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Yu G, Xia Y, Gong W, Min F, Leng J, Xiang H. Comparison of the Efficacy of Complete Endoscopic and Microscopic Vascular Decompression in the Treatment of Classical Trigeminal Neuralgia. World Neurosurg 2024:S1878-8750(24)01234-8. [PMID: 39032638 DOI: 10.1016/j.wneu.2024.07.094] [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: 07/08/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE To compare whether there is a difference in the efficacy of complete endoscopic microvascular decompression (EVD) and microscopic microvascular decompression (MVD) in patients with classical trigeminal neuralgia (CTN). METHODS From January 2014 to January 2021, 297 CTN patients were assigned to the retrosigmoid approach EVD (138 cases) and the MVD groups (159 cases); to compare whether there are differences in the pain control rate, recurrence, complications of CTN patients between the 2operations, and separately predict the factors related to prognosis of both groups. RESULTS There was no significant difference in painless rates at 1, 3, and 5 years after surgery (P = 0.356, P = 0.853, P = 1), and overall incidence of complications (P = 0.058) between the EVD and MVD groups. The EVD group had shorter surgical decompression duration than the MVD group (P < 0.001). The painless rate of patients with vertebrobasilar trigeminal neuralgia in the EVD group was higher than that in the MVD group, but the difference was not statistically significant (90% vs. 61.1%, P = 0.058). The independent risk factors associated with a good prognosis in the EVD group were a shorter course of the disease and severe neurovascular conflict, while severe neurovascular conflict is the only independent risk factor associated with a good prognosis in the MVD group. CONCLUSIONS For CTN patients, compared with traditional MVD, EVD is also safe and effective and has the advantage of shorter decompression time.The predictive results of prognostic factors also suggest that CTN patients may benefit more from early surgical treatment.
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Affiliation(s)
- Gui Yu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, China; Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Yinghua Xia
- Medical College of Nanchang University, Nanchang, China; Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Wanxin Gong
- The First People's Hospital of Xiushui, Jiujiang, China
| | - Feixiang Min
- Medical College of Nanchang University, Nanchang, China; Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Jingxing Leng
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Hui Xiang
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China.
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2
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Mori K, Otani N, Toyooka T, Morita S, Numazawa S, Wada K, Watanabe S. Validation of Efficacy and Safety of TachoSil ® Tissue Sealant for Vessel Transposition in Microvascular Decompression. Oper Neurosurg (Hagerstown) 2023; 25:417-425. [PMID: 37820076 DOI: 10.1227/ons.0000000000000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/25/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Use of TachoSil ® as the transposition material of microvascular decompression (MVD) for hemifacial spasm (HFS) and trigeminal neuralgia (TN) is easy and safe to perform, but the efficacy and safety of this technique are unknown. This study attempted to validate the efficacy and safety of TachoSil ® as a transposition material of MVD. METHODS A retrospective study of the surgical results and complications of 63 patients (35 HFS and 28 TN) treated by the TachoSil ® technique between January 2011 and December 2021 was conducted. The efficacy of the treatment was evaluated by Kaplan-Meier survival analysis. Magnetic resonance imaging follow-up study was performed to detect any adverse events including a mass formation. RESULTS The rate of complete disappearance of HFS was 91.4% at 1 year and estimated to be 85.7% after a 10-year follow-up. The rate of no pain without medication for TN was 85.4% at 1 year and estimated to be 69.0% after a 9-year follow-up. These surgical results are comparable with those previously reported. Flaking of TachoSil ® releasing the offending artery was only recognized in one case (1.6%). Therefore, TachoSil ® can be considered as an effective transposition material for MVD. TachoSil ® did not increase the rate of acute and subacute adverse events such as inflammation and delayed facial palsy. Magnetic resonance imaging follow-up identified no abnormalities including mass that suggested granuloma formation. CONCLUSION The efficacy of the TachoSil ® technique for HFS and TN and the reliability of TachoSil ® as an adhesive material in MVD were verified. No adverse events associated with TachoSil ® use in MVD were found. We conclude that the TachoSil ® technique has relatively long efficacy and safety for MVD.
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Affiliation(s)
- Kentaro Mori
- Department of Neurosurgery, Tokyo General Hospital, Tokyo , Japan
- Department of Neurosurgery, National Defense Medical College, Tokorozawa , Saitama , Japan
| | - Naoki Otani
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo , Japan
| | - Terushige Toyooka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa , Saitama , Japan
| | - Shuhei Morita
- Department of Neurosurgery, Tokyo General Hospital, Tokyo , Japan
| | | | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa , Saitama , Japan
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3
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Kalluri AL, So RJ, Nair SK, Materi J, Wang D, Behera N, Kornberg MD, Huang J, Lim M, Bettegowda C, Xu R. The role of multiple sclerosis subtype in microvascular decompression outcomes for patients with trigeminal neuralgia. Clin Neurol Neurosurg 2023; 233:107967. [PMID: 37703615 DOI: 10.1016/j.clineuro.2023.107967] [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: 03/01/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES While patients with concomitant trigeminal neuralgia (TN) and multiple sclerosis (MS) are understood to experience a more intractable pain phenotype, whether TN pain outcomes differ by the presenting MS subtype is not well characterized. This study's objective is to compare post-operative pain and numbness outcomes following microvascular decompression (MVD) in TN patients with either relapsing-remitting MS (RRMS) or progressive MS. METHODS We retrospectively reviewed all TN patients who underwent MVDs at our institution from 2007 to 2020. Of the 1044 patients reviewed, 45 (4.3%) patients with MS were identified. Patient demographics, procedural characteristics, and post-operative pain and numbness scores were recorded and compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions. RESULTS Of the resulting 45 MS patients, 34 (75.6%) patients presented with the RRMS subtype, whereas 11 (24.4%) patients exhibited progressive MS. Using an adjusted multivariate ordinal regression, the subtype of MS was not significantly associated with the Barrow Neurological Institute (BNI) pain score at final follow-up. Using a Kaplan-Meier survival analysis and a multivariate Cox proportional hazards regression, respectively, RRMS was significantly associated with a shorter post-operative pain-free interval (p = 0.04) as well as a greater risk for pain recurrence (p = 0.02). CONCLUSIONS Although the degree of pain at final follow-up may not differ, RRMS patients are at increased risk for pain recurrence following MVD for TN. These results align with a growing understanding that neuroinflammation may play a significant role in TN pain.
