Trends in surgical treatment for trigeminal neuralgia in the United States of America from 1988 to 2008

Efficacy and safety of a third stereotactic radiosurgery for recurrent trigeminal neuralgia: an international, multicenter study

BACKGROUND AND OBJECTIVES

Trigeminal Neuralgia (TN) is a debilitating facial pain disorder, often necessitating surgical interventions when medication proves insufficient. Stereotactic Radiosurgery (SRS) is an established therapeutic option. Limited studies explored the feasibility of a third SRS procedure. Our study investigates the safety and efficacy of a third SRS procedure for recurrent TN.

METHODS

We performed a retrospective analysis across multiple centers using databases collected prospectively. Pain status was evaluated utilizing the BNI Pain Intensity Scales. The Kaplan-Meier method was employed to estimate the time to recurrence, with group comparisons conducted using log-rank tests. Associations were explored using Chi-square and logistic regression models.

RESULTS

Ten institutions contributed with a total of 35 patients. A third SRS revealed sustained effectiveness with a pain control rate of 82.7%. The median time to recurrence was 35.5 months. New sensory dysfunction following the third procedure occurred in 22% of patients who had preserved sensory function after the second procedure. When considering those who developed sensory dysfunction after the second procedure, 40% of the entire cohort was affected. There were no significant differences in pain recurrence intervals among the three procedures. A meta-analysis, combining data from previous studies, showed that 89.6% of patients achieved some degree of pain control after a third SRS, with 27.4% experiencing new sensory dysfunction and a median time to recurrence of 31.6 months.

CONCLUSION

Our study, the largest on the topic, affirms the sustained effectiveness of a third SRS for TN, providing comparable pain relief to initial procedures. Notably, an extended pain-free interval after the third SRS session was observed. Facial sensory dysfunction emerged as the primary side effect. Larger studies are warranted to explore correlations with demographics and treatment parameters for a comprehensive understanding of repeat SRS in managing recurrent TN.

Health Disparities in the Neurosurgical Care of Patients with Trigeminal Neuralgia

BACKGROUND

There has been limited investigation into how social determinants of health impact treatment outcomes in patients with trigeminal neuralgia (TN). We aimed to investigate how social determinants of health may alter the course of clinical care for patients with TN.

METHODS

The electronic medical record was queried for patients with a diagnosis of TN comanaged by neurosurgeons and other facial pain specialists at our medical center. Area Deprivation Index served as a proxy for socioeconomic status (SES). Multivariable linear regression models were performed using RStudio to assess the impact of social determinants on the time to neurosurgical referral and surgical intervention.

RESULTS

A total of 229 patients (mean age 50 years, 74% female) were included. Of these, 135 (60%) patients underwent a neurosurgical procedure after referral, the most common being microvascular decompression (n = 84, 62%) (Table 1). Most of the patients were white (76.3%) and insured by Medicare (51.8%), followed by private insurance (38.6%). Age and sex were significant predictors of time to neurosurgical referral after symptom onset, as older patients (P < 0.01, Figure 3) and females (P = 0.02) tended to have a greater delay between symptom onset and specialist referral. Race, SES, and insurance status were not significantly associated with time-to-referral or time-to-treatment.

CONCLUSION

This study found that older and female patients with TN had a longer time from symptom onset to specialist referral. Based on these data, there is no association between race, SES, and insurance status with time-to-referral or time-to-treatment in patients with TN.

When the nerve keeps firing: an institutional experience and systematic review on delayed response after microvascular decompression for trigeminal neuralgia

BACKGROUND

This study aimed to investigate the occurrence of delayed response following microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and identify potential contributing factors. Additionally, we present two cases with delayed relief observed at our institution.

METHOD

Two TN patients with delayed response and clear intra-operative arterial findings are presented in this study. Furthermore, we conducted a systematic review by searching electronic bibliographic databases, including MEDLINE (PubMed), Web of Science, Scopus, and Embase, from inception to 2022.

RESULTS

We identified a total of 28 full-text articles involving 322 TN patients who experienced delayed pain relief. Out of these, only 11 studies provided sufficient evidence and were included in the final analysis. Among the patients, 73.46% were female. The mean incidence rate of delayed response after MVD treatment for TN was 10.5%, with a range of 0.95 to 57.14% across different studies. The mean age of these patients was 59.86 years. The reported time to pain relief in the existing reports was at least 4 days post-surgery. In 72.88% of the reported cases, right-side dominance was observed. The majority of delayed cases experienced pain relief within 3 months, with a median time of 1 month.

