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Paolini S, Mancarella C, Scafa AK, Arcidiacono U, Morace R, Chiarella V, Di Castelnuovo A, Esposito V. Circumferential nerve wrapping with muscle autograft: a modified strategy of microvascular decompression for trigeminal neuralgia. Neurosurg Rev 2025; 48:32. [PMID: 39789374 DOI: 10.1007/s10143-024-03100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 10/02/2024] [Accepted: 11/11/2024] [Indexed: 01/12/2025]
Abstract
Microvascular decompression is considered a first-line treatment in classical trigeminal neuralgia. Teflon is the material commonly used. The use of autologous muscle has been occasionally reported. Failure may result from insufficient nerve decompression, inflammatory reaction to Teflon or late displacement of the offending vessel. In this paper, we illustrate an MVD technique that involves a modified muscle insertion method. In a series of 57 consecutive patients who underwent microvascular decompression, the trigeminal nerve was coated circumferentially with a substantial amount of autologous muscle graft. The coverage was extended well beyond the site of neurovascular conflict to create a cushioned environment and protect the nerve. Pain intensity was assessed using the Barrow-Neurological-Institute (BNI) grading scale. The mean follow-up period was 28.8 months (range: 12 to 75 months). Preoperatively, all patients experienced typical pain that was scored as BNI V. No postoperative mortality was observed. After surgery two patients developed incomplete facial nerve palsy, which resolved over 6-months and one patient experienced hearing loss (the only permanent complication). Ten patients (17.5%) developed mild hemifacial numbness, as detailed in the postoperative data and pain outcome section. There were no infections or cerebrospinal fluid leakages. Immediately after surgery, all patients achieved satisfactory pain control: 55 cases (96.5%) scoring as BNI grade I and 2 cases (3.5%) scoring as BNI grade II. At the latest follow-up, three patients (5.3%) experienced symptoms controlled by medications (grade III). Recurrence of pain BNI IV to V was observed in two cases (3.5%). Circumferential nerve wrapping using abundant autologous muscle resulted in immediate pain control in all patients treated, with a low recurrence rate.
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Affiliation(s)
- Sergio Paolini
- Department of Neurosurgery, IRCCS Neuromed, Via Atinense 18, Pozzilli, IS, 86077, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Cristina Mancarella
- Department of Neurosurgery, IRCCS Neuromed, Via Atinense 18, Pozzilli, IS, 86077, Italy.
| | | | | | - Roberta Morace
- Department of Neurosurgery, IRCCS Neuromed, Via Atinense 18, Pozzilli, IS, 86077, Italy
| | - Vito Chiarella
- Department of Neurosurgery, IRCCS Neuromed, Via Atinense 18, Pozzilli, IS, 86077, Italy
| | | | - Vincenzo Esposito
- Department of Neurosurgery, IRCCS Neuromed, Via Atinense 18, Pozzilli, IS, 86077, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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Zhang Z, Zhao H, Tang Y, Wang B, Yuan Q, Wang H, Cai X, Zhu W, Li S. Microvascular Decompression Using the Gelatin Sponge Insertion Technique for Trigeminal Neuralgia: A Retrospective Cohort Study. Oper Neurosurg (Hagerstown) 2025; 28:52-58. [PMID: 38888321 DOI: 10.1227/ons.0000000000001229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/15/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Microvascular decompression (MVD) is the primary surgical intervention for trigeminal neuralgia (TN), with Teflon being the most conventional decompressing material. However, Teflon has been associated with adhesion and granulomas after MVD, which closely correlated with the recurrence of TN. Therefore, we developed a new technique to prevent direct contact between Teflon and nerve. The purpose of this study is to compare the efficacy of MVD using the gelatin sponge (GS) insertion technique with that of Teflon inserted alone in treating primary TN. METHODS We retrospectively analyzed the medical records and the follow-up data of 734 patients with unilateral primary TN who underwent MVD at our center from January 2014 to December 2019. After exclusions, we identified 313 cases of GS-inserted MVD and 347 cases of traditional MVD. The follow-up exceeded 3 years. RESULTS The operating time of the GS-inserted group was longer than that of the Teflon group (109.38 ± 14.77 vs 103.53 ± 16.02 minutes, P < .001). There was no difference between 2 groups in immediate surgical outcomes and postoperative complications. The yearly recurrence rate for GS-inserted MVD was lower at first (1.0%), second (1.2%), and third (1.2%) years after surgery, compared with its counterpart of Teflon group (3.7%, 2.9%, and 1.7% respectively). The first-year recurrence rate ( P = .031) and total recurrence rate in 3 years ( P = .013) was significantly lower in the GS-inserted group than Teflon group. Kaplan-Meier survival analysis demonstrated better outcomes in GS-inserted MVD groups ( P = .020). CONCLUSION The application of the GS insertion technique in MVD reduced first-year postoperative recurrence of TN, with similar complications rates compared with traditional MVD.
