Predictors of long-term success after microvascular decompression for trigeminal neuralgia

Miller, Jonathan P.; Magill, Stephen T.; Acar, Feri̇dun; Burchiel, Kim J.

doi:10.3171/2008.9.17660

Cited by 86 publications

(41 citation statements)

References 16 publications

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“…Microvascular decompression has proven to be a particularly effective mode of treatment, with some studies reporting as many as 98% of patients with typical TN obtaining some pain relief immediately postoperatively and up to 80% obtaining complete relief immediately following surgery. 3,22,32 As the world's population ages, the safety of MVD in older persons has become a topic of increased interest. 2,8,9,12,13,25,27,29,30 To date, the safety of MVD in older patients has been examined through several small case series, which were * CHF = congestive heart failure.…”

Section: Discussionmentioning

confidence: 99%

Safety of microvascular decompression for trigeminal neuralgia in the elderly

Rughani

Dumont

Lin

et al. 2011

JNS

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Since its description by Jannetta, 10,11 MVD has proven to be a successful surgical treatment for TN. As the incidence of TN increases with age, 17 the safety of MVD in the elderly population represents an important clinical question for treating physicians. Several small studies, 2,8,9,12,13,25,27,30 including a recent prospective analysis, 29 have suggested that the efficacy and safety of MVD in elderly patients are comparable with those in younger patients. Unfortunately these studies are limited by small sample sizes. Utilizing a large national data set, we determined that the impact of an advanced age on perioperative complication rates associated with MVD for TN could be better elucidated. MethodsThe NIS was obtained from the Agency for Health Division of Neurosurgery, University of Vermont, Burlington, VermontObject. Microvascular decompression (MVD) offers an effective and durable treatment for patients suffering from trigeminal neuralgia (TN). Because the disorder has a tendency to occur in older persons, the risks of surgical treatment in the elderly have been a topic of recent interest. To date, evidence derived from several small retrospective and a single prospective case series has suggested that age does not increase the complication rate associated with surgery. Using a large national database, the authors aimed to study the impact of age on in-hospital complications following MVD for TN.Methods. Using the Nationwide Inpatient Sample (NIS) for the 10-year period from 1999 to 2008, the authors selected all patients who underwent MVD for TN. The primary outcome of interest was the in-hospital mortality rate. Secondary outcomes of interest were cardiac, pulmonary, thromboembolic, cerebrovascular, and wound complications as well as the duration of hospital stay, total hospital charges, and discharge location. An elderly cohort of patients was first defined as those 65 years of age and older and then redefined as those 75 years and older.Results. A total of 3273 patients who underwent MVD for TN were identified, having a median age of 57 years. Within this sample, 31.5% were 65 years and older and 10.7% were 75 years and older. The in-hospital mortality rate was 0.68% for patients 65 years or older (p = 0.0087) and 1.16% for those 75 years or older (p = 0.0026). In patients younger than 65 years, the in-hospital mortality rate was 0.13% (3 deaths among 2241 patients). As analyzed using the chi-square test (for both 65 and 75 years as the age cutoff) and the Pearson rank correlation coefficient, the risk of cardiac, pulmonary, thromboembolic, and cerebrovascular complications was higher in older patients (that is, those 65 and older and those 75 and older), but the risks of wound complications and CNS infection were not. The risk of any in-hospital complication occurring in a patient 65 years and older was 7.36% (p < 0.0001) and 10.0% in those 75 years and older (p < 0.0001). There was no difference in the total hospital charges associated with age. The duration of the hospital stay was longer in olde...

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Section: Discussionmentioning

confidence: 99%

Safety of microvascular decompression for trigeminal neuralgia in the elderly

Rughani

Dumont

Lin

et al. 2011

JNS

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“…For example, it is well accepted that Type I TN (TN-I) and Type II TN (TN-II) have distinct natural histories and responses to MVD treatment. 24,26 The presence or absence of NVC may likewise reflect distinct patient populations with TN.…”

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Trigeminal neuralgia without neurovascular compression presents earlier than trigeminal neuralgia with neurovascular compression