CONCLUSIONS

A thorough examination of the probability of delayed pain relief after MVD for TN and understanding the characteristics of this phenomenon can offer surgeons valuable post-operative guidance and aid in decision-making regarding potential immediate reoperation.

Safety and Cost Savings Associated with Reduced Inpatient Hospitalization for Microvascular Decompression

OBJECTIVES

Microvascular decompression (MVD) has grown as a first-line surgical intervention for severe facial pain from trigeminal neuralgia and/or hemifacial spasm. We sought to examine the safety and cost-benefits of discharging patients with MVD within 1 day of admission.

METHODS

We retrospectively reviewed patients undergoing MVD at our institution from 2008 to 2020. Patients were sorted by 1 day, 2 days, or >2 days until discharge and by year from 2008 to 2013, 2014 to 2018, or 2019 to 2020. Patient presenting characteristics, intraoperative measures, and complications were documented. Statistical differences were calculated by one-way analysis of variance and χ2 analyses.

RESULTS

Our cohort included 976 patients undergoing MVD, with 231 (23.6%) between 2008 and 2013, 517 (52.9%) between 2014 and 2018, and 228 (23.3%) between 2019 and 2020. Over time, postoperative admission rates to the critical care unit, total inpatient hospital admission times, and Barrow Neurological Institute scores at first follow-up decreased. Postoperative complications, including cerebrospinal fluid leak, decreased significantly. In addition, patients discharged within 1 day of admission incurred a total hospital cost of $26,689, which was $3588 lower than patients discharged within more than 1 day of admission, P < 0.0001. Discharging carefully selected patients who are appropriate for discharge within 1 day of admission could translate to a potential cost-savings of $255,346 per year in our clinical practice.

CONCLUSIONS

In our experience, MVDs are a safe, elective intervention. Our findings suggest that postoperative day 1 discharge in patients with an uncomplicated postoperative course may be safe while improving hospital resource use.

Outcomes using linear accelerator stereotactic radiosurgery for the treatment of trigeminal neuralgia: A single-center, retrospective study

Background:

Linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) treatment of trigeminal neuralgia (TN) may have similar efficacy to Gamma Knife SRS (GK-SRS), but the preponderance of data comes from patients treated with GK-SRS. Our objective was to analyze the outcomes for LINAC-based treatment of TN in patients at our institution.

Methods:

We retrospectively analyzed data for patients who underwent LINAC-based SRS for TN from 2006 to 2018. Data were collected from the patients’ medical records. Nonparametric statistics were used for the analysis.

Results:

Of the 41 patients treated with LINAC-based SRS (typically 90 Gy dosed using a 4 mm collimator for one fraction) during that time, follow-up data of >3 weeks post-SRS were available for 32 patients. The median pretreatment Barrow Neurological Institute (BNI) pain score was 5 (range 4–5). The follow-up period ranged from 0.9 to 113.2 months (median 5 months). There was significant improvement in postradiation BNI pain score (P < 0.001), with 23 (72%) patients who improved to a BNI pain score of 1–3. One patient had bothersome hypoesthesia postradiation. Approximately 38% of patients who had initial pain control had recurrence of symptoms (BNI > 3). Survival analysis showed a median time to pain recurrence of 30 months. There was no relationship between prior microvascular decompression (MVD) surgery and change in BNI pain score pre- to posttreatment.

Conclusion:

The results demonstrate that LINAC-based SRS is an effective means to treat TN. Prior MVD surgery did not affect efficacy of SRS in lowering the BNI score from pre- to posttreatment in this patient cohort.

Case Series in the Utility of Invasive Blood Pressure Monitoring in Microvascular Decompression

BACKGROUND

The utility of arterial lines in microvascular decompression (MVD) is not well described.

OBJECTIVE

To examine the safety and costs of arterial lines compared with noninvasive blood pressure (NIBP) monitoring in MVDs.

METHODS

We retrospectively reviewed patients undergoing MVD from 2012 to 2020. Patients were grouped by procedure date from 2012 to 2014 and 2015 to 2020, reflecting our institution's decreasing trend in arterial line placement around 2014 to 2015. Patient features, intraoperative characteristics, and postoperative complications were collected for all cases. Statistical differences were evaluated using chi-squared analyses and t-tests.