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Affiliation(s)
- Zhongding Zhang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Hua Zhao
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Yinda Tang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Baimiao Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Qing Yuan
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Haopeng Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Xiaomin Cai
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Wanchun Zhu
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
| | - Shiting Li
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai , China
- The Cranial Nerve Disease Center of Shanghai Jiao Tong University, Shanghai , China
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Rheaume AR, Pietrosanu M, Ostertag C, Sankar T. Repeat Surgery for Recurrent or Refractory Trigeminal Neuralgia: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:370-380.e2. [PMID: 38403014 DOI: 10.1016/j.wneu.2024.02.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/17/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited data exist to guide the selection of salvage surgical procedures. We aimed to compare pain relief outcomes after repeat microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS) to determine which modality was most efficacious for surgically refractory TN. METHODS A PRISMA systematic review and meta-analysis was performed, including studies of adults with classical or idiopathic TN undergoing repeat surgery. Primary outcomes included complete (CPR) and adequate (APR) pain relief at last follow-up, analyzed in a multivariate mixed-effect meta-regression of proportions. Secondary outcomes were initial pain relief and facial numbness. RESULTS Of 1299 records screened, 61 studies with 68 treatment arms (29 MVD, 14 PR, and 25 SRS) comprising 2165 patients were included. Combining MVD, PR, and SRS study data, 68.8% achieved initial CPR after a repeat TN procedure. On average, 49.6% of the combined sample of MVD, PR, and SRS had CPR at final follow-up, which was on average 2.99 years postoperatively. The proportion (with 95% CI) achieving CPR at final follow-up was 0.57 (0.51-0.62) for MVD, 0.60 (0.52-0.68) for PR, and 0.35 (0.30-0.41) for SRS, with a significantly lower proportion of pain relief with SRS. Estimates of initial CPR for MVD were 0.82 (0.78-0.85), 0.68 for PR (0.6-0.76), and 0.41 for SRS (0.35-0.48). CONCLUSIONS Across MVD, PR, and SRS, about half of TN patients maintain complete CPR at an average follow-up time of 3 years after repeat surgery. In treating refractory or recurrent TN, MVD and PR were superior to SRS in both initial pain relief and long-term pain relief at final follow-up. These findings can inform surgical decision-making in this challenging population.
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Affiliation(s)
- Alan R Rheaume
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Curtis Ostertag
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tejas Sankar
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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Wang H, Li S, Wang Z, Wu D, Guo Z, Zhao B, Wan J. Online dynamic nomogram for predicting pain recurrence after microvascular decompression in trigeminal neuralgia. Exp Ther Med 2023; 26:431. [PMID: 37602298 PMCID: PMC10433436 DOI: 10.3892/etm.2023.12130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/05/2023] [Indexed: 08/22/2023] Open
Abstract
Trigeminal neuralgia (TN) is one of the most common causes of facial pain. Microvascular decompression (MVD) is the first-choice surgical treatment. The present study aimed to develop a novel practical assessment system based on preoperative clinical and imaging factors for clinicians to predict the likelihood of pain recurrence following MVD in TN. A total of 56 patients with primary unilateral TN who underwent MVD were retrospectively analyzed. Patients were followed up to observe pain recurrence 1 year after MVD. An online dynamic nomogram was constructed for predicting the probability of pain recurrence after MVD in patients with TN based on multivariate logistic model. The concordance index (C-index) and receiver operating characteristic (ROC) were used to measure model discrimination. Bootstrap resampling was used for internal validation of the model and calibration curve was constructed. Decision curve analysis (DCA) was used to assess clinical applicability. Factors such as numeric rating scale (to score pain degree of patients with TN), response to neuroanalgesic drugs and neurovascular contact on magnetic resonance imaging were independent risk factors affecting the pain recurrence rate (all P<0.05). C-index was 0.973 (95%CI, 0.938-1.000) and the area under the ROC was 0.973 (95%CI, 0.938-1.000). Calibration curve with a 1,000 bootstrap resampling showed a good fit between dynamic nomogram prediction and actual observations. The DCA showed that at a threshold probability between 0 and 100%, this model can achieve a greater net benefit than if all patients had surgery or none had surgery. In conclusion, this online dynamic nomogram reliably predicted risk of pain recurrence in patients with TN following MVD.
