Microvascular decompression for trigeminal neuralgia in the elderly: efficacy and safety

Preoperative Evaluation of Neurovascular Relationship in Primary Trigeminal Neuralgia(PTN) by Magnetic Resonance Virtual Endoscopy(MRVE) Combined with 3D-FIESTA-c and 3D-TOF-MRA

Objective

This study aims to evaluate the effectiveness of Magnetic Resonance Virtual Endoscopy combined with 3D-FIESTA-c and 3D-TOF-MRA in preoperative assessment of MVD for PTN, with a focus on accurately detecting neuromuscular contact.

Methods

We retrospectively analyzed clinical and imaging data from 240 patients with unilateral primary trigeminal neuralgia undergoing MVD surgery between April 2016 and July 2023. Preoperative scans with 3D-FIESTA-c and 3D-TOF-MRA were performed, and MRVE images were obtained to analyze the relationship between the trigeminal nerve and adjacent vessels. Using the findings during microvascular decompression (MVD) surgery as the gold standard, the diagnostic results of 3D-TOF-MRA + 3D-FIESTA-c were considered as group I, while the combined use of MRVE, 3D-TOF-MRA + 3D-FIESTA-c was considered as group II.

Results

In 240 cases, group I had a positive rate of 96.25% and an accuracy rate of 86.25% for identifying responsible blood vessels, while group II had a positive rate of 98.3% and an accuracy rate of 94.17%. There were no statistically significant differences in positive rates between group I and group II, group I and MVD, or group II and MVD (P > 0.05). However, there were statistically significant differences in accuracy rates (P < 0.05). The accuracy for single and multiple arteries with group I was 99.38% and 80.0%, respectively, while with group II, it was 100% and 95.0%. No statistically significant difference was found in accuracy for single or multiple arteries (P>0.05). The accuracy of evaluating responsibility veins with or without other vessels was 52.73% and 80.0%, respectively, with a statistically significant difference (P<0.05).

Conclusion

MRVE combined with 3D-TOF-MRA + 3D-FIESTA-c significantly improves the accuracy of identifying responsibility vessels, especially veins, in preoperative assessment for MVD. This has important clinical implications for preoperative decision-making and surgical planning.

Outcomes of Different Surgical Interventions for Treating Trigeminal Neuralgia: A Review

Trigeminal neuralgia (TN) is a debilitating condition characterized by severe facial pain. Various surgical interventions are employed to manage this condition, including microvascular decompression (MVD), percutaneous radiofrequency rhizotomy (PRR), glycerol rhizotomy, percutaneous balloon compression (PBC), and stereotactic radiosurgery such as Gamma Knife radiosurgery (GKRS). This review synthesizes the outcomes of these interventions to provide an understanding of their efficacy and associated risks. MVD, known for its high initial relief rates, shows substantial long-term effectiveness, with recurrence rates varying based on patient demographics and comorbidities. GKRS offers significant pain relief with a favorable adverse event profile; however, recurrence rates increase over time, necessitating repeat procedures for sustained efficacy. PBC demonstrates high initial success, but pain recurrence is common, especially in patients with atypical TN. PRR provides immediate relief with a manageable recurrence rate and is particularly suitable for elderly patients and those with comorbidities. Glycerol rhizotomy, a cost-effective procedure, yields comparable outcomes to other interventions but requires careful patient selection. This review highlights the importance of tailored treatment approaches based on individual patient profiles, emphasizing the need for precise diagnostic criteria and careful patient selection to optimize outcomes. Long-term follow-up and the potential for repeat interventions are critical considerations in managing TN surgically.

