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Blue R, Yang AI, Ajmera S, Spadola M, Howard S, Saylany A, Kvint S, Harber A, Daly M, Shekhtman E, Nair A, Deshpande R, Lee JY. Pain Outcomes Following Endoscopic Microvascular Decompression for Trigeminal Neuralgia Based on Vascular Compression Type. J Neurol Surg B Skull Base 2024; 85:287-294. [PMID: 38721365 PMCID: PMC11076079 DOI: 10.1055/a-2065-9650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background Arterial compression of the trigeminal nerve at the root entry zone has been the long-attributed cause of compressive trigeminal neuralgia despite numerous studies reporting distal and/or venous compression. The impact of compression type on patient outcomes has not been fully elucidated. Objective We categorized vascular compression (VC) based on vessel and location of compression to correlate pain outcomes based on compression type. Methods A retrospective video review of 217 patients undergoing endoscopic microvascular decompression for trigeminal neuralgia categorizing VC into five distinct types, proximal arterial compression (VC1), proximal venous compression (VC2), distal arterial compression (VC3), distal venous compression (VC4), and no VC (VC5). VC type was correlated with postoperative pain outcomes at 1 month ( n = 179) and last follow-up (mean = 42.9 mo, n = 134). Results At 1 month and longest follow-up, respectively, pain was rated as "much improved" or "very much improved" in 89 69% of patients with VC1, 86.6 and 62.5% of patients with VC2, 100 and 87.5% of patients with VC3, 83 and 62.5% of patients with VC4, and 100 and 100% of patients with VC5. Multivariate analysis demonstrated VC4 as a significant negative of predictor pain outcomes at 1 month, but not longest follow-up, and advanced age as a significant positive predictor. Conclusion The degree of clinical improvement in all types of VC was excellent, but at longest follow-up VC type was not a significant predictor out outcome. However distal venous compression was significantly associated with worse outcomes at 1 month.
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Affiliation(s)
- Rachel Blue
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Andrew I. Yang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sonia Ajmera
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Michael Spadola
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Susanna Howard
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anissa Saylany
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Alexander Harber
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Megan Daly
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Emily Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anjana Nair
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Riddhi Deshpande
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - John Y.K. Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Hirata S, Kobayashi M, Ujihara M, Takabatake K, Fujimaki T. Preoperative findings in relation to the usefulness of endoscopic assistance for microvascular decompression. Acta Neurochir (Wien) 2023; 165:3011-3017. [PMID: 37656306 DOI: 10.1007/s00701-023-05762-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Endoscopy is known to be a useful adjunct for microvascular decompression (MVD) surgery, assisting observation in blind spots such as Meckel's cave in cases of trigeminal neuralgia (TN) and the root exit zone (REZ) in hemifacial spasm (HFS). However, few reports have discussed the usefulness of endoscopy in relation to individual patient characteristics or preoperative magnetic resonance imaging (MRI). METHODS We retrospectively reviewed the medical records of 109 patients (98 with HFS and 11 with TN, 85 women, median age 55 years) who had undergone endoscopically assisted MVD at our institution between 2017 and 2021. The usefulness of endoscopy in individual cases was scored by three neurosurgeons using a grading scale: 2, essential and indispensable; 1, useful and helpful; 0, not necessary. The mean value of the assigned scores was taken as an indicator of "usefulness," and endoscopy was considered to have been "useful" in cases with a score of > 1.0. RESULTS Endoscopic assistance was judged to have been useful in 69% of the patients. The proportion of patients evaluated as useful was significantly lower for TN (18.2%) than for HFS (74.5%). Patients with superior cerebellar artery compression had significantly lower scores than patients with other vessels. Endoscopy was considered useful in a significantly higher proportion of patients with anatomically complicated offending vessels (bifurcation or strong meandering) in the REZ detected by preoperative MRI (P < 0.005). CONCLUSION Endoscopy for MVD is useful for patients with HFS, especially when preoperative MRI shows bifurcation or strongly meandering vessels in the REZ.
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Affiliation(s)
- Sachiko Hirata
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan.