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Affiliation(s)
- Anita L Kalluri
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Raymond J So
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Dorothy Wang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Niranjan Behera
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Michael D Kornberg
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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4
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Geraily G, Ameri A, Mahmoudi A, Moafee M, Teymouri J. Assessing the Risk of Secondary Cancer Induction in Radiosensitive Organs During Trigeminal Neuralgia Treatment With Gamma Knife Radiosurgery: Impact of Extracranial Dose. Dose Response 2023; 21:15593258231210432. [PMID: 37900619 PMCID: PMC10605703 DOI: 10.1177/15593258231210432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
Purpose Gamma knife radiosurgery (GKRS) delivers high-dose external radiation to a small intracranial lesion. However, scattering and leaked radiation can deposit a portion of the dose outside the radiation field, which may pose a risk to radiation-sensitive patients, such as pregnant women. Trigeminal Neuralgia (TN) is treated with one of the highest GKRS doses (80-90 Gy). This study aimed to estimate the risk of secondary cancer induction in the uterus, ovaries, thyroid gland, and eyes of TN patients undergoing GKRS. Methods Radiation doses to the uterus, ovary, eyes, and thyroid gland were measured for 25 female TN patients, with a mean age of 35 years, utilizing Thermo Luminescent Dosimeters (TLD). Results The mean absorbed dose for the uterus, ovary, thyroid gland, and eyes were .63 ± .24, .471 ± .2, 8.26 ± 1.01, and 10.64 ± 1.08 cGy, respectively. Lifetime Attributable Risk (LAR) has been calculated using BEIR VII (2006) method. LAR for the uterus, ovary, and thyroid gland was 1, 2, and 23, respectively. Conclusion The results of this study and its comparison with standard values demonstrate that on average, mean doses to mentioned organs were smaller than their tolerance doses, and there is no limitation to treating patients suffering from TN by GK.
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Affiliation(s)
- Ghazale Geraily
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ameri
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Radiation Oncology Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Mahmoudi
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohadese Moafee
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Teymouri
- Department of Radiation Oncology, Iran Gamma Knife Centre, Tehran, Iran
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Yang R, Xiong B, Wang M, Wu Y, Gao Y, Xu Y, Deng H, Pan W, Wang W. Gamma Knife surgery and deep brain stimulation of the centromedian nucleus for chronic pain: A systematic review. Asian J Surg 2023; 46:3437-3446. [PMID: 37422388 DOI: 10.1016/j.asjsur.2023.06.026] [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: 11/20/2022] [Revised: 04/11/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023] Open
Abstract
Chronic pain has been a major problem in personal quality of life and social economy, causing psychological disorders in people and a larger amount of money loss in society. Some targets were adopted for chronic pain, but the efficacy of the CM nucleus for pain was still unclear. A systematic review was performed to summarize GK surgery and DBS of the CM nucleus for chronic pain. PubMed, Embase and Medline were searched to review all studies discussing GK surgery and DBS on the CM nucleus for chronic pain. Studies that were review, meet, conference, not English or not the therapy of pain were excluded. Demographic characteristics, surgery parameters and outcomes of pain relief were selected. In total, 101 patients across 12 studies were included. The median age of most patients ranged from 44.3 to 80 years when the duration of pain ranged from 5 months to 8 years. This review showed varied results of 30%-100% pain reduction across studies. The difference in the effect between GK surgery and DBS cannot be judged. Moreover, three retrospective articles related to GK surgery of the CM nucleus for trigeminal neuralgia presented an average pain relief rate of 34.6-82.5%. Four studies reported adverse effects in a small number of patients. GK surgery and DBS of the CM nucleus might be promising therapeutic approaches for chronic refractory pain. More rigorous studies and larger samples with longer follow-up periods are needed to support the effectiveness and safety.
