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Montano N, Menna G, Musarra A, Martinelli R, Izzo A, D'Alessandris QG, D'Ercole M, Olivi A. A systematic review on the efficacy of adjunctive surgical strategies during microvascular decompression for trigeminal neuralgia without intraoperative evidence of neurovascular conflict. Neurosurg Rev 2024; 47:276. [PMID: 38884812 DOI: 10.1007/s10143-024-02498-7] [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: 04/09/2024] [Revised: 05/11/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024]
Abstract
Aim of the present study was to conduct a comprehensive review of surgical strategies that can be offered to patients with trigeminal neuralgia undergoing microvascular decompression (MVD) surgery and without intraoperative evidence of neurovascular conflict, with a high pre-operative suspicion of conflict lacking intraoperative confirmation, or individuals experiencing recurrence after previous treatment. This systematic review followed established guidelines (PRISMA) to identify and critically appraise relevant studies. The review question was formulated according to the PICO (P: patients; I: intervention; C: comparison; O: outcomes) framework as follows. For patients with trigeminal neuralgia (P) undergoing MVD surgery (I) without demonstrable preoperative neurovascular conflict, high suspicion of conflict but no intraoperative confirmation or recurrence after previous treatment (C), do additional surgical techniques (nerve combing, neurapraxia, arachnoid lysis) (O) improve pain relief outcomes (O)? The search of the literature yielded a total of 221 results. Duplicate records were then removed (n = [76]). A total of 143 papers was screened, and 117 records were excluded via title and abstract screening; 26 studies were found to be relevant to our research question and were assessed for eligibility. Upon full-text review, 17 articles were included in the review, describing the following techniques; (1) internal neurolysis (n = 6) (2) arachnoid lysis/adhesiolysis (n = 2) (3) neurapraxia (n = 3) (4) partial rhizotomy of the sensory root (n = 4) (5) pontine descending tractotomy (n = 2). The risk of bias was assessed using the ROBINS-I (Risk of Bias in Non-randomized Studies - of Interventions) assessment tool. While the described techniques hold promise, further research is warranted to establish standardized protocols, refine surgical approaches, and comprehensively evaluate long-term outcomes.
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Affiliation(s)
- Nicola Montano
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Grazia Menna
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Alessandra Musarra
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Renata Martinelli
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Olivi
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Lavergne P, Piper K, Vinjamuri S, Kelly P, Evans JJ. Internal Neurolysis for Trigeminal Neuralgia: Technical Nuances and a Single-Institution Experience. World Neurosurg 2024; 184:e9-e16. [PMID: 37666299 DOI: 10.1016/j.wneu.2023.08.126] [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: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Trigeminal neuralgia is a facial pain syndrome most commonly caused by a neurovascular compression (NVC) of the trigeminal nerve. Microvascular decompression (MVD) is the most durable surgical treatment; however, patients without an NVC are not candidates for this procedure. Alternative treatments such as percutaneous rhizotomy and radiosurgery are effective but with higher recurrence rates. Internal neurolysis (IN) is a less frequently used procedure that aims to provide long-term relief to patients without NVC. OBJECTIVE We present the surgical techniques for IN developed at our institution. We also discuss the technical nuances related to nerve consistency and present a new classification based on these findings. We provide pain and numbness outcomes for our cohort of patients stratified by the extent of neurolysis and nerve consistency. METHODS Patients with medically intractable trigeminal neuralgia eligible for posterior fossa exploration are eligible for MVD and possible IN. If no NVC or a mild NVC is encountered, IN is performed. We have divided the procedure into 4 main steps: opening the outer connective sheath, fascicular dissection, inside-out dissection and the fascicular irrigation technique. Trigeminal nerve consistency has been classified into 3 main types: type 1 is soft and friable; type 2 is intermediate consistency and ideal for neurolysis; and type 3 is firm and presents a more challenging dissection. CONCLUSIONS In the absence of microvascular compression, we advocate for a thorough neurolysis using the techniques described in our article.