Factors associated with outcomes following microvascular decompression for the treatment of primary trigeminal neuralgia in adults: a systematic review and meta-analysis

This study aimed to evaluate pain assessment strategies and factors associated with outcomes after microvascular decompression for the treatment of primary trigeminal neuralgia in adults. We conducted a systematic review and meta-analysis of English, Spanish, and French literature. We searched three databases, PubMed, Ovid, and EBSCO, from 2010 to 2022 and selected studies including patients with primary trigeminal neuralgia, clear pain assessment, and pain outcomes. Population means and standard deviations were calculated. Studies that included factors associated with postoperative outcomes were included in the meta-analysis. A total of 995 studies involving 5673 patients with primary trigeminal neuralgia following microvascular decompression were included. Patients with arteries compressing the trigeminal nerve demonstrated optimal outcomes following microvascular decompression (odds ratio [OR]= 0.39; 95% confidence interval [CI] = 0.19-0.80; X2 = 46.31; Dof = 15; I2 = 68%; P = < 0.0001). Conversely, when comparing arterial vs venous compression of the trigeminal nerve (OR = 2.72; 95% CI = 1.16-6.38; X2 = 23.23; Dof = 10; I2 = 57%; P = 0.01), venous compression demonstrated poor outcomes after microvascular decompression. Additionally, when comparing single-vessel vs multiple-vessel compression (OR = 2.72; 95% CI = 1.18-6.25; X2 = 21.17; Dof = 9; I2 = 57%; P = 0.01), patients demonstrated unfavorable outcomes after microvascular decompression. This systematic review and meta-analysis evaluated factors associated with outcomes following microvascular decompression (MVD) for primary trigeminal neuralgia (PTN). Although MVD is an optimal treatment strategy for PTN, a gap exists in interpreting the results when considering the lack of evidence for most pain assessment strategies.

A Case Series of Stereotactic Radiosurgery First for Trigeminal Neuralgia: A History of Stereotactic Radiosurgery Does Not Complicate Microvascular Decompression

BACKGROUND AND OBJECTIVES

The influence of prior stereotactic radiosurgery (SRS) on outcomes of subsequent microvascular decompression (MVD) for patients with trigeminal neuralgia (TN) is not well understood. To directly compare pain outcomes in patients undergoing primary MVD vs those undergoing MVD with a history of 1 prior SRS procedure.

METHODS

We retrospectively reviewed all patients undergoing MVD at our institution from 2007 to 2020. Patients were included if they underwent primary MVD or had a history of SRS alone before MVD. Barrow Neurological Institute (BNI) pain scores were assigned at preoperative and immediate postoperative time points and at every follow-up appointment. Evidence of pain recurrence was recorded and compared via Kaplan-Meier analysis. Multivariate Cox proportional hazards regression was used to identify factors associated with worse pain outcomes.

RESULTS

Of patients reviewed, 833 met our inclusion criteria. Thirty-seven patients were in the SRS alone before MVD group, and 796 patients were in the primary MVD group. Both groups demonstrated similar preoperative and immediate postoperative BNI pain scores. There were no significant differences between average BNI at final follow-up between the groups. Multiple sclerosis (hazard ratio (HR) = 1.95), age (HR = 0.99), and female sex (HR = 1.43) independently predicted increased likelihood of pain recurrence on Cox proportional hazards analysis. SRS alone before MVD did not predict increased likelihood of pain recurrence. Furthermore, Kaplan-Meier survival analysis demonstrated no relationship between a history of SRS alone and pain recurrence after MVD ( P = .58).

CONCLUSION

SRS is an effective intervention for TN that may not worsen outcomes for subsequent MVD in patients with TN.

Microvascular decompression for young onset primary trigeminal neuralgia: a single-center experience