RESULTS

Eight hundred fifty-eight patients underwent MVDs, with 204 between 2012 and 2014 and 654 between 2015 and 2020. Over time, the frequency of arterial line placement decreased from 64.2% to 30.1%, P < .001. Arterial lines involved 11 additional minutes of preincision time, P < .001. Patients with arterial lines required both increased doses and costs of vasoactive medications intraoperatively. Patients receiving arterial lines demonstrated no significant differences in complications compared with patients with NIBP monitoring. On average, patients with arterial lines incurred $802 increased costs per case compared with NIBP monitoring.

CONCLUSION

NIBP monitoring in MVDs provides neurologically and hemodynamically safe outcomes compared with invasive blood pressure monitoring. For patients without significant cardiopulmonary risk factors, NIBP monitoring may be a cost-effective alternative in MVDs.

Hospitalization outcomes among brain metastasis patients receiving radiation therapy with or without stereotactic radiosurgery from the 2005-2014 Nationwide Inpatient Sample

The purpose of this study was to compare hospitalization outcomes among US inpatients with brain metastases who received stereotactic radiosurgery (SRS) and/or non-SRS radiation therapies without neurosurgical intervention. A cross-sectional study was conducted whereby existing data on 35,199 hospitalization records (non-SRS alone: 32,981; SRS alone: 1035; SRS + non-SRS: 1183) from 2005 to 2014 Nationwide Inpatient Sample were analyzed. Targeted maximum likelihood estimation and Super Learner algorithms were applied to estimate average treatment effects (ATE), marginal odds ratios (MOR) and causal risk ratio (CRR) for three distinct types of radiation therapy in relation to hospitalization outcomes, including length of stay (' ≥ 7 days' vs. ' < 7 days') and discharge destination ('non-routine' vs. 'routine'), controlling for patient and hospital characteristics. Recipients of SRS alone (ATE = - 0.071, CRR = 0.88, MOR = 0.75) or SRS + non-SRS (ATE = - 0.17, CRR = 0.70, MOR = 0.50) had shorter hospitalizations as compared to recipients of non-SRS alone. Recipients of SRS alone (ATE = - 0.13, CRR = 0.78, MOR = 0.59) or SRS + non-SRS (ATE = - 0.17, CRR = 0.72, MOR = 0.51) had reduced risks of non-routine discharge as compared to recipients of non-SRS alone. Similar analyses suggested recipients of SRS alone had shorter hospitalizations and similar risk of non-routine discharge when compared to recipients of SRS + non-SRS radiation therapies. SRS alone or in combination with non-SRS therapies may reduce the risks of prolonged hospitalization and non-routine discharge among hospitalized US patients with brain metastases who underwent radiation therapy without neurosurgical intervention.

The changing face of trigeminal neuralgia-A narrative review

OBJECTIVE

This narrative review aims to update the reader on the new classification of trigeminal neuralgia (TN), clinical signs, pathophysiologic evidence, and their implications on management. This review is based on the authors' collective experience and knowledge of the literature in addition to a literature search.

BACKGROUND

In recent years, the phenotype of TN has been intensively studied leading to discrete groups of patients. These include patients with TN with additional continuous pain, and patients with and without neurovascular compression of the trigeminal dorsal root entry zone. A number of associated clinical signs such as tearing and sensory changes need further research.

METHODS

The literature on TN was searched in PubMed with the aims of providing evidence for the recently published third edition of the International Classification of Headache Disorders (ICHD) and update the clinical phenotype and management of the TN subcategories.

RESULTS

The ICHD's new classification for TN is based on reliable clinical data, imaging, and neurophysiologic studies. The TN classification reflects current knowledge and has improved the possibility for clinicians to choose adequate management options. However, there is a lack of effective, safe drugs for the management of TN and sparse, robust data on neurosurgical options.

CONCLUSION

Research into all aspects of TN-diagnosis, pharmacotherapy, surgery, long-term management prognosis, and natural history-is needed. Research should adhere to the ICHD's schema for TN. Improved drugs are needed along with rigorous research into surgical options and their efficacy for different subtypes of TN.

