Bilateral trigeminal neuralgia: a 14-year experience with microvascular decompression

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✓ Thirty-five patients with trigeminal neuralgia (TN) bilaterally underwent posterior fossa microvascular decompression (MVD) between 1971 and 1984. They comprised 5.0% of a larger series of 699 patients with TN who underwent MVD during that interval. Compared to the subgroup of 664 patients with only unilateral symptoms, the population with bilateral TN included a greater percentage of females (74% vs. 58%, p < 0.1), a higher rate of “familial” TN (17% vs. 4.1%, p < 0.001), and an increased incidence of additional cranial nerve dysfunction (17% vs. 6.6%, p < 0.05) and hypertension (34% vs. 19%, p < 0.05).

Of the 35 patients with bilateral TN, 10 underwent bilateral MVD (22 procedures) and 25 underwent unilateral MVD (30 procedures). In the latter patients, pain on the nonoperative side was well controlled with medication alone or had previously been treated by ablative procedures. Good or excellent pain control was achieved after one MVD was performed in 40 of the 45 sides treated (89%), and was maintained 1, 5, and 10 years after surgery in 82%, 66%, and 60%, respectively, based on life-table analysis. Six of 10 patients with recurrent symptoms underwent repeat unilateral MVD. Good or excellent long-term pain control was maintained in all six. With these repeat procedures included, symptom control at 1, 5, and 10 years after initial surgery was maintained in 87%, 78%, and 78% of the treated sides, respectively. Overall, 26 of 35 patients (74%) maintained good or excellent pain relief throughout the duration of the study (mean follow-up period 75 months) without resumption of regular medication usage. Although preoperative neurological deficits resulting from previous ablative procedures were seen in the majority of patients before MVD, no patient developed new major trigeminal sensory loss or masseter weakness after MVD. Operative mortality was zero. The results indicate that posterior fossa MVD is an effective and relatively safe treatment for the majority of patients with bilateral “idiopathic” TN, avoiding the risks of bilateral trigeminal nerve injury seen with other approaches.

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Address reprint requests to: Peter J. Jannetta, M.D., Department of Neurological Surgery, Room 9402, Presbyterian-University Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.

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    Life-table analysis in 25 patients undergoing unilateral and 10 undergoing bilateral microvascular decompression (MVD) with operations on 45 sides. This graph illustrates the percent of treated sides with good or excellent symptom control after one MVD per treated side (dotted line) and after one or two MVD's per treated side (solid line) as a function of the follow-up time. Treatment failure was defined as a lasting recurrence of moderate to severe TN or a resumption of regular medication use.

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    Life-table analysis in 10 patients undergoing bilateral microvascular decompression (MVD) with operations on 20 sides. This graph illustrates the percent of treated sides with good or excellent symptom control after one MVD per treated side (dotted line) and after one or two MVD's per treated side (solid line) as a function of the follow-up time.

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