This study aims to explore the causes of primary young onset trigeminal neuralgia (TN) and the clinical outcomes of these patients. From May 2015 to December 2020, 19 primary TN patients with onset age under 30 years underwent microvascular decompression (MVD) in Nanjing Drum Tower Hospital. In this study, the clinical characteristics, surgical outcomes, and postoperative complications of these patients were analyzed retrospectively. Of the 19 patients, 5 were males and 14 were females, and the pain was located on the right side in 10 cases (52.6%). Vascular compression was observed in 17 patients, including 14 cases of superior cerebellar artery (SCA) alone, 2 cases of superior petrosal vein (SPV) alone, and 1 case of SCA and SPV combined. Two patients had no neurovascular conflict, and nerve combing was performed. After surgery, 18 patients got immediate pain relief; 1 patient improved but still had occasional pain. With a mean follow-up of 42.7 ± 22.3 months, one patient was found to have a relapse 45 months after MVD. Surgical complications including mild facial numbness in two patients and hearing impairment in one patient. Neurovascular compression is the main cause of young onset primary TN, and the most commonly encountered vascular was SCA. MVD is a safe and effective treatment for these patients.

Radiomics analysis of unaffected side changes in classic trigeminal neuralgia

OBJECTIVE

To investigate the subtle differences in the structure of the unaffected trigeminal nerve between patients with classic trigeminal neuralgia (CTN) and healthy controls (HCs) by means of radiomics, so as to further explore the etiological mechanism of trigeminal neuralgia (TN).

METHODS

The imagine data of 95 CTN patients and 89 matched HCs were collected and retrospectively analyzed. They were assigned to four groups according to the presence or absence of neurovascular compression (NVC) of the unaffected trigeminal nerve (HCs with and without NVC; CTN patients with and without NVC on the unaffected side). All patients underwent magnetic resonance imaging (MRI) scans. Bilateral trigeminal cisternal segments were manually delineated, followed by feature extraction, dimensionality reduction, feature selection, model construction and model evaluation.

RESULTS

Six weighted textural signatures (sphericity, maximum 2D diameter, skewness, robust mean absolute deviation, large dependence low gray level emphasis, and surface-to-volume ratio) were found in HCs with and without NVC, while 7 were found in CTN patients without NVC on the unaffected side and HCs without NVC. The Rad_score was statistically different between the two groups (P < 0.05). The AUC of the training set was consistent with that of the validation set. The calibration curves of the training and validation sets demonstrated the high accuracy of the model.

CONCLUSIONS

NVC can alter trigeminal nerve structure and cause alterations in related characteristics; but NVC is not a necessary condition for the formation of CTN, and its incidence is also high in asymptomatic healthy people, and thus it is necessary to grade the severity of NVC. In addition, there are differences in the characteristics of the unaffected side between CTN patients and HCs, which may be due to congenital or secondary factors.

Microvascular decompression in trigeminal neuralgia - a prospective study of 115 patients

Background

Trigeminal neuralgia is a severe facial pain disorder. Microvascular decompression is first choice surgical treatment of patients with classical TN. There exist few prospective studies with an independent evaluation of efficacy and complications after MVD.

Objectives

We aimed to assess outcome and complications after microvascular decompression from our center.

Methods

We prospectively recorded clinical characteristics, outcome, and complications from consecutive patients with either classical or idiopathic (only patients with a neurovascular contact) trigeminal neuralgia undergoing microvascular decompression. Neurovascular contact was evaluated by 3.0 Tesla MRI. Patients were assessed before and 3, 6, 12, and 24 months after surgery by independent assessors.

Results

Of 115 included patients, 86% had a clinically significant outcome (i.e., BNI I – BNI IIIb). There was a significant association between an excellent surgical outcome and the male sex (OR 4.9 (CI 1.9–12.8), p = 0.001) and neurovascular contact with morphological changes (OR 2.5 (CI 1.1–6.0), p = 0.036). Significantly more women (12/62 = 19%) than men (2/53 = 4%) had a failed outcome, p = 0.019. The most frequent major complications were permanent hearing impairment (10%), permanent severe hypoesthesia (7%), permanent ataxia (7%), and stroke (6%). Most patients (94%) recommend surgery to others.

Conclusion

Microvascular decompression is an effective treatment for classical and idiopathic (only patients with a neurovascular contact) trigeminal neuralgia with a high chance of a long-lasting effect. The chance of an excellent outcome was highest in men and in patients with classical trigeminal neuralgia. Complications are relatively frequent warranting thorough patient evaluation and information preoperatively.