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Affiliation(s)
- Hongliang Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Sai Li
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Zhiwei Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Dejun Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Zhifei Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Bing Zhao
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Cerebral Vascular Disease Research Center, Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Jinghai Wan
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100000, P.R. China
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Uhl C, Vajkoczy P. Contact-free transposition and interposition techniques for trigeminal neuralgia: a systematic review. J Neurosurg Sci 2023; 67:36-45. [PMID: 36082834 DOI: 10.23736/s0390-5616.22.05514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Surgical treatment for trigeminal neuralgia (TGN), by means of interposition of material between nerve and offending vessel, has been shown to be highly efficient. In recent years, treatment by means of vessel transposition has become more frequent, as in singular cases of recurrence, nerval reactions towards interposed material have been noted. In this review we research the classic microvascular decompression (MVD) techniques (interposition) as well as the more recent transposition and their effectiveness, considering patient outcomes as well as complications and recurrences. EVIDENCE ACQUISITION We searched online databases MEDLINE and LIVIVO, using key words trigeminal neuralgia AND transposition/ AND sling/ AND non compressive technique/ AND microvascular decompression. EVIDENCE SYNTHESIS We included 8 studies for transposition and 20 studies for the interposition, combining for 2045 patients (302 for transposition and 1743 for interposition). 96.1% of patients in the transposition and 93.1% in the interposition group reported a positive outcome immediately postoperatively. At follow-up, 87.4% in the transposition group (follow-up 51.2 months) and 87.9% of patients in the interposition group (follow-up 36.5 months), reported a positive outcome. 16.2% of patients in the transposition and 13.1% in the interposition group had postoperative complications. Recurrence was reported in 5.6% of patients treated with transposition and 2.3% of patients treated with interposition. CONCLUSIONS Transposition presents similar results concerning short- and long-term patient satisfaction for treatment of TGN as well as similar numbers of complications of recurrences as interposition. Yet, current evidence is restricted to a few retrospective studies, thus, evidence is limited so far.
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Affiliation(s)
- Christian Uhl
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany -
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Park CK, Park BJ. Surgical treatment for Trigeminal neuralgia. J Korean Neurosurg Soc 2022; 65:615-621. [PMID: 35430788 PMCID: PMC9452382 DOI: 10.3340/jkns.2021.0265] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
Abstract
Various treatments for trigeminal neuralgia (TN) are known to yield initial satisfactory results; however, the surgical treatment has excellent long-term outcomes and a low recurrence rate. Surgical treatment addresses the challenge of vascular compression, which accounts for 85% of the causes of TN. As for surgical treatment for TN, microvascular decompression (MVD) has become the surgical treatment of choice after Peter J. Jannetta reported the results of MVD surgery in 1996. Since then, many studies have reported a success rate of over 90% for the initial surgical treatment. Most MVDs aim to separate (decompress) the culprit vessel from the trigeminal nerve. To increase the success rate of surgery, accurate indications for MVD and management of the offender vessels without complications are critical. In addition, if there is no vascular compression, partial sensory rhizotomy or internal neurolysis can be performed to improve surgical outcomes.