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Affiliation(s)
- Ruiqing Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Botao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Mengqi Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Yang Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Hao Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Wei Pan
- Department of Neurosurgery, West China Hospital, Sichuan University, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
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Rapisarda A, Battistelli M, Izzo A, D'Ercole M, D'Alessandris QG, Polli FM, Santi S, Martinelli R, Montano N. Outcome Comparison of Drug-Resistant Trigeminal Neuralgia Surgical Treatments-An Umbrella Review of Meta-Analyses and Systematic Reviews. Brain Sci 2023; 13:brainsci13040530. [PMID: 37190495 DOI: 10.3390/brainsci13040530] [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: 03/07/2023] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 05/17/2023] Open
Abstract
Medical treatment for trigeminal neuralgia (TN) is not always a feasible option due to a lack of full response or adverse effects. Open surgery or percutaneous procedures are advocated in these cases. Several articles have compared the results among different techniques. Nevertheless, the findings of these studies are heterogeneous. Umbrella reviews are studies sitting at the peak of the evidence pyramid. With this umbrella review, we provided a systematic review of the outcomes of the surgical procedures used for TN treatment. Only systematic reviews and meta-analyses were included following the PRISMA guidelines. Ten articles were enrolled for qualitative and quantitative assessment. Level of evidence was quantified using a specific tool (AMSTAR-2). Results were heterogenous in terms of outcome and measurements. Microvascular decompression (MVD) appeared to be the most effective procedure both in the short-term (pain relief in 85-96.6% of cases) and long-term follow-up (pain relief in 64-79% of cases), although showed the highest rate of complications. The results of percutaneous techniques were similar but radiosurgery showed the highest variation in term of pain relief and a higher rate of delayed responses. The use of the AMSTAR-2 tool to quantify the evidence level scored three studies as critically low and seven studies as low-level, revealing a lack of good quality studies on this topic. Our umbrella review evidenced the need of well-designed comparative studies and the utilization of validated scales in order to provide more homogenous data for pooled-analyses and meta-analyses in the field of TN surgical treatment.
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Affiliation(s)
- Alessandro Rapisarda
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
| | - Marco Battistelli
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
| | - Samuele Santi
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Renata Martinelli
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Tan H, Stedelin B, Bakr SM, Nerison C, Raslan AM. Neurosurgical Ablation for Pain: A Technology Review. World Neurosurg 2023; 170:114-122. [PMID: 36400357 DOI: 10.1016/j.wneu.2022.11.047] [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: 10/03/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
Neurosurgical ablative procedures for pain have dramatically transformed over the years. Compared to their precursors, present day techniques are less invasive and more precise as a result of advances in both device engineering and imaging technology. From a clinical perspective, understanding the strengths and drawbacks of modern techniques is necessary to optimize patient outcomes. In this review, we provide an overview of the major contemporary neuroablative modalities/technologies used for treating pain. We will compare and contrast these modalities from one another with respect to their intraoperative monitoring needs, invasiveness, range of access, and lesion generation. Finally, we will provide a brief commentary on the future of neuroablation given the advent of neuromodulation options for pain control.
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Affiliation(s)
- Hao Tan
- Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - Caleb Nerison
- Oregon Health & Science University, Portland, Oregon, USA
| | - Ahmed M Raslan
- Oregon Health & Science University, Portland, Oregon, USA.
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8
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Long-term results of microvascular decompression with video endoscopy in the treatment of patients with atypical trigeminal neuralgia. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract114755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The frequency of occurrence of atypical trigeminal neuralgia (aNTN) varies from 1 to 7 people per 100,000 population per year. The main cause of development is compression of the trigeminal nerve root (TN) by a vein and/or artery in the cerebellar cistern. To date, the final tactics of treatment of patients with aNTN have not been determined. The effectiveness of conservative methods of therapy does not exceed 50%. The aim of the study was to evaluate the results of microvascular decompression using video endoscopy in the treatment of patients with atypical trigeminal neuralgia. Methods. In the period from 2014 to 2021 34 patients with atypical HTN were operated on, of which 18 (53%) patients had neuropathic pain (more than 4 points on the DN4 scale), and 15 (44%) patients had a transformation of classical trigeminal neuralgia into atypical. Conservative therapy (carbamazepine, gabapentin, pregabalin), administered to all patients in the preoperative period, was not accompanied by a significant reduction in pain syndrome. The maximum intensity of pain upon admission to the hospital according to the visual analog scale (VAS) was 10 points, according to the severity of pain syndrome BNI (Barrow Neurological Institute) V (severe, persistent pain). All patients underwent internal affairs of the trigeminal nerve root with the use of Teflon; in 12 (35%) patients, in addition to a microscope, video endoscopy was additionally used. The average follow-up period after surgery was 3.4 1.7 years (from 1 to 5 years). Results. In all (100%) patients after surgery, the pain is completely stopped (BNI I). The total fiveyear excellent and good outcome of the disease on the J.Miller and BNI scale (I-II) was noted in 80% (n=27) of patients with atypical NTN. The risk of pain recurrence in the first three years after MVD was 14% (n=3), and after 5 years 34% (n=4). The use of video endoscopy made it possible to identify vessels compressing the root of the trigeminal nerve with minimal displacement of the cerebellum and cranial nerves when visualizing neurovascular conflict. Conclusion. The MVD method with video endoscopy is effective in the treatment of patients with aNTN
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Yu G, Leng J, Xia Y, Min F, Xiang H. Microvascular decompression: Diversified of imaging uses, advantages of treating trigeminal neuralgia and improvement after the application of endoscopic technology. Front Neurol 2022; 13:1018268. [DOI: 10.3389/fneur.2022.1018268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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10
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Zhang Z, Wang F, Yu F, Kwok SC, Yin J. Delayed pain relief in patients with trigeminal neuralgia following microvascular decompression: A single-central retrospective study. Front Neurol 2022; 13:946897. [PMID: 36341100 PMCID: PMC9635510 DOI: 10.3389/fneur.2022.946897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background Compared to hemifacial spasm after microvascular decompression (MVD), delayed relief (DR) rarely occurs in patients with trigeminal neuralgia (TGN). Objective To analyze the characteristics of post-MVD DR in TGN patients to provide useful clues for the clinical differential diagnosis of postoperative DR. Methods The clinical data of all patients with TGN who underwent MVD in our center from January 1, 2016, to December 31, 2020, were reviewed retrospectively. Results In 272 TGN MVD patients, DR occurred in nine patients (3.3%) during the follow-up periods of 1–6 years. During surgery, all nine DR-TGN patients were identified as having neurovascular conflicts (NVCs), involving the offending artery (OA) in eight patients (two OAs in two patients) and both an artery and a vein in the other patient. The compression site was near the root entry zone (REZ) in most DR patients (7/9). Delayed relief was relieved in seven patients within 5 days after surgery and within 30 days in the other two patients. No recurrence or serious complications were observed within the mean 4 (1-6)-year follow-up duration. Conclusion Delayed relief rarely occurs in TGN patients after MVD. Neurovascular conflicts located at the REZ and NVC of grade III may be two important factors contributing to DR in TGN patients. Delayed relief may occur when the pain gradually improves after the operation and responds effectively to a small dose of carbamazepine. The recurrence rate of TGN seems even lower in such patients.