Does the Surgical Intervention for Trigeminal Neuralgia Refractory to Pharmacotherapy Improve Quality-of-Life? - A Systematic Review

PURPOSE

Trigeminal neuralgia (TN) refractory to pharmacotherapy requires surgical interventions which vary from percutaneous procedure to microvascular decompression (MVD). The aim of the systematic review is to find evidence for the surgical treatment for TN with high success rate and low complications which improves the quality-of-life (QOL).

METHODS

A systematic literature search was made on published studies from MEDLINE, SCOPUS, Science direct, and Cochrane Library databases that report the available surgical treatment for TN up to March 2020 and studies referred in the selected papers. Relevant studies were selected based on predefined eligibility criteria. The primary outcome measured was success rate, pain relief and secondary outcome measured was QOL, recurrence and complication rate.

RESULTS

Ten studies with a sum of 11,154 individuals were included in this qualitative analysis. Seven studies compared MVD whereas 4 studies compared Gamma knife radiosurgery with other techniques like percutaneous balloon compression, percutaneous glycerol rhizotomy etc. The result showed that MVD has a considerable higher rate of initial pain-free outcomes (96.6%) followed by Gamma knife radiosurgery (96.2%), cryotherapy (95.4%), percutaneous balloon compression (87%), percutaneous glycerol rhizotomy (85%) and the lowest rate of cohorts who were never pain-free (1.7%).QOL was improved to 100% as a result of pain relief which was evaluated in only 2 studies . Overall the recurrence rate was 0.45 to 52%. MVD has lower rate of long-term recurrence 0.45 and 6.1% for 2 years and 8 years, respectively, and cryotherapy has the highest rate of 52% at 6 months.

CONCLUSION

Outcomes of the literature search showed that it lacks the knowledge to generally support 1 or the other treatment. Each type of TN requires individualized protocols to treat based on pain response which ultimately improve the QOL. We also propose there should be more reliable data reporting by using a universally acceptable pain scale for better analysis of treatment outcome.

Efficacy and safety of acupuncture for trigeminal neuralgia: A protocol for systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a disease accompanied by severe facial pain, which seriously affects the daily life of patients. Acupuncture is widely used by Traditional Chinese Medicine doctors to treat various painful diseases. Acupuncture combined with the treatment of trigeminal neuralgia can increase the analgesic effect and reduce side effects. However, there is still a lack of more quality multi-center clinical controlled trials and comprehensive meta-analysis, and a lack of more comprehensive and stronger evidence-based medical evidence.

METHODS

The 2 reviewers used the same search strategy to search CNKI, PubMed, Web of Science, Cochrane Library, Scopus, EBSCO, and the search date is until July 19, 2020. Two people read the retrieved literatures independently, and then delete duplications. Then, use the "risk of bias" tool in Cochrane Handbook 5.2 to score. Only documents with a score greater than 5 can be included. Make a table of literature characteristics, extract baseline patient data, research methods and possible risks of bias in the literature, interventions in treatment and control groups, outcome evaluation indicators (BNI, VAS, ER and AE), and research funding support. Use Review Manager 5.3.5 for meta-analysis, use Stata 15 for regression analysis to find the source of heterogeneity, and then perform subgroup analysis to resolve the heterogeneity based on the corresponding source.

RESULTS

The analysis of BNI, VAS, ER and AE data can provide high-quality evidence for high-quality synthesis and/or descriptive analysis of the effectiveness and safety of acupuncture treatment of various causes of urinary retention.

CONCLUSION

This study can provide more comprehensive and strong evidence to prove whether acupuncture is effective and safe in the treatment of TN patients.

REGISTRATION

The research has been registered and approved on the PROSPERO website. The registration number is CRD42019119606.

Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

BACKGROUND

Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood.

OBJECTIVE

To describe rates and predictors for pain freedom following MVD.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors.

RESULTS

Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67).

CONCLUSION

Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations.

Effect of Training on Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia: A Long-Term, Retrospective Comparison of Staff Neurosurgeon and Trainee Complications and Efficacy

OBJECTIVE

The role of trainee involvement in lesioning procedures for trigeminal neuralgia (TN) has not yet been investigated in reported studies. The objective of the present study was to compare the complications and efficacy of percutaneous glycerol rhizotomy (GR) when performed by staff neurosurgeons and trainees.

