial numbness. Two patients (7%) developed anesthesia dolorosa; both had undergone PNS. Two patients (7%) had hearing loss after surgery.

Conclusions

Repeat PFE for patients with idiopathic TN has facial pain outcomes that are comparable with both percutaneous needle-based techniques and stereotactic radiosurgery. Patients with persistent or recurrent TN should be considered for repeat PFE, especially if other less invasive surgeries have not relieved their facial pain.

Abbreviations used in this paper: MR = magnetic resonance; MVD = microvascular decompression; PFE = posterior fossa exploration; PNS = partial nerve section; TN = trigeminal neuralgia.

Article Information

Address correspondence to: Bruce E. Pollock, M.D., Department of Neurological Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. email: pollock.bruce@mayo.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph summarizing the number and type of operations performed on 20 patients between PFEs. BMC = balloon microcompression; GK = Gamma Knife surgery; PRGR = percutaneous retrogasserian glycerol rhizotomy; RFL = radiofrequency rhizotomy.

  • View in gallery

    Gadolinium-enhanced axial MR image obtained for Gamma Knife surgical planning in a patient with persistent right-sided TN after an MVD. Note the enhancing material lateral to the internal auditory canal. At reoperation, this material was found to be Teflon from the prior operation.

  • View in gallery

    Graph summarizing the percentage of patients with idiopathic TN with excellent facial pain outcome after repeat PFE as a function of months after surgery.

  • View in gallery

    Graph summarizing the percentage of patients with excellent facial pain outcome after repeat PFE as a function of months after surgery, grouped according to Burchiel type. Patients with Burchiel Type 1 TN (24 patients, solid line) had better outcomes compared with patients with Burchiel Type 2 TN (5 patients, dotted line); hazard ratio = 5.4, 95% confidence interval 1.4–21.1, p = 0.02.

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