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Affiliation(s)
- Zhengyu Zhang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fang Wang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Feng Yu
- Department of Neurosurgery, 960th Hospital of PLA, Jinan, Shandong, China
| | - Sze Chai Kwok
- Shanghai Key Laboratory of Brain Functional Genomics, Key Laboratory of Brain Functional Genomics Ministry of Education, Shanghai Key Laboratory of Magnetic Resonance, Affiliated Mental Health Center (ECNU), School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
- Division of Natural and Applied Sciences, Duke Kunshan University, Kunshan, China
- Shanghai Changning Mental Health Center, Shanghai, China
| | - Jia Yin
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Jia Yin
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11
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Lee S, Lee JI. Gamma Knife Radiosurgery for Trigeminal Neuralgia : Review and Update. J Korean Neurosurg Soc 2022; 65:633-639. [PMID: 35774033 PMCID: PMC9452385 DOI: 10.3340/jkns.2021.0303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/27/2022] [Indexed: 11/27/2022] Open
Abstract
Accurate diagnosis of trigeminal neuralgia (TN) is the starting point for optimal treatment. Gamma knife radiosurgery (GKRS) is currently regarded as one of the first-line treatment options for medically refractory TN. GKRS is a less invasive treatment with a low risk of complications than other surgical procedures that provides a favorable pain control (BNI I–IIIb) rate of >75% at short-term follow-up. Drawbacks of GKRS include the latency period before pain relief and higher recurrence rate compared with microvascular decompression. Therefore, repeat treatment is necessary if the initial GKRS was effective but followed by recurrence. The concept of dose rate and the biologically effective dose of radiation has been actively studied in radiation oncology and is also applied in GKRS for TN to achieve high safety and efficacy by prescribing the optimal dose. Recent progress in functional imaging, such as diffusion tensor imaging, enables us to understand the pathophysiology of TN and predict the clinical outcome after GKRS. Here, we review TN, GKRS, and recent updates, especially in the concepts of radiation dose, diffusion tensor imaging studies, and repeat treatment in GKRS for TN.
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Affiliation(s)
- Seunghoon Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Sun J, Wang M, Zhang L, Yu Y. A meta-analysis of the effectiveness and safety of microvascular decompression in elderly patients with trigeminal neuralgia. J Clin Neurosci 2022; 99:22-34. [DOI: 10.1016/j.jocn.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/30/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
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Racke MK, Frohman EM, Frohman T. Pain in Multiple Sclerosis: Understanding Pathophysiology, Diagnosis, and Management Through Clinical Vignettes. Front Neurol 2022; 12:799698. [PMID: 35095742 PMCID: PMC8794582 DOI: 10.3389/fneur.2021.799698] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Neuropathic pain and other pain syndromes occur in the vast majority of patients with multiple sclerosis at some time during their disease course. Pain can become chronic and paroxysmal. In this review, we will utilize clinical vignettes to describe various pain syndromes associated with multiple sclerosis and their pathophysiology. These syndromes vary from central neuropathic pain or Lhermitte's phenomenon associated with central nervous system lesions to trigeminal neuralgia and optic neuritis pain associated with nerve lesions. Muscular pain can also arise due to spasticity. In addition, we will discuss strategies utilized to help patients manage these symptoms.