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Jiao L, Ye H, Lv J, Xie Y, Sun W, Ding G, Cui S. A Systematic Review of Repeat Microvascular Decompression for Recurrent or Persistent Trigeminal Neuralgia. World Neurosurg 2021; 158:226-233. [PMID: 34875391 DOI: 10.1016/j.wneu.2021.11.129] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE When conservative therapy fails, microvascular decompression (MVD) has been the preferred treatment of primary trigeminal neuralgia (TN). However, the management of recurrent or persistent TN after MVD can often be difficult. The purpose of the present systematic review was to objectively analyze and summarize the reported literature regarding the feasibility of repeat MVD. METHODS We conducted a database search using the MEDLINE and PubMed databases until July 2020. The search terms used for title and abstract screening were as follows: "recurrent trigeminal neuralgia," "persistent trigeminal neuralgia," "repeat microvascular decompression," and "reexploration." The inclusion criteria for the systematic review were as follows: clinical studies (excluding case studies), repeat MVD treatment of TN, and studies that had recorded the pain relief outcomes, operative findings, and complications (if any). RESULTS Of the 1771 initial results obtained, we performed a full text screening of 43 studies, and, ultimately, 19 were deemed eligible. A total of 2247 patients had undergone MVD for TN, of whom, 311 had experienced recurrence (13.84%). Of the 311 patients, 178 had undergone repeat MVD. The average pain-free interval was 27.75 months after the first MVD. The effective rate of repeat MVD was 91.66%, and 71.48% of the patients had had obvious compression found at repeat MVD. The postoperative complication rate after repeat MVD was 37.31% and was due to postoperative adhesions around the nerve and nerve injury caused by partial sensory rhizotomy. The most common complication after repeat MVD was facial numbness (21.89%), although the incidence of other complications was <5%. CONCLUSIONS For patients with recurrent or persistent pain after MVD, the findings from our systematic review support that repeat MVD remains a feasible treatment for recurrent or persistent TN.
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Affiliation(s)
- Liwu Jiao
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China.
| | - Hao Ye
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
| | - Jibo Lv
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
| | - Yong Xie
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
| | - Wei Sun
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
| | - Guolin Ding
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
| | - Simin Cui
- Department of Neurosurgery, Qujing First People's Hospital, Kunming Medical University Affiliated Qujing Hospital, Qujing City, China
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Liu J, Wu G, Xiang H, Liu R, Li F, Hei B, Qian W, Song H, Liu Z. Long-Term Retrospective Analysis of Microvascular Decompression in Patients With Recurrent Trigeminal Neuralgia. Front Neurol 2020; 11:584224. [PMID: 33408683 PMCID: PMC7779790 DOI: 10.3389/fneur.2020.584224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/01/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the clinical characteristics of patients with recurrent trigeminal neuralgia (TN) and the experience of microvascular decompression (MVD) in the treatment of such patients. Methods: We retrospectively analyzed clinical data, imaging examination results, surgical methods, and treatment efficacies in 127 patients with recurrent typical TN from January 2005 to December 2014. Results: The age of the recurrent group was higher than that of the non-recurrent group (p < 0.05). The duration of pain before the first MVD procedure was longer in the recurrent group than in the non-recurrent group (p < 0.05). Patients in the recurrent group were more likely to have compression of the trigeminal nerve by the vertebrobasilar artery (VBA) or multiple vessels than patients in the non-recurrent group (p < 0.05). A Kaplan-Meier curve showed a median pain-free survival of 12 months after the first MVD procedure. The severity of pain (preoperative visual analog scale [VAS] score) in patients with recurrence was lower than that in patients with first-onset TN (p < 0.05). Vessel compression, Teflon compression or granuloma and arachnoid adhesion were considered the main causes of recurrence. Postoperative Barrow Neurological Institute (BNI) scores in the redo MVD group were excellent (T = 2) for 69 patients (53.33%) and good (T = 3) for 46 patients (36.22%). The postoperative follow-up was 63-167 months (105.92 ± 25.66). During the follow-up, no recurrence was noted. All complications were cured or improved. Conclusions: Microvascular decompression (MVD) is an effective surgical method for the treatment of TN. For recurrent patients, reoperation can achieve good results.