| | - Masahito Kobayashi
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Masaki Ujihara
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Kazuhiko Takabatake
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Takamitsu Fujimaki
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
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Rath TJ, Policeni B, Juliano AF, Agarwal M, Block AM, Burns J, Conley DB, Crowley RW, Dubey P, Friedman ER, Gule-Monroe MK, Hagiwara M, Hunt CH, Jain V, Powers WJ, Rosenow JM, Taheri MR, DuChene Thoma K, Zander D, Corey AS. ACR Appropriateness Criteria® Cranial Neuropathy: 2022 Update. J Am Coll Radiol 2022; 19:S266-S303. [PMID: 36436957 DOI: 10.1016/j.jacr.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Cranial neuropathy can result from pathology affecting the nerve fibers at any point and requires imaging of the entire course of the nerve from its nucleus to the end organ in order to identify a cause. MRI with and without intravenous contrast is often the modality of choice with CT playing a complementary role. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Tanya J Rath
- Division Chair of Neuroradiology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Bruno Policeni
- Panel Chair; Department of Radiology Vice-Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa; President Iowa Radiological Society and ACR Councilor
| | - Amy F Juliano
- Panel Vice-Chair, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; NI-RADS committee chair
| | - Mohit Agarwal
- Froedtert Memorial Lutheran Hospital Medical College of Wisconsin, Milwaukee, Wisconsin; Fellowship Program Director
| | - Alec M Block
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois
| | - Judah Burns
- Montefiore Medical Center, Bronx, New York; Vice-Chair for Education & Residency Program Director, Montefiore Medical Center; Vice-Chair, Subcommittee on Methodology
| | - David B Conley
- Practice Director, Northwestern ENT and Rhinology Fellowship Director, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and Member, American Academy of Otolaryngology-Head and Neck Surgery
| | - R Webster Crowley
- Rush University Medical Center, Chicago, Illinois; Neurosurgery expert; Chief, Cerebrovascular and Endovascular Neurosurgery; Medical Director, Department of Neurosurgery; Surgical Director, Rush Comprehensive Stroke Center; Program Director, Endovascular Neurosurgery
| | | | - Elliott R Friedman
- University of Texas Health Science Center, Houston, Texas; Diagnostic Radiology Residency Program Director
| | - Maria K Gule-Monroe
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Medical Director of Diagnostic Imaging at Houston Area Location Woodlands
| | - Mari Hagiwara
- Neuroradiology Fellowship Program Director and Head and Neck Imaging Director, New York University Langone Medical Center, New York, New York
| | | | - Vikas Jain
- MetroHealth Medical Center, Cleveland, Ohio; Medical Director, Lumina Imaging
| | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology
| | - Joshua M Rosenow
- Neuroradiology Fellowship Program Director and Head and Neck Imaging Director, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M Reza Taheri
- George Washington University Hospital, Washington, District of Columbia; Director of Neuroradiology
| | - Kate DuChene Thoma
- Director of Faculty Development Fellowship, University of Iowa Hospital, Iowa City, Iowa; Primary care physician
| | - David Zander
- Chief of Head and Neck Radiology, University of Colorado Denver, Denver, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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Awake microvascular decompression with fat-teflon sandwich technique: Clinical implications of a novel approach for cranial nerve neuralgias. J Clin Neurosci 2019; 64:77-82. [PMID: 31014908 DOI: 10.1016/j.jocn.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/23/2019] [Accepted: 04/12/2019] [Indexed: 11/21/2022]
Abstract
Re-appearance of trigeminal neuralgia (TN) pain following microvascular decompression (MVD) is a challenging issue. A selective ablation with MVD provides the best response in such recurrences. The absence of intra-operative indicator for immediate correction of sub-optimal decompression is the primary factor for failure. We analysed the effectiveness and safety of awake MVD in minimizing failure, by tailoring the procedure according to intra-operative response with re-exploration or additional procedure like internal neurolysis in the same setting, especially in patients without vascular compression and those unfit for General Anesthesia (GA). The prospective study from June 2016 to June 2017 includes one glossopharyngeal neuralgia (GPN) and 6 trigeminal neuralgia (TN). Five cases responded with immediate complete pain relief but in 2 cases, incomplete pain relief resulted in alteration of intraoperative decision. In one case, a partial pain relief, mandated an additional internal neurolysis in the same setting, resulting in complete pain relief while in the other, re-exploration revealed a hidden venous conflict, not identified on MRI following which an additional IN was performed. All cases were followed up with BNI PIS for a minimum of one year without recurrence. Awake MVD is safe and reliable intraoperative neurophysiological prognostic marker of immediate pain relief and provides a window for an immediate correction of sub-optimal decompression with Internal Neurolysis when needed, in the same setting, especially in neuroimaging negative and elderly cases unfit for GA. It has the potential to reduce the rate of re-intervention and increase the overall effectiveness of MVD by specifically ameliorating the pain burden and quality of life.
