Choice of open or percutaneous procedures in the surgical treatment of trigeminal neuralgia

Abstract

IntroductionTrigeminal neuralgia (TN) can be managed by medical and surgical treatment. Half of the patients are cured by drugs (particularly carbamazepine) without side effects, 25% are cured but have intolerable side effects and 25% are not cured [1]. Then, half of the patients require surgical treatment. When drugs become ineffective or not tolerated, the question of which intervention (percutaneous or open) is appropriate becomes an important issue. Among modern operations, three are percutaneous (trigeminal percutaneous Guido OrlandiniAbstract The aim of this study was to define criteria for the selection of patients for percutaneous or open operations for the cure of drug-resistant trigeminal neuralgia (TN). Trigeminal percutaneous radiofrequency thermorhizotomy (TPRT) has an established place because of its safety in elderly patients, while microvascular decompression (MVD) has appeal in younger patients because of its non-destructive nature and because it attacks what is believed to be the primary etiology of tic douloureux. Nevertheless, MVD is a successful operation only when true neurovascular conflict (NVC) is ascertained, rather than a simple arterial loop and neurovascular contact. Probably, many immediate failures and early relapses are the consequence of the inadequate patient selection for MVD on the presumption that this operation is in any case the ideal cure. The inadequate selection can be explained by the difficult preoperative diagnosis of NVC in the past.Indeed, angiography and computed tomography showed the neurovascular contact but not the size of compression. Fortunately, today magnetic resonance imaging is a reliable instrument to ascertain NVC. So, the diatribe between the supporters of percutaneous techniques and MVD can be concluded with the following: (1) percutaneous techniques are indicated for patients without demonstrated NVC (including patients with TN in multiple sclerosis) and in those with NVC if MVD is contraindicated by ill-health or refused by the informed patient; and (2) MVD is indicated for patients with ascertained NVC who are in good health and who, informed of the surgical risk, favor this operation desiring no sensory deficit.

A prospective study of 39 patients with trigeminal neuralgia treated with percutaneous balloon compression

“…Immediate pain relief is very common (about 90%); however, total relief may be delayed by several days. Our good results of PBC have been confirmed in large series by other authors 5,7,13,18,23 . Trigeminal neuralgia has a significant impact on the quality of life of the patients.…”

“…In previously published data, half of the patients were controlled by drugs without side effects, 25% were controlled but endured intolerable side effects and 25% were not controlled 7 . When drugs become ineffective or intolerable, the discussion on the appropriate surgical intervention, whether percutaneous or open, becomes important.…”

“…When drugs become ineffective or intolerable, the discussion on the appropriate surgical intervention, whether percutaneous or open, becomes important. There are well-known surgical options to treatment of TN: three percutaneous procedures (trigeminal percutaneous radiofrequency thermorhizotomy, retrogasserian glycerol injection and PBC) and two open surgery (partial sensory rhizotomy and microvascular decompression) 7 . In our opinion, percutaneous procedures have a well established place for its safety, particularly in elderly patients.…”

“…Microvascular decompression (MVD) has been preferred in younger patients due to its non-ablative nature. However, there are currently no clear guidelines for surgical treatment of TN 7 . PBC is predicated on matching the time of balloon inflation with radiographic imaging and may be performed under general anesthesia, which is pain-free to the patient during the entire procedure and may add to the comfort level of the surgeon.…”

“…The treatment should be tailored to each patient, and depends on the patient's age, trigeminal nerve division involved, medical comorbidities, surgeon's experience and the risks that the patient is willing to take. Percutaneous balloon compression (PBC), as first described by Mullan 5 using a Fogarty embolectomy catheter to compress the ganglion and retrogasserian nerve, is a useful and minimally invasive technique with low risks and low morbidity 6,7 . The goals of this study are to review our results with PBC technique and to assess its side effects and the factors influencing the outcome.…”