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Affiliation(s)
- Jiayu Liu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Guangyong Wu
- Department of Neurosurgery, The Hospital of Shunyi District Beijing, Beijing, China
| | - Hui Xiang
- Department of Neurosurgery Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Ruen Liu
- Department of Neurosurgery Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China.,Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Fang Li
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Bo Hei
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Weiqiang Qian
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Haidong Song
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
| | - Zhi Liu
- Department of Neurosurgery, Peking University People's Hospital, Beijing, China
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Hoz SS, Al-Sharshahi ZF, Dolachee AA, Chotai S, Salih H, Albanaa SA, Mohammed HJ. Transposition of Vessels for Microvascular Decompression of Posterior Fossa Cranial Nerves: Review of Literature and Intraoperative Decision-Making Scheme. World Neurosurg 2020; 145:64-72. [PMID: 32890843 DOI: 10.1016/j.wneu.2020.08.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/22/2020] [Accepted: 08/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Microvascular decompression with transposition of the involved vessels provides good surgical outcomes in cases of complex and recurrent neurovascular compression syndromes. We conducted a literature review to illustrate the variations in the surgical techniques used for transposition and to provide a practical decision-making scheme for transposition of the involved vessel. METHODS A PubMed Medline database record search was conducted using the following algorithm ("Microvascular Decompression Surgery"[Mesh]) OR (((Microvascular) OR (Macrovascular)) AND decompression AND surgery) AND (transposition). Only articles that detailed the intraoperative techniques were included. RESULTS A total of 48 articles were included. The adjacent anatomical walls to which the compressing vessel can be anchored were divided into 4 groups; A: roof (tentorium cerebelli), B: anterior wall (posterior surface of petrous bone and clivus), C: posterior wall (petrosal surface of the cerebellum), and D: "no wall" required. A new decision-making scheme based on the following 2 questions was designed: 1) is the conflicting vessel amenable to transposition to a nearby wall in the cerebello-brainstem space? 2) what is the closest wall to secure the transposed vessel? CONCLUSIONS Transposition of the involved vessel is a valuable procedure for microvascular decompression of the posterior fossa cranial nerves. Anchoring the vessel to the adjacent anatomical wall ensures secure transposition. The proposed algorithm provides a systemic scheme to identify the optimal anatomical wall, and to determine the technique and material that can be used to anchor involved vessel. This scheme is an efficient method to inform the intraoperative decision-making process.
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Affiliation(s)
- Samer S Hoz
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | | | - Ali Adnan Dolachee
- Department of Surgery, College of Medicine, University of Al-Qadisiyah, Diwaniyah, Iraq
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hayder Salih
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
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Nova CV, Zakrzewska JM, Baker SR, Riordain RN. Treatment Outcomes in Trigeminal Neuralgia-A Systematic Review of Domains, Dimensions and Measures. World Neurosurg X 2020; 6:100070. [PMID: 32123867 PMCID: PMC7036566 DOI: 10.1016/j.wnsx.2020.100070] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/16/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock-like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measures. The aim of this systematic review was to summarize all the outcomes and outcomes measures that have been published to date and highlight variability in their use. METHODS We have conducted a literature search using a wide range of databases (1946-2019 for medical and 2008-2019 for surgical treatment), for all intervention studies in TN. Four hundred and sixty-seven studies were selected for data extraction on TN classification, data collection method, intervention, and treatment outcomes mapped to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT guidelines). RESULTS Most studies collected data on pain (n = 459) and side effects (n = 386) domains; however, very few collected data on the impact of treatment on physical (n = 46) and emotional functioning (n = 17) and on patient satisfaction (n = 35). There was high variability on outcome measures used for pain relief (n = 10), pain intensity (n = 9), and frequency of pain episodes (n = 3). CONCLUSIONS A clear definition of what are the important outcomes for patients with TN is essential. The choice of standardized outcome measures allowing for consistent reporting in TN treatment will allow for comparison of studies and facilitate treatment choice for patients and clinicians thus, improving health outcomes and reducing health care cost.