Trial registration

Clinical.trials.gov registration no. NCT04445766.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01520-x.

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

Classical trigeminal neuralgia (CTN) is a unilateral and severe facial pain disease, which seriously affects the patient's quality of life. Microvascular decompression (MVD) is currently the most effective surgical method, and it is the only treatment for the etiology of CTN. Imaging for MVD has been increasingly used, and the advantages and disadvantages of endoscopy-assisted vascular decompression surgery have been controversially debated. In this review, we aimed to discuss the advantages of MVD in the treatment of patients with CTN, the importance of using imaging in disease management, and the improvements of vascular decompression surgery through the application and maturity of endoscopic techniques. Compared with other surgical methods, MVD has more prominent short- and long-term treatment effects. Its selection depends on the accurate discovery of neurovascular compression by preoperative imaging. Moreover, magnetic resonance imaging plays a diverse role in MVD, not only in identifying the responsible vessels but also in determining the prognosis and as a tool for scientific research. The use of endoscopic techniques provides improved visualization of the MVD and additional benefits for vascular decompression surgery.

Surgical and Clinical Outcomes of Microvascular Decompression: A Comparative Study between Young and Elderly Patients

Microvascular decompression (MVD) is the only etiological technique for the treatment of trigeminal neuralgia (TN). Whilst there is a consensus MVD is likely effective regardless of age, the elderly population is thought to be more prone to have a higher rate of surgical complication, morbidity, and mortality. The main objective of our single-center, retrospective study was to analyze the surgical and clinical outcomes of MVD in TN elderly patients. From a surgical series of patients with TN who had undergone MVD from April 2018 to April 2022, 76 patients who matched the inclusion criteria were divided into two groups: twenty-five (32.9%) patients were older than 65 years and included in the elderly group, while the remaining fifty-one (61.1%) patients were below 65 years included in the non-elderly one. There were no differences between the groups in terms of acute pain relief (APR), Barrow Neurological Index (BNI) at follow-up, complications, and recurrence rate. In multivariate analysis (Cox proportional hazards regression analysis) the presence of an offending artery with nerve root distortion/indentation emerged as the only independent prognostic factor for pain-free survival (p = 0.0001). Our data endorse MVD as a safe and effective surgical procedure also for elderly patients with TN.

Incidence of repeat procedures and healthcare utilization following surgery, radiosurgery, and percutaneous procedures in elderly patients with trigeminal neuralgia

OBJECTIVE

Management of trigeminal neuralgia (TN) in elderly patients poses significant challenges. The impact of different treatment modalities (surgery, radiosurgery [RS], and percutaneous techniques [PTs]) on healthcare utilization is not well defined in the management of TN in elderly patients. The aim of this study was to compare the long-term healthcare utilization metrics of different interventions in the management of elderly patients with TN.

METHODS

The MarketScan database was queried using the International Classification of Diseases, Ninth Revision and Current Procedural Terminology, from 2000 to 2016. TN patients ≥ 65 years of age managed using surgery, RS, and PTs with at least 5 years of follow-up after the index procedure were included. Outcomes analyzed were hospital admissions, outpatient services, and medication refills.

RESULTS

Of 993 patients, 43% (n = 430) underwent RS, 44% (n = 432) had PTs, and only 13% (n = 131) underwent surgery for TN. Overall, the median age of patients was 74 years old, 64% were females, 90% had Medicare insurance, and 17% had an Elixhauser index ≥ 3. Patients in the surgery group were younger (median age 71 years) with a higher comorbidity index (≥ 3; 24%) compared with patients undergoing RS and PTs (13% and 17%, respectively). At 1, 2, and 5 years after the index procedure, 41%, 48%, and 57% of patients in the PT cohort underwent any repeat procedure compared with 11%, 18%, and 29% for the RS cohort, and 6%, 9%, and 11% for the surgical cohort, respectively. Also, patients in the PT cohort incurred 1.8, 1.9, and 2.0 times the combined payment at 1, 2, and 5 years, respectively, compared with the surgery cohort. Similarly, patients who underwent RS for TN incurred 1.4, 1.5, and 1.5 times the combined payment at 1, 2, and 5 years, respectively, compared with the surgery cohort. At 5 years after the index procedure, combined payments for the PT cohort were $79,753 (IQR $46,013, $144,064) compared with $61,016 (IQR $27,114, $117,097) for the RS cohort and $41,074 (IQR $25,392, $87,952) for the surgery cohort (p < 0.0001).

