Studies on the operative outcomes and mechanisms of microvascular decompression in treating typical and atypical trigeminal neuralgia

OBJECTIVE: To evaluate the operative outcomes and mechanisms of microvascular decompression in treating typical and atypical trigeminal neuralgia. METHODS: A group of 45 patients with typical trigeminal neuralgia and 17 patients with atypical trigeminal neuralgia treated by micro-vascular decompression from 2000 to 2002 were reviewed, including their clinical presentations, operative findings, and outcomes. RESULTS: Of 45 patients with typical trigeminal neuralgia, the mean duration was 3.1 years, and the mean age of pain onset was 60.3 years. Single trigeminal division was involved in 20 patients (44.4%), and 2 or 3 divisions were involved in the other 25 patients (55.6%). During the operation, artery compression was found in 39 patients (86.7%), and the combined artery and venous compression was found in 6 patients (13.3%). Postoperatively, complete pain relief was achieved in 44 patients (97.8%), and significant pain relief was achieved in 1 patient (2.2%). As for 17 patients with atypical trigeminal neuralgia, the mean duration and the mean age of pain onset was 8.7 years and 55.5 years, respectively. Two or 3 trigeminal divisions were involved in all of these patients. During operation, artery compression occurred in 10 patients (58.8%), and the combined artery and venous compression was found in 7 patients (41.2%). Postoperatively, complete pain relief was achieved in 5 patients (29.4%), and partial pain relief was achieved in 10 patients (58.8%), and 2 patients showed no response to microvascular decompression. CONCLUSIONS: The operative outcome of microvascular decompression in patients with typical trigeminal neuralgia was better than that of patients with atypical trigeminal neuralgia, which perhaps related to short duration, late onset of pain, limited distribution, artery compression, and complete operative decompression.     

Cervicomedullary junction spinal cord stimulation for head and facial pain

Objective.— To review our experience with cervicomedullary junction spinal cord stimulation (SCS), to alleviate head and facial pain. Background.— There is a dearth of literature regarding the use of spinal cord stimulation for treating head and facial pain. Design.— We performed a Boolean search of the electronic medical record (1990‐2009) and identified 35 patients (9 men, 26 women) for whom the senior author (J.J.M) trialed paddle lead cervicomedullary junction stimulation (CMJ‐S) for intractable head or facial pain. Twenty‐five patients (71.4%) had a successful trial with subsequent implantation of SCS hardware and 10 patients (28.6%) experienced a failed trial. Pain syndromes were categorized into diagnostic groups: trigeminal deafferentation pain (TDP), trigeminal neuropathic pain (TNP), occipital pain/neuralgia, post‐herpetic neuralgia (PHN), and post‐stroke facial pain. Follow‐up via structured telephone interview was obtained in 25 patients (71.4%). Results.— Among the 25 patients available for follow‐up, 16 patients (64%) underwent implantation and 9 patients (36%) had a failed trial of CMJ‐S. The mean patient age and length of follow‐up was 47.3 years old (20‐78 years old) and 53.4 months (2‐120 months), respectively. On a 0‐10 pain intensity scale (0 being no pain and 10 being the worst degree of pain), a mean pretrial pain level of 9.6 (range 7‐10) had been reduced to a mean of 4.8 (0‐10) at follow‐up. Successful trial and subsequent implantation occurred in 7 patients with TDP (70%), 4 patients with TNP (80%), both patients with PHN (100%), and in the single patient with post‐stroke facial pain (100%) but in only 2 patients (28.6%) with occipital neuralgia/pain. At the time of telephone interview, 4 of the implanted patents (25%) had their hardware removed because of loss of effectiveness (3) and infection (1). The other 12 implanted patients (75%) continue to use CMJ‐S on a daily basis and insist that it has improved their quality of life. Six current users (50%) of CMJ‐S have been able to decrease their use of oral pain medications. Complications in the implanted group included infection (1), uncomfortable paresthesias from breakdown of connecting wire insulation (1), and gradual loss of effectiveness (3). Conclusions.— Our preliminary experience suggests that patients suffering from TDP, TNP, and PHN may respond favorably to CMJ‐S whereas patients with occipital neuralgia/pain are rarely palliated by this neuromodulatory approach.     