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Affiliation(s)
| | | | - Sarah R. Baker
- School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom
| | - Richeal Ni Riordain
- UCL Eastman Dental Institute, London, United Kingdom
- Department of Oral Medicine, Cork University Dental School and Hospital, Cork, Ireland
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Zhang D, Barata A, Pires P, Soares P, Marques L. Transposition of Superior Cerebellar Artery for Microvascular Decompression in Trigeminal Neuralgia Using an In Situ Superior Petrosal Vein Sling Technique. World Neurosurg 2019; 134:402-407. [PMID: 31733391 DOI: 10.1016/j.wneu.2019.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Several microvascular decompression technical variations for the treatment of medically refractory trigeminal neuralgia have been proposed that can be categorized generally as interposition and transposition techniques. These latter approaches, so-called slinging techniques, have been increasing in popularity, because they can possibly reduce the long-term recurrence rates by preventing the formation of fibrosis and granulomas at the decompression site. We have reported a technique for transposition of the superior cerebellar artery for microvascular decompression in trigeminal neuralgia using the superior petrosal vein as an in situ sling to anchor and reroute the artery away from the nerve. METHODS We have presented a technical report with illustrative intraoperative images and video from 2 cases of trigeminal neuralgia in which the superior petrosal vein was used as a simple and straightforward in situ sling for transposition of the superior cerebellar artery. RESULTS The technique was applied successfully in 2 patients with complete and immediate remission of trigeminal neuralgia, without surgical morbidity. CONCLUSION The most frequent neurovascular conflict in trigeminal neuralgia involves the superior cerebellar artery, and the strategic location of the superior petrosal vein relative to this neurovascular complex allows for its use as a natural in situ sling that reroutes the artery and prevents its recoil against the nerve. This technique can be added to the increasing armamentarium of transposition techniques for microvascular decompression, with the advantage of simplicity and no requirement for a complex prosthesis to secure the transposition.
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Affiliation(s)
- Ding Zhang
- Department of Neurosurgery, Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisbon, Portugal.
| | - António Barata
- Department of Neurosurgery, Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisbon, Portugal
| | - Pedro Pires
- Department of Neuroradiology, Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisbon, Portugal
| | - Pedro Soares
- Department of Neuroradiology, Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisbon, Portugal
| | - Luís Marques
- Department of Neurosurgery, Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisbon, Portugal
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Steinberg JA, Sack J, Wilson B, Weingarten D, Carter B, Khalessi A, Ben-Haim S, Alksne J. Tentorial sling for microvascular decompression in patients with trigeminal neuralgia: a description of operative technique and clinical outcomes. J Neurosurg 2019; 130:1315-1320. [PMID: 29676696 DOI: 10.3171/2017.10.jns17971] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 10/06/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Trigeminal neuralgia is a debilitating pain disorder most often caused by arterial compression of the trigeminal nerve, although there are other etiologies. Microvascular decompression (MVD) remains the most definitive treatment for this disorder, with cure rates reported between 60% and 80%. Traditional MVD techniques involve a retrosigmoid craniotomy with placement of an inert foreign material, such as Teflon, between the nerve and compressive vessel. Recurrence of trigeminal neuralgia after MVD has been associated with vessel migration, adhesion formation, and arterial pulsation against the Teflon abutting the nerve. Additionally, foreign materials such as Teflon have been reported to trigger inflammatory responses, resulting in recurrence of trigeminal pain. An alternative method for decompression involves the use of a sling to transpose the compressive vessel away from the nerve. Results of various sling techniques as a decompressive strategy are limited to small series and case reports. In this study, the authors present their experience utilizing a tentorial sling for MVD in patients with trigeminal neuralgia. METHODS Institutional review board approval was obtained in order to contact patients who underwent MVD for trigeminal neuralgia via the tentorial sling technique. Clinical outcomes were assessed utilizing the Barrow Neurological Institute (BNI) pain intensity score immediately after surgery and at the time of the study. RESULTS The tentorial sling technique was performed in 45 patients undergoing MVD for trigeminal neuralgia. In 41 of these patients, this procedure was their first decompressive surgery. Immediate postoperative relief of pain (BNI score I) was achieved in 80% of patients undergoing their first decompressive procedure. At last follow-up, 73% of these patients remained pain free. Three patients experienced recurrent trigeminal pain, with surgical exploration demonstrating an intact tentorial sling. The complication rate was 6.6%. CONCLUSIONS Transposition techniques for MVD have been described previously in small series and case reports. This study represents the largest experience in which the utilization of a tentorial sling for MVD in patients with trigeminal neuralgia is described. The technique represents a novel method for decompression of the trigeminal nerve by transposition of the offending vessel without the use of foreign material. Although the authors' preliminary results parallel the historical cure rate, further outcome data are required to assess long-term durability of this method.