CONCLUSIONS

PTs followed by RS were the common procedures used in the majority of elderly patients with TN. However, surgery for TN resulted in durable control with the least need for reoperations up to 5 years after the index procedure, followed by RS and PTs. PTs for TN resulted in the highest utilization of healthcare resources and need for reoperations at all time points. These findings should be considered in clinical decision-making when selecting appropriate treatment modalities in elderly patients with TN.

Microvascular decompression for pediatric onset trigeminal neuralgia: patterns and variation

OBJECTIVES

Pediatric trigeminal neuralgia has been rarely reported in the literature, which were only 28 cases. Although microvascular decompression (MVD) has been widely accepted as effective therapy for trigeminal neuralgia, the etiology and surgical treatment of pediatric ones are seldom addressed. We report our experience with MVD for pediatric trigeminal neuralgia patients with emphasis on the vascular conflict patterns and surgical skills.

METHODS

This retrospective report included 11 pediatric TN patients, who underwent MVD and were followed for 3-86 months. The data were retrospectively analyzed with emphasis on the clinical features.

RESULTS

This series included 4 boys and 7 girls with average age of 13 ± 3.4 years old, their onset age were from 7 to 18 years old. The singular vein and combined artery/vein conflictions account for 7/11. 9 (81.8%) patients achieved immediate excellent outcomes. One recurrence was observed after 5 months and refused the second surgery.

CONCLUSIONS

The etiology of pediatric onset trigeminal neuralgia is still vascular conflict, whose patterns are different from adults, of which combined artery/vein and singular venous compression patterns have a much more higher proportion. Because of the smaller operative space and fragile-thin venous wall with adhesion to other structures, it is much more difficult to decompress the trigeminal nerve among pediatric patients. Sufficient arachnoid release, full exploration, and decompression along the trigeminal nerve were necessary, which will increase the excellent rate among pediatric patients.

Prognostic nomogram for percutaneous balloon compression in the treatment of trigeminal neuralgia

Because of its convenience and safety, percutaneous balloon compression (PBC) has become a more popular remedy for trigeminal neuralgia (TN) recently. The objective of this study was to establish a nomogram that can be used to preoperatively prognosticate the likelihood of pain-free based on preoperative disease characteristics. Clinical data were collected from those TN cases who had undergone PBC during the period of 2015 and 2020 in Qingdao Municipal Hospital. We excluded the cases caused by space-occupying lesion or had undergone MVD, percutaneous glycerol rhizotomy (PGR), and glycerol rhizotomy (GR). A nomogram was established based on the results of multivariable logistic analysis. A receiver operating characteristic curve (ROC) analysis was applied to evaluate the reliability of models. The plotted decision curves were also used to assess the net benefit of nomogram-assisted decisions. Internal validation was performed using the ROC by bootstrap sampling. Finally, 16 cases and 69 cases were included into the ineffective and effective groups respectively. In the crude, adjust I and adjust II models, response to carbamazepine positively, the grade II or III compression severity score, and classical TN type were all considered to be significant predictors of pain relief (BNI grades I-III) at 3 months' follow-up. The AUC, accuracy, specificity, and sensitivity of the nomogram system were 0.83, 0.85, 0.75, and 0.87 respectively for predicting patient outcomes. The decision curves showed good performance for the nomogram system in terms of clinical application, while more research with validation in multiple, external independent patient populations is needed.