Oxcarbazepine for trigeminal neuralgia may induce lower extremity weakness: A case report

BACKGROUND Although few studies have reported hyponatremia due to carbamazepine or oxcarbazepine in patients with epilepsy,no study has investigated cases of carbamazepine-or oxcarbazepine-induced hyponatremia or unsteady gait in patients with neuropathic pain.Herein,we report a case of oxcarbazepineinduced lower leg weakness in a patient with trigeminal neuralgia and summarize the diagnosis,treatment,and changes of clinical symptoms.CASE SUMMARY A 78-year-old male with a history of lumbar spinal stenosis was admitted to the hospital after he experienced lancinating pain around his right cheek,eyes,and lip,and was diagnosed with trigeminal neuralgia at the right maxillary and mandibular branch.He was prescribed oxcarbazepine(600 mg/d),milnacipran(25 mg/d),and oxycodone/naloxone(20 mg/10 mg/d)for four years.Four years later,the patient experienced symptoms associated with spinal stenosis,including pain in the lower extremities and unsteady gait.His serum sodium level was 127 mmol/L.Assuming oxcarbazepine to be the cause of the hyponatremia,oxcarbazepine administration was put on hold and the patient was switched to topiramate.At subsequent visit,the patient’s serum sodium level had normalized to 143 mmol/L and his unsteady gait had improved.CONCLUSION Oxcarbazepine-induced hyponatremia may cause lower extremity weakness and unsteady gait,which should be differentiated from those caused by spinal stenosis.     

Consumer views on management of trigeminal neuralgia

OBJECTIVE: To assess consumers' views on treatments used for trigeminal neuralgia and to compare their assessments with those of clinicians. METHODS: A short self-administered questionnaire was distributed to 133 individuals with trigeminal neuralgia and 21 clinicians attending national support group meetings in the United States and United Kingdom. RESULTS: Responses were obtained from 82% of those with trigeminal neuralgia and from 50% of the clinicians. All sufferers had used medical therapies (mean of three drugs), and 40% to 50% had undergone surgical treatment. All of the attendees with trigeminal neuralgia reported at least one side effect (mean +/- SD, 4.9 +/- 1.8). The clinicians underestimated the number of side effects, but both groups agreed that drowsiness and cognitive impairment are side effects that are particularly disliked. The mean current quality-of-life score, measured on a scale of 1 to 5 (5 = worse), was 2.7 +/- 1.5. Only 37% of sufferers gave an opinion as to the best form of treatment. CONCLUSIONS: Therapy leads to side effects which tend to be underestimated by clinicians. Patients currently find it difficult to make decisions about treatment. More collaborative research with active involvement of sufferers would improve the evidence base on which decisions can be made.     

Defining the role for gabapentin in the treatment of trigeminal neuralgia: a retrospective study.

The preferred treatment for trigeminal neuralgia consists of antiepileptic drugs. Among them, gabapentin has shown promise in relieving some forms of neuropathic pain. This retrospective review examined 194 consecutive cases of trigeminal neuralgia, many of whom had paroxysmal facial pain resistant to previous surgical interventions or treatment with multiple medications. Of the 92 who had received a trial of gabapentin, 43 reported reduction in facial pain. This benefit was complete in 16, nearly complete in 9, moderate in 12, and partial in 6. Onset of pain relief occurred generally within 1 to 3 weeks, depending on the rate and end point of dose titration. The effective range of stable daily dosing varied from 100 to 2400 mg divided 3 times a day, with a mean of 930 mg. Pain relief was sustained in two thirds during a mean follow-up time of 8 months. The fact that gabapentin was well-tolerated and without serious side effects is an important advantage when prescribing for elderly patients. The present study suggests that gabapentin can be effective as first or second line treatment of trigeminal neuralgia, even in cases resistant to traditional treatment modalities.     

Percutaneous controlled thermocoagulation in the treatment of trigeminal neuralgia

This study reviews the results and complications of 162 percutaneous thermocoagulations of the gasserian ganglion in 124 patients with typical idiopathic trigeminal neuralgia. The mean duration of follow-up observation was 3.7 years (range, 1-6 years). One hundred eighteen of 124 patients continued to show complete pain relief 1 month after the operation, and at the end of follow-up observation, 83 of 124 patients (67%) continued to enjoy complete pain relief (recurrence rate, 28.2%). Anesthesia dolorosa occurred in 3% of cases, dysesthesia in 3%, and paresthesia in 17%; neuroparalytic keratitis with permanent reduction of visual acuity was observed in 2% of cases, permanent diplopia in 1%, permanent hearing deficit in 3%, and permanent impairment of mastication in 3%. We compare thermocoagulation with other surgical procedures (microvascular decompression, glycerol injection, and percutaneous decompression) used in the treatment of trigeminal neuralgia.     

The use of electromyography to predict functional outcome following transforaminal epidural spinal injections for lumbar radiculopathy.