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Affiliation(s)
- Pascal Lavergne
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Department of Surgery, Hôpital du Sacré-Cœur de Montréal, University of Montréal, Montréal, Québec, Canada
| | - Keenan Piper
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Shreya Vinjamuri
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Patrick Kelly
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Sabourin V, Lavergne P, Mazza J, Head J, Al-Saiegh F, Stefanelli T, Karsy M, Evans JJ. Internal Neurolysis for the Treatment of Trigeminal Neuralgia: A Systematic Review. World Neurosurg 2021; 158:e829-e842. [PMID: 34823039 DOI: 10.1016/j.wneu.2021.11.068] [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: 09/01/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Trigeminal neuralgia (TN) remains a challenging disease with debilitating symptoms and variable efficacy in terms of treatment options. Microvascular decompression (MVD) with internal neurolysis (IN) is an alternative treatment that might benefit patients but has limited understanding. We performed a systematic review of IN for the treatment of TN. METHODS Studies from 2000 to 2021 that had assessed IN for TN were aggregated and independently reviewed. RESULTS A total of 520 patients in 12 studies were identified, with 384 who had undergone IN (mean age, 53.8 years; range, 46-61.4 years; mean follow-up, 36.5 months). Preoperative symptoms had been present for ∼55.0 months before treatment, and pain was predominantly in V2 and V3 (26.8%), followed by other distributions. Of the patients, 83.7% (range, 72%-93.8%) had had an excellent to good outcome (Barrow Neurological Institute pain scale score [BNI-PS], I-II). The pain outcomes at 1 year were excellent for 58%-78.4%, good or better for 77%-93.75%, and fair or better for 80%-93.75% of the patients. On average, facial numbness after IN was experienced by 96% of the patients. However, at follow-up, facial numbness remained in only 1.75%-10%. Most of the remaining numbness was not significantly distressing to the patients. Subgroup comparisons of IN versus recurrent MVD, IN versus radiofrequency ablation, the effects of IN in the absence of vascular compression, and IN with and without MVD were also evaluated. CONCLUSIONS IN represents a promising surgical intervention for TN in the absence of vascular compression and for potential cases of recurrence. Complications were limited in general but require further study.
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Affiliation(s)
- Victor Sabourin
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Lavergne
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jacob Mazza
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jeffrey Head
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tony Stefanelli
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - James J Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Zawy Alsofy S, Welzel Saravia H, Nakamura M, Ewelt C, Lewitz M, Sakellaropoulou I, Sarkis HM, Fortmann T, Schipmann S, Suero Molina E, Santacroce A, Salma A, Stroop R. Virtual reality-based evaluation of neurovascular conflict for the surgical planning of microvascular decompression in trigeminal neuralgia patients. Neurosurg Rev 2021; 44:3309-3321. [PMID: 33586035 DOI: 10.1007/s10143-021-01500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/13/2020] [Accepted: 02/08/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Trigeminal neuralgia (TN) is a lightning bolt of violent, electrifying, and stinging pain, often secondary to the neurovascular conflict (NVC). The vessels involved in NVC are mostly arteries and rarely veins. Evaluation of NVC in the deep infratentorial region is inseparably connected with cranial imaging. We retrospectively analyzed the potential influence of three-dimensional (3D) virtual reality (VR) reconstructions compared to conventional magnetic resonance imaging (MRI) scans on the evaluation of NVC for the surgical planning of microvascular decompression in patients with TN. METHODS Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative MRI scans were retrospectively visualized via VR software to detect the characteristics of NVC. A questionnaire of experienced neurosurgeons evaluated the influence of VR visualization technique on identification of anatomical structures involved in NVC and on surgical strategy. RESULTS Twenty-four patients were included and 480 answer sheets were evaluated. Compared to conventional MRI, image presentation using 3D-VR modality significantly influenced the identification of the affected trigeminal nerve (p = 0.004), the vascular structure involved in the NVC (p = 0.0002), and the affected side of the trigeminal nerve (p = 0.005). CONCLUSIONS In patients with TN caused by NVC, the reconstruction of conventional preoperative MRI scans and the spatial and anatomical presentation in 3D-VR models offers the possibility of increased understanding of the anatomy and even more the underlying pathology, and thus influences operation planning and strategy.
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Affiliation(s)
- Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany. .,Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany.
| | - Heinz Welzel Saravia
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Köln-Merheim, Witten/Herdecke University, Köln, Germany
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | - Marc Lewitz
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | - Ioanna Sakellaropoulou
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | - Hraq Mourad Sarkis
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | - Thomas Fortmann
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany
| | | | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Antonio Santacroce
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfälische Wilhelms-University Münster, Hamm, Germany.,Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | - Asem Salma
- Department of Neurosurgery, St. Rita's Neuroscience Institute, Lima, Ohio, USA
| | - Ralf Stroop
- Department of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
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Urculo E, Elua A, Arrazola M, Torres P, Torres S, Undabeitia J. Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why. Neurocirugia (Astur) 2019; 31:53-63. [PMID: 31668629 DOI: 10.1016/j.neucir.2019.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call "trigeminal root massage" (TRM). METHODS 52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. RESULTS All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. CONCLUSIONS The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don't find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as "nerve combing". Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.
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Affiliation(s)
- Enrique Urculo
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain.
| | - Alejandro Elua
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Mariano Arrazola
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Patricia Torres
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Sergio Torres
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Jose Undabeitia
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
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