Comparative evaluation of surgical procedures for trigeminal neuralgia: a literature review

Abstract

Trigeminal Neuralgia (TN) has been described in the literature as one of the commonest types of craniofacial pain disorders. TN refers to recurrent lancinating pain that occurs in the distribution of one or more branches of the fifth cranial nerve. The pain perception is typically unilateral, abrupt in onset, brief in duration, and usually starts after trivial stimuli. The overall prevalence of TN was reported around 0.7/1000 persons, but it tends to be higher in more advanced age groups since the initial onset of the symptoms most frequently starts at the age of 50–60 years. Although TN is more commonly seen in adults, pediatric TN represents <1.5% of all cases. Pediatric TN differs from adult TN primarily being bilateral in nature (42%) and associated with compression of multiple cranial nerves (46%). This review will evaluate the current surgical procedures used for the treatment of TN. Operative interventions for TN include microvascular decompression (MVD), balloon compression (BC), radiofrequency thermocoagulation (RF TC), glycerol rhizotomy (GR), and stereotactic radiosurgery (SRS). We review the historical development, advantages, and limitations of these operations. Additionally, we compare specific parameters for all current surgical procedures. We evaluated the short- and long-term outcomes, risk factors, complications and side effects in patients with TN who underwent operations. Arguments for and against the use of surgery for TN are presented. Next, surgical decision-making algorithm for refractory classical or idiopathic TN is proposed for patients who require surgery. This algorithm may be used by neurosurgeons in selecting the best surgical treatment. Lastly, we show the data on current clinical trials, the role of genetics to search for genes predisposing to TN. This project begins with the presumption that the risk for developing classical TN is in large part determined genetically. If so, given the power of modern genetic analysis, it should be possible to identify the underlying gene(s). At present, there is no ideal surgical procedure for trigeminal neuralgia—one that is minimally invasive, uniformly effective, lacking complications, and without failures or recurrences. MVD still remains the standard by which all other contemporary procedures are measured. MVD provides the longest pain-free interval, yet it is not free of morbidity and mortality. Stereotactic radiosurgery provides a reasonable noninvasive option, but it has delayed onset and a recurrence interval (a few years).