This study aimed to determine if electromyographic (EMG) diagnostic evaluation can predict functional outcome in patients undergoing transforaminal lumbar spine epidural injections. In this retrospective study, functional outcome by Oswestry Disability Index (ODI) and verbal rating scale (VRS) for current pain severity was evaluated in 39 patients undergoing lumbar transforaminal epidural spinal injections (ESI). Subjects with low back pain (mean age, 60 +/- 12.5 years) were evaluated for functional improvement post EMG and ESI. Of 39 patients tested with EMG before injection, 18 patients were positive for radiculopathy and 21 had a normal or negative examination. The patients were followed postinjection on average of 10.8 (SD +/- 3.9) weeks. Pretreatment ODI scores were not significantly different between groups showing positive (72.3 SD +/- 12.7) and negative (65.9 SD +/- 18.6, P > .05) EMG findings. There was significantly greater improvement of ODI for EMG positive radiculopathy (7.11 SD +/- 9.5) compared with negative EMG (3.2 SD +/- 17.4, P < .05). Positive radiculopathy subjects complained of more pain by VRS before ESI than subjects with negative EMG findings, 8.1 SD +/- 1.0 and 7.3 SD +/- 0.8, respectively, which was not significant (P > .05). VRS mean improvement was not significantly different in the positive EMG group (1.8 SD +/- 1.2) compared with a negative EMG (1.2 SD +/- 1.2, P > .05). PERSPECTIVE: The results appear to show that patients undergoing transforaminal ESI, who have a positive radiculopathy by EMG before injection, will have significant improvement in functional outcome by ODI but not with current pain intensity by VRS. This study suggests the importance and diagnostic value of ordering electromyography studies for lumbar radiculopathy evaluation, which may lead to prediction of outcome with lumbar transforaminal epidural spinal procedures. Furthermore, the current study highlights the difficulty of pain evaluation outcome by VRS.     

原发性三叉神经痛的显微外科治疗

目的 :探讨原发性三叉神经痛的显微外科治疗及其疗效。方法 :根据术中探查有无明确的血管压迫三叉神经 ,分别采用显微血管减压术或感觉根部分切断术。 132例病人中 95例行血管减压术 ;37例行感觉根切断术。结果 :无手术死亡病例。随访 6个月 15年 ,治愈或好转 130例 ,有效率为     

显微血管减压术治疗三叉神经痛66例围术期护理

目的:探讨三叉神经痛行显微血管减压术患者围术期的护理方法.方法:对66例三叉神经痛患者行显微血管减压术,术前加强心理护理、术前准备,术后严密观察、对症处理.结果:本组术后疼痛消失41例,症状缓解22例,3例复发.随访3～10个月,本组治疗效果优46例,良18例,无效2例.结论:加强三叉神经痛行显微血管减压术患者的围术期护理,可减少术后并发症的发生.     

Efficacy of pregabalin in the treatment of trigeminal neuralgia

This prospective, open-label study aimed to evaluate the efficacy of pregabalin treatment in patients suffering from trigeminal neuralgia with and without concomitant facial pain. Fifty-three patients with trigeminal neuralgia (14 with concomitant chronic facial pain) received pregabalin (PGB) 150–600 mg daily and were prospectively followed for 1 year. The primary outcome was number of patients pain free or with reduction of pain intensity by > 50% and of attack frequency by > 50% after 8 weeks. Secondary outcome was sustained pain relief after 1 year. Thirty-nine patients (74%) improved after 8 weeks with a mean dose of 269.8 mg/day (range 150–600 mg/day) PGB: 13 (25%) experienced complete pain relief and 26 (49%) reported pain reduction > 50%, whereas 14 (26%) did not improve. Patients without concomitant facial pain showed better response rates (32 of 39, 82%) compared with patients with concomitant chronic facial pain (7 of 14, 50%, P  = 0.020). Concomitant chronic facial pain appears to be a clinical predictor of poor treatment outcome. PGB appears to be effective in the treatment of trigeminal neuralgia.     

三叉神经痛与颌骨骨腔病变:45例分析

背景三叉神经痛的发病原因中因牙源性感染因素所致,在继发三叉神经痛的病因学研究中愈来愈受到重视,并提出了颌骨骨腔病变学说.目的研究颌骨病变性骨腔与三叉神经痛病因的关系.设计以患者为研究对象,前后对照研究.单位一所大学医院口腔颌面外科.对象1994-02/2003-12青岛大学医学院附属医院口腔颌面外科收治的三叉神经痛患者45例,其中男15例,女30例,共发现病变性骨腔74个.方法45例均行颌骨病变性骨腔清除术,术后应用视觉模拟评分法(VAS)对患者的疼痛程度进行评估.主要观察指标①VAS评分.②手术刮出物病理学检查和细菌培养.结果1次手术后疼痛消失者33例,占73.3%,两三次手术后疼痛消失者10例,占22.2%.疼痛缓解仍需要药物治疗维持2例,占4.5%.病理检查结果多为颌骨慢性炎症及肉芽组织.结论颌骨病变性骨腔是引起三叉神经痛的主要病因之一.     