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Affiliation(s)
- Michael K Racke
- Department of Medical Affairs, Quest Diagnostics, Secaucus, NJ, United States
| | - Elliot M Frohman
- Neuroimmunology Laboratory of Lawrence Steinman, Stanford University School of Medicine, Stanford, CA, United States
| | - Teresa Frohman
- Neuroimmunology Laboratory of Lawrence Steinman, Stanford University School of Medicine, Stanford, CA, United States
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Xu R, Xie ME, Jackson CM. Trigeminal Neuralgia: Current Approaches and Emerging Interventions. J Pain Res 2021; 14:3437-3463. [PMID: 34764686 PMCID: PMC8572857 DOI: 10.2147/jpr.s331036] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022] Open
Abstract
Trigeminal neuralgia (TN) has been described in the literature as one of the most debilitating presentations of orofacial pain. This review summarizes over 150 years of collective clinical experience in the medical and surgical treatment of TN. Fundamentally, TN remains a clinical diagnosis that must be distinguished from other types of trigeminal neuropathic pain and/or facial pain associated with other neuralgias or headache syndromes. What is increasingly clear is that there is no catch-all medical or surgical intervention that is effective for all patients with trigeminal neuralgia, likely reflective of the fact that TN is likely a heterogenous group of disorders that jointly manifests in facial pain. The first-line treatment for TN remains anticonvulsant medical therapy. Patients who fail this have a range of surgical options available to them. In general, microvascular decompression is a safe and effective procedure with immediate and durable outcomes. Patients who are unable to tolerate general anesthesia or whose medical comorbidities preclude a suboccipital craniectomy may benefit from percutaneous methodologies including glycerol or radiofrequency ablation, or both. For patients with bleeding diathesis due to blood thinning medications who are ineligible for invasive procedures, or for those who are unwilling to undergo open surgical procedures, radiosurgery may be an excellent option-provided the patient understands that maximum pain relief will take on the order of months to achieve. Finally, peripheral neurectomies continue to provide an inexpensive and resource-sparing alternative to pain relief for patients in locations with limited economic and medical resources. Ultimately, elucidation of the molecular mechanisms underlying trigeminal neuralgia will pave the way for novel, more effective and less invasive therapies.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Surgical Management of Trigeminal Neuralgia Induced by Brainstem Infarct: A Systematic Review of the Literature. World Neurosurg 2021; 151:209-217. [PMID: 33940266 DOI: 10.1016/j.wneu.2021.04.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although cases of trigeminal neuralgia (TN) induced by brainstem infarct have been reported, the neurosurgical literature lacks a comprehensive review for this subpopulation of patients. We present the first systematic review of the literature to discuss pathology, surgical management, and future directions for therapeutic innovation in this population. METHODS Our systematic review was conducted according to PRISMA guidelines. Resulting articles were screened for those that presented cases of TN associated with brainstem infarct. RESULTS A review of the literature identified 18 case reports of 21 patients with TN induced by brainstem infarct: 14 pontine infarcts and 7 medullary infarcts. Although many cases of ischemic brainstem lesions are caused by acute stroke, cerebral small vessel disease also plays a role in certain cases, and the relationship between these chronic lesions and TN is more likely to be overlooked. Furthermore, we found that reports of self-resolving TN pain after brainstem infarct is disproportionately biased, as most case reports published their data within the first few months after initial presentation. Reports with follow-up periods >13 months reported eventual pain recurrence that necessitated surgical intervention. Microvascular decompression was not sufficient to treat TN pain associated with concurrent neurovascular compression and brainstem infarct. CONCLUSIONS Brainstem infarcts affecting the trigeminal pathway represent an understudied pathologic cause of TN. Although the neurosurgical literature lacks a clear picture of the most efficacious interventions in this population, we are optimistic that this review will encourage further investigation into the best treatment for these patients.
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Chaves JPG, DE Oliveira TVHF, Francisco AN, Trintinalha MDO, Carvalho NVP. Trigeminal neuralgia recurrence: a comparison of microvascular decompression and percutaneous balloon compression: a five years follow-up study. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:51-55. [PMID: 33656112 DOI: 10.1590/0004-282x-anp-2020-0115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/15/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND About 50% of patients that suffer from trigeminal neuralgia do not experience sustained benefit from the use of oral medication. For their adequate management, a few surgical procedures are available. Of these, percutaneous balloon compression (PBC) and microvascular decompression (MD) are two of the most performed worldwide. In this retrospective study, we present the outcomes of these techniques through estimation of initial pain relief and subsequent recurrence rate. METHODS Thirty-seven patients with medically refractory trigeminal pain surgically treated at Hospital Cajuru, Curitiba, Brazil, with PBC, MD or both between 2013 and 2018 were enrolled into this retrospective study. The post-procedural rate for pain relief and recurrence and associations between patient demographics and outcomes were analyzed. RESULTS MD had an earlier recurrence time than balloon compression. Of the 37 patients, the mean age was 61.6 years, approximately one third were male and most had type I neuralgia. The most affected branch was the maxillary (V2). The time for recurrence after surgery was on average 11.8 months for PBC and 9.0 months for MD. Complications were seen only with microsurgery. CONCLUSIONS MD presented with a more precocious recurrence of pain than PBC in this article. Moreover, it had a higher recurrence rate than described in the literature as well, which is possibly explained by the type of graft (muscle) that was used to separate the neurovascular structures.