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Full Endoscopic Vascular Decompression in Trigeminal Neuralgia: Experience of 230 Patients. World Neurosurg 2018; 113:e612-e617. [DOI: 10.1016/j.wneu.2018.02.108] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 12/22/2022]
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Ishikawa M, Soma N, Kojima A, Naritaka H. Straightening the trigeminal nerve axis by complete dissection of arachnoidal adhesion and its neuroendoscopic confirmation for trigeminal neuralgia without neurovascular compression. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Lee JYK, Pierce JT, Sandhu SK, Petrov D, Yang AI. Endoscopic versus microscopic microvascular decompression for trigeminal neuralgia: equivalent pain outcomes with possibly decreased postoperative headache after endoscopic surgery. J Neurosurg 2017; 126:1676-1684. [DOI: 10.3171/2016.5.jns1621] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndoscopic surgery has revolutionized surgery of the ventral skull base but has not yet been widely adopted for use in the cerebellopontine angle. Given the relatively normal anatomy of the cerebellopontine angle in patients with trigeminal neuralgia (TN), the authors hypothesized that a fully endoscopic microvascular decompression (E-MVD) might provide pain outcomes equivalent to those of microscopic MVD (M-MVD) but with fewer complications.METHODSThe authors conducted a single-institution, single-surgeon retrospective study with patients treated in the period of 2006–2013. Before surgery, all patients completed a questionnaire that included a validated multidimensional pain-outcome tool, the Penn Facial Pain Scale (PFPS, formerly known as Brief Pain Inventory–Facial), an 11-point scale that measures pain intensity, interference with general activities of daily living (ADLs), and facial-specific ADLs. Using a standardized script, independent research assistants conducted follow-up telephone interviews.RESULTSIn total, 167 patients were available for follow-ups (66.5% female; 93 patients underwent M-MVD and 74 underwent E-MVD). Preoperative characteristics (i.e., TN classification, PFPS components, and medication use) were similar for the 2 surgical groups except for 2 variables. Patients in the M-MVD group had slightly higher incidence of V3 pain, and the 2 groups differed in the date of surgery and hence in the length of follow-up (2.4 years for the M-MVD group and 1.3 years for the E-MVD group, p < 0.05). There was a trend toward not finding neurovascular conflict at the time of surgery more frequently in the M-MVD than in the E-MVD group (11% vs 7%, p = 0.052). Internal neurolysis was more often performed in the E-MVD group (26% vs 7%, p = 0.001). The 2 groups did not significantly differ in the length of the MVD procedure (approximately 2 hours). Self-reported headaches at 1 month postoperatively were present in 21% of the patients in the M-MVD group versus 7% in the E-MVD group (p = 0.01). Pain outcomes at the most recent followup were equivalent, with patients reporting a 5- to 6-point (70%–80%) improvement in pain intensity, a 5-point (85%) improvement in pain interference with ADLs, and a 6-point (85%) improvement in interference with facial-specific ADLs. Actuarial freedom from pain recurrence was equivalent in the 2 groups, with 80% pain control at 3 years.CONCLUSIONSBoth the fully endoscopic MVD and the conventional M-MVD appear to provide patients with equivalent pain outcomes. Complication rates were also similar between the groups, with the exception of the rate of headaches, which was significantly lower in the E-MVD group 1 month postoperatively.
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Abstract
Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadav Nishtha
- Department of Radio Diagnosis and Imaging, All India Institute of Medical Science, New Delhi, India
| | - Pande Sonjjay
- Department of Radio Diagnosis and Imaging, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Parihar Vijay
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ratre Shailendra
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Khare Yatin
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Montano N, Conforti G, Di Bonaventura R, Meglio M, Fernandez E, Papacci F. Advances in diagnosis and treatment of trigeminal neuralgia. Ther Clin Risk Manag 2015; 11:289-99. [PMID: 25750533 PMCID: PMC4348120 DOI: 10.2147/tcrm.s37592] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Various drugs and surgical procedures have been utilized for the treatment of trigeminal neuralgia (TN). Despite numerous available approaches, the results are not completely satisfying. The need for more contemporaneous drugs to control the pain attacks is a common experience. Moreover, a number of patients become drug resistant, needing a surgical procedure to treat the neuralgia. Nonetheless, pain recurrence after one or more surgical operations is also frequently seen. These facts reflect the lack of the precise understanding of the TN pathogenesis. Classically, it has been related to a neurovascular compression at the trigeminal nerve root entry-zone in the prepontine cistern. However, it has been evidenced that in the pain onset and recurrence, various neurophysiological mechanisms other than the neurovascular conflict are involved. Recently, the introduction of new magnetic resonance techniques, such as voxel-based morphometry, diffusion tensor imaging, three-dimensional time-of-flight magnetic resonance angiography, and fluid attenuated inversion recovery sequences, has provided new insight about the TN pathogenesis. Some of these new sequences have also been used to better preoperatively evidence the neurovascular conflict in the surgical planning of microvascular decompression. Moreover, the endoscopy (during microvascular decompression) and the intraoperative computed tomography with integrated neuronavigation (during percutaneous procedures) have been recently introduced in the challenging cases. In the last few years, efforts have been made in order to better define the optimal target when performing the gamma knife radiosurgery. Moreover, some authors have also evidenced that neurostimulation might represent an opportunity in TN refractory to other surgical treatments. The aim of this work was to review the recent literature about the pathogenesis, diagnosis, and medical and surgical treatments, and discuss the significant advances in all these fields.
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Affiliation(s)
| | | | | | - Mario Meglio
- Institute of Neurosurgery, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Fabio Papacci
- Institute of Neurosurgery, Catholic University, Rome
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