METHODS

A retrospective medical record analysis of 165 patients with medically refractory TN who had undergone 293 GR procedures by either a staff attending (n = 156) or trainee (n = 137) from 2007 to 2018 was performed. The data were analyzed with respect to procedure time, fluoroscopy time and radiation exposure, complication rates and outcomes.

RESULTS

No difference was found in procedure duration between the teaching and nonteaching cases and only a nonsignificant trend was found toward a longer fluoroscopy time for the latter. The initial response rates to GR were equal for staff attending (88.7%) and trainee (87.2%) cases (P = 0.708). Similarly, no statistically significant difference (P = 0.48) was found between the median time to recurrence for the staff attending cases (1.6 ± 0.3 years) compared with that of the trainee cases (1.7 ± 0.3 years). The overall incidence of complications was low (7.5%). The occurrence of facial hypoesthesia correlated with the amount of glycerol injected (P < 0.01).

CONCLUSIONS

GR for the treatment of TN can safely be performed by senior residents and fellows under supervision.

Adverse Events After Microvascular Decompression: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications.

OBJECTIVE

To determine the incidence and risk factors for adverse events after MVD.

METHODS

Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006-2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay.

RESULTS

Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III-IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P < 0.04).

CONCLUSIONS

In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

Nationwide Shift From Percutaneous Rhizotomy to Microvascular Decompression for Treatment of Trigeminal and Other Cranial Nerve Neuralgias

OBJECTIVE

The aim of this study was to report the trends in the use of common surgical interventions over the past decade to treat cranial nerve neuralgias.

METHODS

The Centers for Medicare and Medicaid Services Part B National Summary Data File from 2000 to 2016 were studied.

RESULTS

A total of 57.1 million persons were enrolled in 2016, up from 39.6 million persons in 2000. Suboccipital craniectomy done for cranial nerve decompressions (including cranial nerves V, VII, and IX) increased by 33.9 cases per year so that in 2016 the number of cases was 167% of what it was 17 years earlier (ie, from 655 cases in 2000 to 1096 cases in 2016). The less commonly used subtemporal approach craniectomy to treat trigeminal neuralgia (TN) increased by 1.13 cases per year (ie, from 25 cases in 2000 to 46 cases in 2016). The less invasive percutaneous rhizotomy procedures, including glycerol and radiofrequency ablation, for treatment of TN decreased by 42.9 cases per year (64%; ie, from 2578 cases in 2000 to 1206 cases in 2016).

CONCLUSIONS

Overall trends show increased use of open surgery and decreased use of percutaneous rhizotomy, including destruction of the trigeminal nerve using balloon compression, glycerol injection, or thermal injury. These trends may be related to differences in outcomes between treatment modalities.

Diabetes and morbid obesity are associated with higher reoperation rates following microvascular decompression surgery: An ACS-NSQIP analysis

Background:

Microvascular decompression (MVD) is the preferred treatment for refractory trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia. Despite its high rate of success, MVD carries risk of complications. In this study, we examine outcomes following MVD and identify risk factors associated with adverse outcomes.

Methods:

A review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was performed with CPT code 61458 queried between 2007 and 2014. Demographics, preoperative comorbidities, and 30-day outcomes were analyzed. Univariate and multivariate regression analyses were performed to identify predictors of reoperation and adverse events.

Results:

Five hundred and six craniotomies were studied. Nineteen (5.5%) instances of 30-day readmission were reported, with 14 (2.8%) patients returning to the operating room. No instances of death or hemorrhage requiring operation were reported. Morbid obesity (body mass index >40) (P = 0.030) and diabetes (P = 0.017) were associated with risk of reoperation. Age, operative time, and indication for surgery were not associated with significant differences in adverse events.

Conclusions:

MVD is a common and effective procedure with a relatively safe profile and low 30-day risk of reoperation. Advanced age is not associated with worse outcomes. Obesity and diabetes, however, are associated with increased risk of reoperation and may warrant additional precautions.

Operative Landscape at Canadian Neurosurgery Residency Programs

Background Currently, the literature lacks reliable data regarding operative case volumes at Canadian neurosurgery residency programs. Our objective was to provide a snapshot of the operative landscape in Canadian neurosurgical training using the trainee-led Canadian Neurosurgery Research Collaborative.