Lee

Raslan

et al. 2015

JNS

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I n 1934, Dandy proposed neurovascular compression (NVC) as an etiology for trigeminal neuralgia (TN).In his series, he reported that the superior cerebellar artery caused NVC in 30.7% of patients. 6 He noted veins, tumors, and vascular and cranial malformations as other "gross findings" causing compression of the trigeminal nerve; nevertheless, in 40% of cases, he observed no evidence of a gross lesion.6 He did document, however, that his posterior fossa approach did not allow for visualization of the entire root entry zone (REZ). After years of observation, and an autopsy series that showed no NVC in cadavers without TN, 13 Jannetta advanced the hypothesis that TN was a "nerve entrapment syndrome," resulting from arteries both lengthened and rendered tortuous by arteriosclerotic cerebrovascular disease. 13 This putative mechanism accounted for recurrence Charts were reviewed, and imaging and operative data were collected for patients with and without NVC. Mean, median, and the empirical cumulative distribution of onset age were determined. Statistical analysis was performed using Student t-test, Wilcoxon and Kolmogorov-Smirnoff tests, and Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model. results The charts of 219 patients with TN were reviewed. There were 156 patients who underwent posterior fossa exploration and microvascular decompression or internal neurolysis: 129 patients with NVC and 27 without NVC. Mean age at symptoms onset for patients with and without NVC was 51.1 and 42.6 years, respectively. This difference (8.4 years) was significant (t-test: p = 0.007), with sufficient power to detect an effect size of 8.2 years. Median age between groups with and without NVC was 53.25 and 41.2 years, respectively (p = 0.003). Histogram analysis revealed a bimodal age at onset in patients without NVC, and cumulative distribution of age at onset revealed an earlier presentation of symptoms (p = 0.003) in patients without NVC. Chi-square analysis revealed a trend toward female predominance in patients without NVC, which was not significant (p = 0.08). Multivariate analysis revealed that age at onset was related to NVC but not sex, symptom side or distribution, or patient response to medical treatment. coNclusioNs NVC is neither sufficient nor necessary for the development of TN. Patients with TN without NVC may represent a distinct population of younger, predominantly female patients. Further research into the pathophysiology underlying this debilitating disease is needed.

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“…20 While it can be curative for a majority of patients with typical TN symptoms, the response to MVD is sometimes incomplete and some patients do not respond at all. 16 Risk factors for pain recurrence include lack of immediate relief, longer preoperative duration of symptoms, female sex, lack of vascular compression at surgery, and a significant component of constant, rather than episodic, pain. 2,14,16,22 Nevertheless, some patients who otherwise appear to be excellent surgical candidates still experience suboptimal outcome.…”

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Degree of distal trigeminal nerve atrophy predicts outcome after microvascular decompression for Type 1a trigeminal neuralgia

Duan

Sweet

Munyon

et al. 2015

JNS

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obJect Trigeminal neuralgia is often associated with nerve atrophy, in addition to vascular compression. The authors evaluated whether cross-sectional areas of different portions of the trigeminal nerve on preoperative imaging could be used to predict outcome after microvascular decompression (MVD). methods A total of 26 consecutive patients with unilateral Type 1a trigeminal neuralgia underwent high-resolution fast-field echo MRI of the cerebellopontine angle followed by MVD. Preoperative images were reconstructed and reviewed by 2 examiners blinded to the side of symptoms and clinical outcome. For each nerve, a computerized automatic segmentation algorithm was used to calculate the coronal cross-sectional area at the proximal nerve near the root entry zone and the distal nerve at the exit from the porus trigeminus. Findings were correlated with outcome at 12 months. results After MVD, 17 patients were pain free and not taking medications compared with 9 with residual pain. Across all cases, the coronal cross-sectional area of the symptomatic trigeminal nerve was significantly smaller than the asymptomatic side in the proximal part of the nerve, which was correlated with degree of compression at surgery. Atrophy of the distal trigeminal nerve was more pronounced in patients who had residual pain than in those with excellent outcome. Among the 7 patients who had greater than 20% loss of nerve volume in the distal nerve, only 2 were pain free and not taking medications at long-term follow-up. coNclusioNs Trigeminal neuralgia is associated with atrophy of the root entry zone of the affected nerve compared with the asymptomatic side, but volume loss in different segments of the nerve has very different prognostic implications. Proximal atrophy is associated with vascular compression and correlates with improved outcome following MVD. However, distal atrophy is associated with a significantly worse outcome after MVD.

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Predictors of long-term success after microvascular decompression for trigeminal neuralgia

Cited by 86 publications

References 16 publications

Safety of microvascular decompression for trigeminal neuralgia in the elderly

Safety of microvascular decompression for trigeminal neuralgia in the elderly

Trigeminal neuralgia without neurovascular compression presents earlier than trigeminal neuralgia with neurovascular compression

Degree of distal trigeminal nerve atrophy predicts outcome after microvascular decompression for Type 1a trigeminal neuralgia

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