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.
KalkanisSNEskanderENCarterBSBarkerFGII: Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates and the effects of hospital and surgeon volumes. Neurosurgery52:1251–12622003
KanpolatYSavasABekarABerkC: Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience in 1,600 patients. Neurosurgery48:524–5342001
MassagerNLorenzoniJDevriendtDDesmedtFBrotchiJLevivierM: Gamma knife surgery for idiopathic trigeminal neuralgia using a faranterior cisternal target and a high dose of radiation. J Neurosurg100:597–6052004
SindouMHoweidyTAcevedoG: 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)144:1–132002
TronnierVMRascheDHamerJKienleAKunzeS: Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression. Neurosurgery48:1261–12682001
Tyler-KabaraECKassamABHorowitzMHUrgoLHadjipanayisCLevyEI: Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg96:527–5312002