Trigeminal postherpetic neuralgia responsive to treatment with capsaicin 8?% topical patch: a case report

Postherpetic neuralgia has been variably defined but is generally understood to be pain that persists for longer than a few months after an attack of herpes zoster. Pain persists for years in approximately 10 % of those afflicted with acute herpes zoster. The likelihood of postherpetic neuralgia increases with older age, severity of the zoster, trigeminal location, and other factors. Postherpetic neuralgia is a neuropathic pain and treatment usually involves sequential trials of topical and systemic drugs; a variety of other therapies may be considered in refractory cases. A new topical capsaicin 8 % patch has been approved for this indication based on the positive studies in patients with non-trigeminal postherpetic neuralgia. Experience with the use of the capsaicin 8 % patch for trigeminal distribution neuralgia is lacking. We report a case of trigeminal postherpetic neuralgia which was safely and effectively treated with capsaicin 8 % patch.     

Treatment of idiopathic trigeminal neuralgia: comparison of long-term outcome after radiofrequency rhizotomy and microvascular decompression. (Heidelberg College of Medicine, Heidelberg, Germany) Neurosurgery. 2001;48:1261–1267.

The purpose of this study was to evaluate the long‐term outcome of patients after either percutaneous trigeminal rhizotomy or microvascular decompression (MVD) for idiopathic trigeminal neuralgia at a single institution. Overall, the results of the study showed that there was a 50% risk of recurrence of pain 2 years after percutaneous radiofrequency rhizotomy. Conversely, 64% of the patients who underwent MVD remained completely pain free 20 years postoperatively. Patients without sensory impairment after MVD were pain free significantly longer than patients who experienced postoperatively hypesthesia or partial rhizotomy. Conclude that because it is curative and nondestructive, MVD is considered the treatment of choice for trigeminal neuralgia in otherwise healthy people. In this study, it was proved to be a more effective and long‐lasting procedure for patients with typical trigeminal neuralgia than radiofrequency rhizotomy. Patients without postoperative sensory deficit remained pain free significantly longer, which is a strong argument against the “trauma” hypothesis of this procedure. Comment by Ron Pawl, M.D. This paper is noteworthy in that comparing the follow‐up on 225 of 378 patients who underwent microvascular decompression (MVD) with 206 of 316 who underwent radiofrequency thermocoagulation (RFT), the RFT group stood a 50% risk of recurrent pain by 2 years after the procedure, whereas 64% of those undergoing MVD were pain‐free after 20 years. Furthermore, after MVD, those patients with no postoperative sensory deficit, measured with von Frey hairs, remained pain‐free longer than those with a sensory deficit. This latter finding flies in the face of the concept that to be effective, surgery for trigeminal neuralgia must damage the nerve. The whole concept of RF lesioning of the nerve is to damage it enough to deaden the trigger zone of the affected nerve branch. However, in this study it is noted that postoperative hypesthesia was only temporary after RF lesioning, which might well explain the high rate of pain recurrence in this series. Although the long‐term pain relief in the MVD group is excellent, it must be weighed against the complications. In the MVD group, there were 3 mortalities, diminished hearing in 5%, loss of hearing in 2.6%, facial paralysis in 4 patients, and tinnitus in 4 patients, none of which occurred in the RF group.     

McGill疼痛问卷在三叉神经痛诊断和治疗中的应用

目的:通过采用McGill疼痛问卷(McGill pain questionnaire,MPQ)鉴别三叉神经痛,并观察射频热凝术的疗效,研究MPQ在面痛诊断上的重要性。方法:本研究共观察159例三叉神经痛患者,其中136例患有典型三叉神经痛(CTN),23例患有混合型三叉神经痛(MTN)。采用MPQ评估患者的疼痛,并观察其中124例术后患者疼痛的缓解情况。结果:CTN组的平均现有疼痛强度(PPI)值为4.20±0.34,MTN组的平均PPI值为3.50±0.57,明显低于CTN组(P0.001);与MTN患者相比,CTN患者在疼痛分级指数(PRI)-感觉项上报告了更高的强度(P0.001);两组间PRI-情感和PRI-评价项上有明显区别,CTN组的得分更高(P0.001);RFT术后CTN患者显示了高的立即疼痛缓解率,达到93.6%。MTN患者的结果没有CTN组的好,只有58.8%的患者疼痛明显缓解。结论:MPQ可以很好鉴别不同类型的三叉神经痛,鉴于射频热凝治疗两种三叉神经痛疗效的差异,使用MPQ在面痛诊断中有重要意义。     

Diagnosis and differential diagnosis of trigeminal neuralgia.