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Gerwin R. Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7012. [PMID: 32992770 PMCID: PMC7579138 DOI: 10.3390/ijerph17197012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/07/2023]
Abstract
Trigeminal neuralgia (TN), the most common form of severe facial pain, may be confused with an ill-defined persistent idiopathic facial pain (PIFP). Facial pain is reviewed and a detailed discussion of TN and PIFP is presented. A possible cause for PIFP is proposed. (1) Methods: Databases were searched for articles related to facial pain, TN, and PIFP. Relevant articles were selected, and all systematic reviews and meta-analyses were included. (2) Discussion: The lifetime prevalence for TN is approximately 0.3% and for PIFP approximately 0.03%. TN is 15-20 times more common in persons with multiple sclerosis. Most cases of TN are caused by neurovascular compression, but a significant number are secondary to inflammation, tumor or trauma. The cause of PIFP remains unknown. Well-established TN treatment protocols include pharmacotherapy, neurotoxin denervation, peripheral nerve ablation, focused radiation, and microvascular decompression, with high rates of relief and varying degrees of adverse outcomes. No such protocols exist for PIFP. (3) Conclusion: PIFP may be confused with TN, but treatment possibilities differ greatly. Head and neck muscle myofascial pain syndrome is suggested as a possible cause of PIFP, a consideration that could open new approaches to treatment.
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Affiliation(s)
- Robert Gerwin
- Department of Neurology School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
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18
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Liu MX, Zhong J, Xia L, Dou NN, Shi J. Treatment of Trigeminal Neuralgia with "Microvascular Decompression Plus" Technique. J Neurol Surg B Skull Base 2020; 82:e295-e299. [PMID: 34306952 DOI: 10.1055/s-0040-1710520] [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: 09/10/2019] [Accepted: 03/15/2020] [Indexed: 10/24/2022] Open
Abstract
Objective Although microvascular decompression (MVD) has been widely accepted as an effective treatment of trigeminal neuralgia (TN), some patients have not been cured. To improve the postoperative outcome, the surgical procedure should be further refined. Design This is a retrospective study. Setting Present study conducted at a cranial nerve disorder center. Participants Clinical data were collected from patients with TN who had undergone surgery in our center, including 685 who had undergone traditional MVD and 576 who had undergone the "MVD plus" procedure, in which any vessel attached to the trigeminal nerve was freed away ("nerve-combing"), which was followed by intraoperative neurolysis. Main Outcome Measures Postoperative outcomes and complications in the two groups were compared. Results Among patients who underwent traditional MVD, the rates of immediate relief and 1-year relief were 89.9 and 86.9%, respectively; among patients who underwent MVD plus group, these rates were 95.1 and 94.6%, respectively ( p = 0.05). Patients who underwent MVD plus initially exhibited a higher rate of facial numbness ( p < 0.05), but this finding decreased over time and reached the same level as that in the traditional MVD group within 3 months ( p > 0.05). Conclusion Sufficient MVD with nerve-combing for the treatment of TN may produce a high rate of cure with less recurrence.
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Affiliation(s)
- Ming-Xing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, People's Republic of China
| | - Jun Zhong
- Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, People's Republic of China
| | - Lei Xia
- Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, People's Republic of China
| | - Ning-Ning Dou
- Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, People's Republic of China
| | - Juanhong Shi
- Department of Pathology, Tongji Hospital, Shanghai Tongji University, Shanghai, People's Republic of China
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19
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Shi J, Qian Y, Han W, Dong B, Mao Y, Cao J, Guan W, Zhou Q. Risk Factors for Outcomes After Microvascular Decompression for Trigeminal Neuralgia. World Neurosurg 2020; 136:e559-e566. [DOI: 10.1016/j.wneu.2020.01.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 01/21/2023]
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20
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Holste K, Chan AY, Rolston JD, Englot DJ. Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 86:182-190. [PMID: 30892607 PMCID: PMC8253302 DOI: 10.1093/neuros/nyz075] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 02/14/2019] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Katherine Holste
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Alvin Y Chan
- Department of Neurosurgery, University of California, Irvine, Irvine, California
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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21
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Baldauf J, Rosenstengel C, Schroeder HWS. Nerve Compression Syndromes in the Posterior Cranial Fossa. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:54-60. [PMID: 30855007 DOI: 10.3238/arztebl.2019.0054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 03/29/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nerve compression syndromes in the posterior cranial fossa can severely impair patients' quality of life. There is often uncertainty about the best treatment. In this article, we provide an overview of these conditions and the corresponding treatment strategies. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed and on a scientific analysis of the authors' patient collective. RESULTS These syndromes are caused by compression of a cranial nerve by an artery or vein at the zone of the nerve's entry to or exit from the brainstem. The best-known neurovascular compression syndrome is trigeminal neuralgia, followed by hemifacial spasm. Less well known are glossopharyngeal neuralgia, nervus intermedius neuralgia, and vestibular paroxysmia. The initial treatment of trigeminal neuralgia is medical: the first line of treatment is with sodium-blocking anticon- vulsants, such as carbamazepine. For patients with hemifacial spasm, botulinum toxin injection is the recommended initial treatment and often leads to a satisfactory regression of the spasms. If these treatments fail, a microvascular decompression operation is indicated. The aim of the procedure is to separate the irritating vessel from the nerve and to keep these structures apart permanently. There is hardly any available evidence on these treatment strategies from randomized controlled trials. CONCLUSION Nerve compression syndromes in the posterior cranial fossa can generally be treated nonsurgically at first. Over the course of the condition, however, treatment failure or intolerable side effects may arise. In such cases, a microvascu- lar decompression operation is indicated. This is a causally directed form of treat- ment that generally yields very good results.
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Affiliation(s)
- Jörg Baldauf
- Department of Neurosurgery, University Medicine Greifswald
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Patra DP, Savardekar AR, Dossani RH, Narayan V, Mohammed N, Nanda A. Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis. J Neurosurg 2019; 131:1197-1206. [PMID: 30485193 DOI: 10.3171/2018.5.jns18583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.