METHODS

Anonymized administrative operative data were gathered from each neurosurgery residency program from January 1, 2014, to December 31, 2014. Procedures were broadly classified into cranial, spine, peripheral nerve, and miscellaneous procedures. A number of prespecified subspecialty procedures were recorded. We defined the resident case index as the ratio of the total number of operations to the total number of neurosurgery residents in that program. Resident number included both Canadian medical and international medical graduates, and included residents on the neurosurgery service, off-service, or on leave for research or other personal reasons.

RESULTS

Overall, there was an average of 1845 operative cases per neurosurgery residency program. The mean numbers of cranial, spine, peripheral nerve, and miscellaneous procedures were 725, 466, 48, and 193, respectively. The nationwide mean resident case indices for cranial, spine, peripheral nerve, and total procedures were 90, 58, 5, and 196, respectively. There was some variation in the resident case indices for specific subspecialty procedures, with some training programs not performing carotid endarterectomy or endoscopic transsphenoidal procedures.

CONCLUSIONS

This study presents the breadth of neurosurgical training within Canadian neurosurgery residency programs. These results may help inform the implementation of neurosurgery training as the Royal College of Physicians and Surgeons residency training transitions to a competence-by-design curriculum.

Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis

INTRODUCTION

 Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment.

METHODS

 We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL.

RESULTS

MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence.

CONCLUSIONS

With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.

Fatal complications following microvascular decompression: could it be avoided and salvaged?

Although the microvascular decompression (MVD) surgery has become an effective remedy for cranial nerve rhizopathies, it is still challengeable and may result in a fatal sequel sometimes. Therefore, the operative skill needs to be further highlighted with emphasis on the safety and a preplan for management of postoperative fatal complications should be established. We retrospectively analyzed 6974 cases of MVD. Postoperatively, 46 patients (0.66 %) presented decline in consciousness with a positive finger-nose test (or failure to be tested) after wake up from the anesthesia, whom were focused on in this study. Their surgical findings and intraoperative manipulation as well as computer tomography (CT) delineation were reviewed in detail. These cases consisted of trigeminal neuralgia in 37 and hemifacial spasm in 9. All these patients underwent an immediate CT scan, which demonstrated cerebellar hemorrhages in 38 and epidural hematomas in 6. A later magnetic resource image delineated cerebral infarctions in basal ganglia in 2. Eventually, 15 (0.2 %) died and 31 survived. Data analysis showed that the mortality is significantly higher in trigeminal cases with cerebellar hematoma and an immediate hematoma evacuation plus ventricular drainage could give the patient more chance of survival (p < 0.05). It appeared that the cerebellar hemorrhage was the predominant cause contributable to the postoperative consciousness decline, which occurred more often in trigeminal cases. To have a safe MVD, an appropriate surgical technique is the priority. It is very important to create a satisfactory working space before decompression of the cranial nerve root, which is obtained by a patient microdissection of the arachnoids rather than blind retraction of the cerebellum and hotheaded sacrifice of the petrous vein. Once a cerebellar hematoma is confirmed, an emergency surgery should not be hesitated. A prompt evacuation of the hematomas followed by a dual ventricular drainage via both the frontal horns may save the patient.

Efficacy of primary microvascular decompression versus subsequent microvascular decompression for trigeminal neuralgia

OBJECTIVE Trigeminal neuralgia (TN) is characterized by intermittent, paroxysmal, and lancinating pain along the distribution of the trigeminal nerve. Microvascular decompression (MVD) directly addresses compression of the trigeminal nerve. The purpose of this study was to determine whether patients undergoing MVD as their first surgical intervention experience greater pain control than patients who undergo subsequent MVD. METHODS A retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis. RESULTS In patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041). Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572). CONCLUSIONS The results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention.

Racial disparities in the diagnosis and management of trigeminal neuralgia

OBJECTIVE A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives. METHODS The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN. RESULTS The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060). CONCLUSIONS According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.

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

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.

The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia

OBJECT

Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain.

METHODS

A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes.

RESULTS

Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months.

CONCLUSIONS

A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.

Microvascular decompression for trigeminal neuralgia

The microvascular decompression procedure has proven to be a safe and effective option in the surgical management of neurovascular compression syndromes in general and trigeminal neuralgia in particular. This article aims to serve as an overview of the decision-making process, application of the surgical technique, and clinical outcome pertaining to this procedure.