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

Restricted access


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.


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.


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.


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:

© AANS, except where prohibited by US copyright law.



  • 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.



Apfelbaum RI: Neurovascular decompression: the procedure of choice?. Clin Neurosurg 46:4734982000


Ashkan KMarsh H: Microvascular decompression for trigeminal neuralgia in the elderly: a review of the safety and efficacy. Neurosurgery 55:8408502004


Barker FG IIJannetta PJBissonette DJJho HD: Trigeminal numbness and tic relief after microvascular decompression for typical trigeminal neuralgia. Neurosurgery 40:39451997


Barker FG IIJannetta PJBissonette DJLarkins MVJho HD: The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 334:107710831996


Bederson JBWilson CB: Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia. J Neurosurg 71:3593671989


Bergenheim ATShamsgovara PRidderheim PA: Microvascular decompression for trigeminal neuralgia: no relation between sensory disturbance and outcome. Stereotact Funct Neurosurg 68:2002061997


Blomstedt PCBergenheim AT: Technical difficulties and perioperative complications of retrogasserian glycerol rhizotomy for trigeminal neuralgia. Stereotact Funct Neurosurg 79:1681812002


Brown JAMcDaniel MDWeaver MT: Percutaneous trigeminal nerve compression for treatment of trigeminal neuralgia: results in 50 patients. Neurosurgery 32:5705731993


Burchiel KJ: A new classification for facial pain. Neurosurgery 53:116411672003


Cho DYCecil CGWang YCWang FHShen CCYang DY: Repeat operations in failed microvascular decompression for trigeminal neuralgia. Neurosurgery 35:6656701994


Hall GCCarroll DParry DMcQuay HJ: Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain 122:1561622006


Jannetta PJBissonette DJ: Management of the failed patient with trigeminal neuralgia. Clin Neurosurg 32:3343471985


Kalkanis SNEskander ENCarter BSBarker FG II: Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates and the effects of hospital and surgeon volumes. Neurosurgery 52:125112622003


Kanpolat YSavas ABekar ABerk C: Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience in 1,600 patients. Neurosurgery 48:5245342001


Kaplan ELMeier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:4574811958


Kureshi SAWilkens RH: Posterior fossa reexploration for persistent or recurrent trigeminal neuralgia of hemifacial spasm: surgical findings and therapeutic implications. Neurosurgery 43:111111171998


Maesawa SSalame CFlickinger JCPirris SKondziolka DLunsford LD: Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 94:14202001


Massager NLorenzoni JDevriendt DDesmedt FBrotchi JLevivier M: Gamma knife surgery for idiopathic trigeminal neuralgia using a faranterior cisternal target and a high dose of radiation. J Neurosurg 100:5976052004


McLaughlin MRJannetta PJClyde BLSubach BRComey CHResnick DK: Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 90:181999


Pollock BE: Percutaneous retrogasserian glycerol rhizotomy for patients with idiopathic trigeminal neuralgia: a prospective analysis of factors related to pain relief. J Neurosurg 102:2232282005


Pollock BEPhuong LKGorman DAFoote RLStafford SLSchomberg PJ: Stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 97:3473532002


Premsagar ICMoss TCoakham HB: Teflon-induced granuloma following treatment of trigeminal neuralgia by microvascular decompression. J Neurosurg 87:4544571997


Rath SAKlein HJRichter HP: Findings and long-term results of subsequent operations after failed microvascular decompression for trigeminal neuralgia. Neurosurgery 39:9339401996


Régis JMetellus PHayashi MRoussel PDonnet ABille-Turc F: Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia. J Neurosurg 104:9139242006


Sindou MHoweidy TAcevedo G: Anatomical observations during microvascular decompression for idiopathic trigeminal neuralgia (with correlations between topography of pain and site of the neurovascular conflict). Prospective study in a series of 579 patients. Acta Neurochir (Wien) 144:1132002


Skirving DJDan NG: A 20-year review of percutaneous balloon compression of the trigeminal ganglion. J Neurosurg 94:9139172001


Taha JMTew JM Jr: A prospective 15-year follow-up of 154 consecutive patients with trigeminal neuralgia treated by percutaneous stereotactic radiofrequency rhizotomy. J Neurosurg 83:9899931995


Theodosopoulos PVMarco EApplebury CLamborn KRWilson CB: Predictive model for pain recurrence after posterior fossa surgery for trigeminal neuralgia. Arch Neurol 59:129713022002


Tronnier VMRasche DHamer JKienle AKunze S: Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression. Neurosurgery 48:126112682001


Tyler-Kabara ECKassam ABHorowitz MHUrgo LHadjipanayis CLevy EI: Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 96:5275312002


Zakrzewska JMLopez BCKim SECoakham HB: Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia. Neurosurgery 56:130413122005




All Time Past Year Past 30 Days
Abstract Views 85 85 26
Full Text Views 165 165 8
PDF Downloads 102 102 5
EPUB Downloads 0 0 0


Google Scholar