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Tajali Y, Ward M, Abraham M, Hillen M, Mahmoud O, Herschman Y, Mammis A, Paskhover B. Minimally invasive trigeminal ablation in patients with refractory trigeminal neuralgia who are ineligible for intracranial intervention. J Clin Neurosci 2019; 70:42-46. [PMID: 31537461 DOI: 10.1016/j.jocn.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/30/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022]
Abstract
We describe the use of minimally invasive trigeminal ablation, an endoscopic ablative technique to treat trigeminal neuralgia in patients who are traditionally poor surgical candidates. We present 4 patients who presented with refractory unilateral trigeminal neuralgia. Three of the patients had previously failed stereotactic radiosurgery and three of them have multiple sclerosis. Due either to lack of neurovascular compression, minimally invasive trigeminal ablation was offered. Intraoperatively, an incision is made along the buccal mucosa or mid-brow and the tissue is endoscopically dissected in a plane towards the symptomatic nerve. Once isolated, the epineurium is partially ablated with thermocautery and the tissue surrounding the nerve is decompressed. All patients reported resolution of their pain post-operatively and were pain free at last follow up. Two patients had mild hypesthesia over the ablated nerve territory. Minimally invasive trigeminal ablation is a safe and effective technique for symptomatic control of trigeminal neuralgia. The efficacy, low risk, and relative ease of the procedure makes it ideal for use in patients who are refractory to medical management and have no neurovascular compression, are unable to tolerate traditional surgery or have failed other therapies.
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Affiliation(s)
- Yasser Tajali
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Max Ward
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Mickey Abraham
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Machteld Hillen
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States.
| | - Omar Mahmoud
- Department of Radiation Oncology, Cancer Institute of New Jersey, Newark, NJ, United States
| | - Yehuda Herschman
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Antonios Mammis
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Boris Paskhover
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States; Department of Facial Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ, United States
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Tohyama S, Hung P, Zhong J, Hodaie M. Early postsurgical diffusivity metrics for prognostication of long-term pain relief after Gamma Knife radiosurgery for trigeminal neuralgia. J Neurosurg 2019; 131:539-548. [PMID: 30117773 DOI: 10.3171/2018.3.jns172936] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/19/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is an important treatment modality for trigeminal neuralgia (TN). Current longitudinal assessment after GKRS relies primarily on clinical diagnostic measures, which are highly limited in the prediction of long-term clinical benefit. An objective, noninvasive, predictive tool would be of great utility to advance the clinical management of patients. Using diffusion tensor imaging (DTI), the authors' aim was to determine whether early (6 months post-GKRS) target diffusivity metrics can be used to prognosticate long-term pain relief in patients with TN. METHODS Thirty-seven patients with TN treated with GKRS underwent 3T MRI scans at 6 months posttreatment. Diffusivity metrics of fractional anisotropy, axial diffusivity, radial diffusivity, and mean diffusivity were extracted bilaterally from the radiosurgical target of the affected trigeminal nerve and its contralateral, unaffected nerve. Early (6 months post-GKRS) diffusivity metrics were compared with long-term clinical outcome. Patients were identified as long-term responders if they achieved at least 75% reduction in preoperative pain for 12 months or longer following GKRS. RESULTS Trigeminal nerve diffusivity at 6 months post-GKRS was predictive of long-term clinical effectiveness, where long-term responders (n = 19) showed significantly lower fractional anisotropy at the radiosurgical target of their affected nerve compared to their contralateral, unaffected nerve and to nonresponders. Radial diffusivity and mean diffusivity, correlates of myelin alterations and inflammation, were also significantly higher in the affected nerve of long-term responders compared to their unaffected nerve. Nonresponders (n = 18) did not exhibit any characteristic diffusivity changes after GKRS. CONCLUSIONS The authors demonstrate that early postsurgical target diffusivity metrics have a translational, clinical value and permit prediction of long-term pain relief in patients with TN treated with GKRS. Importantly, an association was found between the footprint of radiation and clinical effectiveness, where a sufficient level of microstructural change at the radiosurgical target is necessary for long-lasting pain relief. DTI can provide prognostic information that supplements clinical measures, and thus may better guide the postoperative assessment and clinical decision-making for patients with TN.