Trigeminal neuralgia is a chronic facial pain classified as a neuropathic pain. There is widespread agreement regarding the International Association for the Study of Pain definition of classical idiopathic trigeminal neuralgia as "a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve." However, there are variations in presentation that are less easy to diagnose and an erroneous diagnosis of trigeminal neuralgia is occasionally made. In patients with tumors or multiple sclerosis, trigeminal neuralgia is termed secondary. Currently, clinical manifestations are the mainstay for diagnosis because there are no objective tests to validate the diagnosis. The sensitivity and specificity of these clinical manifestations is reviewed. Magnetic resonance imaging (MRI) and three-dimensional fast-in-flow with steady-state precession MRI are performed to determine the presence of tumors or plaques of multiple sclerosis and to assess possible compressions and deformations of the trigeminal nerve. Their specificity and sensitivity regarding compressions found at the time of surgery is reviewed. Other differential diagnoses for chronic unilateral orofacial pain are discussed.     

Duration of attacks of first division trigeminal neuralgia

Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 +/- 11.4 years, and the mean age at onset 64.0 +/- 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 +/- 6.1 s. The unweighted mean was 8.8 +/- 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.     

Treatment of recurrent trigeminal neuralgia due to Teflon granuloma

Recurrent trigeminal neuralgia after microvascular decompression (MVD) may be due to insufficient decompression, dislocation of the implant to pad the neurovascular contact, or the development of granuloma. Here, we report on our experience with Teflon granuloma including its treatment and histopathological examination. In a series of 200 patients with trigeminal neuralgia MVD was performed with Teflon felt according to Jannetta’s technique. In three patients with recurrent facial pain Teflon granuloma was found to be the cause for recurrence. In each instance, the granuloma was removed for histopathological examination. Mean age at the first procedure was 62.3 years and at the second procedure 66.3 years. Recurrence of pain occurred between 1 and 8.5 years after the first procedure. MRI scans demonstrated local gadolineum enhancement in the cerebellopontine angle, and CT scans showed local calcification. Intraoperatively dense fibrous tissue was found at the site of the Teflon granuloma. Histopathological examination revealed foreign body granuloma with multinuclear giant cells, collagen-rich hyalinized scar tissue, focal hemosiderin depositions, and microcalcifications. The Teflon granuloma was completely removed, and a new Teflon felt was used for re-decompression. Patients were free of pain after the second procedure at a mean of 40.3 months of follow-up. Teflon granuloma is a rare cause for recurrent facial pain after MVD. Small bleeding into the Teflon felt at surgery might trigger its development. A feasible treatment option is surgical re-exploration, nerve preserving removal of the granuloma, and repeat MVD.     

Long-term follow-up of patients after surgical treatment for isolated pulmonary valve stenosis

OBJECTIVE: To determine the long-term outcome of patients after surgical repair for pulmonary valve stenosis (PVS). PATIENTS AND METHODS: Fifty-three patients (30 males; mean - SD age, 10+/-13 years; range, 5 days to 50 years) were identified who had surgical treatment for PVS between 1951 and 1982. The status of each patient was determined by medical record review. RESULTS: The mean +/- SD age at follow-up was 43+/-15 years (age range, 19-77 years). Mean follow-up was 33 years (range, 18-51 years). At a median follow-up of 34 years, 35 reinterventions had been performed in 28 patients (53%), Including pulmonary valve replacement for free pulmonary regurgitation in 21 patients (mean interval after initial surgery, 33 years; range, 14-45 years), open valvotomy in 5 and pulmonary balloon valvuloplasty in 3 for residual PVS, closure of atrial septal defect in 2, right ventricular outflow tract reconstruction in 1, closure of iatrogenic ventricular septal defect in 1, ligation of aortopulmonary fistula in 1, and tricuspid valve annuloplasty with simultaneous coronary artery bypass grafting in 1. In addition, atrial and ventricular arrhythmias were common, occurring in 20 patients (38%). Patients who underwent reintervention were more likely to have undergone closed pulmonary valvotomy as the initial repair (P=.008). CONCLUSION: Although overall survival after surgical treatment of isolated PVS remains excellent, many patients undergo late reintervention after 30 years of follow-up, emphasizing the need for lifelong cardiac follow-up.