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The Outcome of Sling Retraction Technique in Microvascular Decompression for Hemifacial Spasm. J Craniofac Surg 2018; 29:e764-e767. [DOI: 10.1097/scs.0000000000004727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chen JN, Yu WH, Du HG, Jiang L, Dong XQ, Cao J. Prospective Comparison of Redo Microvascular Decompression and Percutaneous Balloon Compression as Primary Surgery for Recurrent Trigeminal Neuralgia. J Korean Neurosurg Soc 2018; 61:747-752. [PMID: 30081435 PMCID: PMC6280063 DOI: 10.3340/jkns.2017.0196] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 11/24/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To prospectively compare facial pain outcomes for patients having either a repeat microvascular decompression (MVD) or percutaneous balloon compression (PBC) as their surgery for trigeminal neuralgia (TN) recurrence. METHODS Prospective cohort study of 110 patients with TN recurrence who had either redo MVD (n=68) or PBC (n=42) from July 2010 until September 2016. The mean follow-up was 45.6 months. RESULTS After redo MVD, 65 patients (95.6%) experienced immediate relief of pain. After PBC, 34 patients (81%) were immediately relieved of their neuralgia. After 1 month, the clinical effect of redo MVD was better than PBC (p<0.01). Patients who had redo MVD more commonly were pain free off medications (93.4% at 1 year, 78.2% at 4 years) compared with the PBC patients (85.1% at 1 year, 59.3% at 4 years). However, mean length of stay was longer (p>0.05). Patients after PBC who occurred developed herpes simplex (35.7%), facial numbness (76.2%), annoying dysesthesia (21.4%) more frequently compared with patients after redo MVD who occurred developed herpes simplex (14.7%), facial numbness (8.8%), hypoesthesia (5.9%) (p<0.05). The symptoms recurred respectively in 15 patients (22.1%) and 19 patients (45.2%) after redo MVD and PBC within the entire 6-year follow-up period. CONCLUSION For the patients with TN recurrence, redo MVD was a more effective procedure than PBC. The cure rate and immediate relief of pain were better, and the incidence of complications was lower.
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Affiliation(s)
- Jing-Nan Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Wen-Hua Yu
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Hang-Gen Du
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Li Jiang
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Xiao-Qiao Dong
- Department of Neurosurgery, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Jie Cao
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
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Leidinger A, Muñoz-Hernandez F, Molet-Teixidó J. Absence of neurovascular conflict during microvascular decompression while treating essential trigeminal neuralgia. How to proceed? Systematic review of literature. Neurocirugia (Astur) 2018; 29:131-137. [PMID: 29571561 DOI: 10.1016/j.neucir.2018.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 01/23/2018] [Accepted: 02/03/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario. RESULTS Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described. The success rates of these techniques, pain recurrence rates and rates of complications are also reported. Finally, we provide suggestions based on our experience. CONCLUSIONS There is no gold standard, but several techniques could be successfully used in the absence of neurovascular conflict. The use of destructive techniques, such as PSR, should be held as treatments of last resort.
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Affiliation(s)
- Andreas Leidinger
- Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | | | - Joan Molet-Teixidó
- Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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Gonzalez-Quarante LH, Ruiz-Juretschke F, Agarwal V, Garcia-Leal R. Microvascular Decompression for Trigeminal Neuralgia Using a Novel Fenestrated Clip and Tentorial Flap Technique. World Neurosurg 2017; 106:775-784. [DOI: 10.1016/j.wneu.2017.07.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/24/2022]
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Berger I, Nayak N, Schuster J, Lee J, Stein S, Malhotra NR. Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis. Cureus 2017; 9:e1000. [PMID: 28280653 PMCID: PMC5325747 DOI: 10.7759/cureus.1000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment. METHODS We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL. RESULTS MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence. CONCLUSIONS With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.
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Affiliation(s)
- Ian Berger
- School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Nikhil Nayak
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - James Schuster
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - John Lee
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sherman Stein
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Neil R Malhotra
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Abstract
Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadav Nishtha
- Department of Radio Diagnosis and Imaging, All India Institute of Medical Science, New Delhi, India
| | - Pande Sonjjay
- Department of Radio Diagnosis and Imaging, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Parihar Vijay
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ratre Shailendra
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Khare Yatin
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Second Microvascular Decompression for Trigeminal Neuralgia in Recurrent Cases After Microvascular Decompression. J Craniofac Surg 2015; 26:491-4. [DOI: 10.1097/scs.0000000000001523] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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