Microvascular decompression in trigeminal neuralgia: predictors of pain relief, complication avoidance, and lessons learned

Abstract

Objective To analyze characteristics associated with long-term pain relief after microvascular decompression (MVD) for trigeminal neuralgia (TGN). Description of associated morbidity and complication avoidance. Methods One hundred sixty-five patients with TGN underwent 171 MVD surgeries at the authors’ institution. Patient characteristics and magnetic resonance imaging (MRI) datasets were obtained through the hospital’s archiving system. Patients provided information about pre- and post-operative pain characteristics and neurologic outcome. Favorable outcome was defined as a Barrow Neurological Institute (BNI) pain intensity score of I to III with post-operative improvement of I grade. Results Type of TGN pain with purely paroxysmal pain (p = 0.0202*) and TGN classification with classical TGN (p = 0.0372*) were the only significant predictors for long-term pain relief. Immediate pain relief occurred in 90.6% of patients with a recurrence rate of 39.4% after 3.5 ± 4.6 years. MRI reporting of a neurovascular conflict had a low negative predictive value of 39.6%. Mortality was 0% with major complications observed in 8.2% of patients. Older age was associated with lower complication rates (p = 0.0009***). Re-MVD surgeries showed improved long-term pain relief in four out of five cases. Conclusions MVD is a safe and effective procedure even in the elderly. It has the unique potential to cure TGN if performed on a regular basis, and if key surgical steps are respected. Early MVD should be offered in case of medical treatment failure and paroxysmal pain symptoms. The presence of a neurovascular conflict on MRI is not mandatory. In case of recurrence, re-MVD is a good treatment option that should be discussed with patients. Highlights • Long-term analysis of pain relief after MVD. • Positive predictors for outcome: classical TGN and purely paroxysmal pain. • Presence of neurovascular conflict in MRI is not mandatory for MVD surgery. • Analysis of complications and surgical nuances for avoidance. • MVD is a safe procedure also in the elderly.

Long-term follow-up of microvascular decompression for management of trigeminal neuralgia

“…It has been shown that in about 96% of cases of typical TN, vascular compression is found [8,17]. In the large series published by Barker and Collogues in 1996, the authors reported the operative finding in 1185 patients with trigeminal neuralgia they described that in 75% of his cases SCA was the offending vessel this was followed by AICA in 10% of cases, PICA in 1% and vertebral artery 2% they found that venous compression was a part of nerve compromise in 68% of cases being the only offending factor in 13% of cases [18], this resembles the findings in our patients where the most common offending vessel was the SCA found in 15 Patients (71%), followed by AICA in four patients (19%) venous compression was the offending factor in two patients.…”

Microvascular decompression: Diversified of imaging uses, advantages of treating trigeminal neuralgia and improvement after the application of endoscopic technology

“…Data on the preferred treatment of patients with recurrent TN are limited. Fossa posterior re-exploration (redo MVD) is an effective treatment measure for recurrent TN after failed MVD ( 39 , 42 , 43 ); however, studies have found that re-MVD is more effective in patients with residual responsible vessels ( 44 , 45 ). If no vascular compression is found during re-exploration, partial sensory rhizotomy, internal neurolysis, or trigeminal nerve combing can be used ( 40 , 42 ).…”

“…Studies on prognostic factors have shown that severe NVC indicates a good prognosis for MVD ( 58 ). Other factors related to a good postoperative prognosis include a shorter course of the disease, type I facial pain, age, and sex ( 24 , 36 , 43 , 59 – 61 ). Moreover, a study showed that purely paroxysmal pain is the only significant predictor of long-term pain relief, which indicates that an early choice of MVD may be more beneficial to patients.…”

“…This may be due to the increase in cerebellar atrophy with age, which promotes full exposure of the pontine angle during surgery and improves the decompression success rate ( 60 ). Therefore, MVD is a safe procedure for older patients ( 43 ).…”

Evaluation of Endoscopic Microvascular Decompression for Trigeminal Neuralgia

“…Due to its successful surgical outcomes and ability to avoid long-term recurrence, microvascular decompression [MVD] has come to be recognized as the preferred surgical method for the treatment of trigeminal neuralgia [TN]. For some patients, pharmaceutical therapy is enough to effectively control the symptoms of TN, which include intense, sporadic facial pain brought on by inflammation and injury to the trigeminal or fifth cranial nerve [3][4][5] .…”