Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia

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✓ Outcome after 252 posterior fossa explorations for the treatment of trigeminal neuralgia was determined by a retrospective review. Patients with distortion of the fifth nerve root caused by extrinsic vascular compression underwent microvascular decompression, those with no compression underwent partial sensory rhizotomy, and those with vascular contact but no distortion of the nerve root underwent decompression and rhizotomy. The mean follow-up period was 5.1 years. An excellent (75%) or good (8%) clinical outcome was achieved in 208 patients; 13 patients (5%) experienced little or no pain relief. Thirty-one patients (12%) suffered recurrent trigeminal neuralgia an average of 1.9 pain-free years after operation; recurrence continued at a rate of approximately 2% per year thereafter. Reoperation for recurrent or persistent pain provided excellent or good results in 85% of reoperated patients, but partial sensory rhizotomy was required in most of these patients. Outcome was affected by previous surgical procedures. A previous percutaneous radiofrequency lesion was associated with a significantly greater incidence of fifth nerve complications and a worse outcome after posterior fossa exploration. Because of this finding, the authors recommend that percutaneous radiofrequency rhizolysis be reserved for patients who have failed posterior fossa exploration or who are not candidates for surgery. Patients with compressive nerve root distortion and a short duration of symptoms before surgery had a significantly better outcome than patients with a longer duration of symptoms. In contrast, there was no relationship between the duration of symptoms and outcome of patients without nerve root distortion. Vascular decompression may cause dysfunction of the trigeminal system in tic douloureux, but in patients who remain untreated for long periods an intrinsic abnormality develops that may perpetuate pain even after microvascular decompression. Posterior fossa exploration is recommended as the procedure of choice for patients with trigeminal neuralgia who are surgical candidates.

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    Outcome following microvascular decompression (MVD) alone, partial sensory rhizotomy (PSR) alone, or MVD + PSR for the treatment of trigeminal neuralgia. Patients with vascular contact that caused nerve root distortion underwent MVD. Patients without vascular contact underwent PSR. Patients with vascular contact but no nerve root distortion underwent MVD + PSR. While there was a trend toward better outcome following MVD + PSR and worse outcome following PSR alone, the differences were not significant. P.F.R. = pain-free, recurrence.

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    Relationship of age at onset of pain and duration of symptoms (sx) to outcome following posterior fossa exploration for treatment of trigeminal neuralgia. Patients who experienced an excellent outcome had the shortest duration of symptoms before surgery (asterisks: p < 0.05). See text, Fig. 3, and Table 5. P.F.R. = pain-free, recurrence.

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    Kaplan-Meier curves for pain-free survival after posterior fossa exploration for trigeminal neuralgia. Curve 1: All patients (252 cases). While the great majority of recurrences occurred within 1 year, late recurrences continued at approximately 2% per year thereafter. Curves 2 and 3: Duration of symptoms less than 8 years (Curve 2, 101 cases) vs. duration of symptoms longer than 8 years before surgery (Curve 3, 63 cases) (p = 0.05). Curve 4: Outcome in patients previously treated with an ablative procedure that affected the trigeminal ganglion or root (41 cases) (p < 0.01, vs. Curve 1). Curve 5: Outcome in patients common to Curves 3 and 4 (19 cases) (p < 0.005, vs. Curve 1). There were no significant differences between patients with nerve root distortion treated with microvascular decompression (MVD) and patients with no distortion treated with partial sensory rhizotomy (PSR) or MVD + PSR.

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