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Affiliation(s)
- Sarasa Tohyama
- 1Division of Brain, Imaging, and Behaviour-Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto
- 3Collaborative Program in Neuroscience, University of Toronto; and
| | - Peter Hung
- 1Division of Brain, Imaging, and Behaviour-Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto
- 3Collaborative Program in Neuroscience, University of Toronto; and
| | - Jidan Zhong
- 1Division of Brain, Imaging, and Behaviour-Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto
| | - Mojgan Hodaie
- 1Division of Brain, Imaging, and Behaviour-Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto
- 4Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Inhibition of MicroRNA-195 Alleviates Neuropathic Pain by Targeting Patched1 and Inhibiting SHH Signaling Pathway Activation. Neurochem Res 2019; 44:1690-1702. [PMID: 31004260 DOI: 10.1007/s11064-019-02797-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/11/2019] [Accepted: 04/10/2019] [Indexed: 01/15/2023]
Abstract
Trigeminal neuralgia (TN) is a type of chronic neuropathic pain that is caused by peripheral nerve lesions that result from various conditions, including the compression of vessels, tumors and viral infections. MicroRNAs (miRs) are increasingly recognized as potential regulators of neuropathic pain. Previous evidence has demonstrated that miR-195 is involved in neuropathic pain, but the mechanism remains unclear. To investigate the pathophysiological role of miR-195 and Shh signaling in TN, persistent facial pain was induced by infraorbital nerve chronic constriction injury (CCI-IoN), and facial pain responses were evaluated by Von Frey hairs. qPCR and Western blotting were used to determine the relative expression of miR-195 and Patched1, the major receptor of the Sonic Hedgehog (Shh) signaling pathway, in the caudal brain stem at distinct time points after CCI-IoN. Here, we found that the expression of miR-195 was increased in a rat model of CCI-IoN. In contrast, the expression of Patched1 decreased significantly. Luciferase assays confirmed the binding of miR-195 to Patched1. In addition, the overexpression of miR-195 by an intracerebroventricular (i.c.v) administration of LV-miR-195 aggravated facial pain development, and this was reversed by upregulating the expression of Patched1. These results suggest that miR-195 is involved in the development of TN by targeting Patched1 in the Shh signaling pathway, thus regulating extracellular glutamate.
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Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A, Eide PK, Leal PRL, Maarbjerg S, May A, Nurmikko T, Obermann M, Jensen TS, Cruccu G. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol 2019; 26:831-849. [DOI: 10.1111/ene.13950] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
Affiliation(s)
- L. Bendtsen
- Department of Neurology Faculty of Health and Medical Sciences Danish Headache Center Rigshospitalet‐Glostrup University of Copenhagen Glostrup Denmark
| | - J. M. Zakrzewska
- Pain Management Centre National Hospital for Neurology and Neurosurgery London UK
- Eastman Dental Hospital UCLH NHS Foundation Trust London UK
| | - J. Abbott
- Trigeminal Neuralgia Association UK Oxted Surrey UK
| | | | - G. Di Stefano
- Department of Human Neuroscience Sapienza University Rome Italy
| | - A. Donnet
- Headache and Pain Department CHU La Timone APHM Marseille France
| | - P. K. Eide
- Department of Neurosurgery Oslo University Hospital‐Rikshospitalet Oslo Norway
- Institute of Clinical Medicine Faculty of Medicine University of Oslo Oslo Norway
| | - P. R. L. Leal
- Department of Neurosurgery Faculty of Medicine of Sobral Federal University of Ceará Sobral Brazil
- University of Lyon 1 Lyon France
| | - S. Maarbjerg
- Department of Neurology Faculty of Health and Medical Sciences Danish Headache Center Rigshospitalet‐Glostrup University of Copenhagen Glostrup Denmark
| | - A. May
- Department of Systems Neuroscience Universitäts‐Krankenhaus Eppendorf Hamburg Germany
| | - T. Nurmikko
- Neuroscience Research Centre Walton Centre NHS Foundation Trust Liverpool UK
| | - M. Obermann
- Center for Neurology Asklepios Hospitals Schildautal Seesen Germany
| | - T. S. Jensen
- Department of Neurology and Danish Pain Research Center Aarhus University Hospital University of Aarhus Aarhus C Denmark
| | - G. Cruccu
- Department of Human Neuroscience Sapienza University Rome Italy
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27
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Lu VM, Goyal A, Graffeo CS, Perry A, Jonker BP, Link MJ. Glossopharyngeal Neuralgia Treatment Outcomes After Nerve Section, Microvascular Decompression, or Stereotactic Radiosurgery: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:572-582.e7. [PMID: 30240868 DOI: 10.1016/j.wneu.2018.09.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glossopharyngeal neuralgia (GPN) is a rare neuralgic pain syndrome amenable to neurosurgical treatments, including nerve section (NS), microvascular decompression (MVD), and stereotactic radiosurgery (SRS). However, thorough comparisons of the modalities have not been performed to date. The objective of the present study was to compare the pain and complication outcomes after these approaches to GPN. METHODS Searches of 7 electronic databases from inception to June 2018 were conducted following the appropriate guidelines. The incidence rates (IRs) of short-term (≤3 months) and long-term (≥12 months) pain relief and complications were extracted and analyzed using a meta-analysis. Meta-regression was used to assess for heterogeneity. RESULTS A total of 792 GPN cases managed by NS, MVD, or SRS were described by 6, 11, and 6 studies, reporting outcomes for 282 (36%), 446 (56%), and 67 (8%) cases. The short-term pain relief rate was highest after NS postoperatively (IR, 94%; 95% confidence interval [CI], 88%-98%) and lowest after SRS at 3 months postoperatively (IR, 80%; 95% CI, 68%-96%). The postoperative complication rate was greatest after MVD (IR, 26%; 95% CI, 16%-38%) and lowest after SRS (IR, 0%; 95% CI, 0%-4%). The long-term pain relief rate was greatest after NS (IR, 96%; 95% CI, 91%-99%) and lowest after SRS (IR, 82%; 95% CI, 67%-94%). Statistically significant differences between the approaches were found for each outcome. CONCLUSION Neurosurgical treatment of GPN is frequently performed by 1 of 3 modalities with unique outcomes profiles. NS might provide the most favorable treatment response, with respect to short- and long-term pain relief and postoperative outcomes.
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Affiliation(s)
- Victor M Lu
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| | - Anshit Goyal
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Avital Perry
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin P Jonker
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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