Microvascular decompression and radiofrequency for the treatment of trigeminal neuralgia: a meta-analysis

Microvascular Decompression versus Radiofrequency Ablation in Trigeminal Neuralgia of the Maxillary and Mandibular Divisions

Background  Although medical treatment is the mainstay of therapy, in trigeminal neuralgia (TN), patients failing to respond to it make them candidates to ablative or nonablative procedures. Objective  The aim of this study was to compare the outcome of Microvascular decompression (MVD) and radiofrequency (RF) thermocoagulation in the management of TN affecting the mandibular and maxillary divisions. Materials and Methods  Retrospective analysis of the data of 40 patients suffering from intractable classical TN affecting the maxillary or mandibular divisions or both was carried out. Twenty patients were operated upon by MVD of the trigeminal nerve; and 20 had RF ablation of the maxillary or mandibular divisions of the trigeminal nerve or both. Results  In MVD the overall successful outcome was achieved in 16 patients (80%), while the failure was in 4 patients (20%) of which 3 had a fair outcome and 1 patient had a poor outcome. Whereas in RF the overall successful outcome was achieved in 17 patients (85%), while the failure was in 3 patients (15%) of which 2 had a fair outcome and 1 patient had a poor outcome. Outcome was insignificantly different between both groups ( p -value 0.806). Conclusion  MVD and RF ablation represent safe and efficacious surgical choices for addressing TN that encompasses both the mandibular and maxillary divisions. Long-term follow-up studies demonstrate that MVD consistently yields favorable outcomes, establishing it as the preferred primary surgical technique, unless contraindicated by the patient's general health and specific needs.

Long-term outcomes and predictors of percutaneous radiofrequency thermocoagulation of Gasserian ganglion for maxillary trigeminal neuralgia: a retrospective analysis of 1070 patients with minimum 2-year follow-up

OBJECTIVE

To estimate long-term efficacy and safety for maxillary trigeminal neuralgia (TN) using radiofrequency thermocoagulation (RFT) targeted on Gasserian ganglion, and to identify the factors which may influence outcomes after procedure.

METHODS

From 2006 to 2019, 1070 patients underwent RFT for the treatment of medically refractory maxillary TN was included. All patients were followed up for at least 2 years. Outcomes and complications were recorded and analysed. Logistic regression analysis was employed to identify risk factors of long-term pain recurrence. Prognostic value was calculated from receiver-operating characteristic curve (ROC).

RESULTS

Longitudinal analysis was taken place for 97 non-responders (9.1%) with ineffective pain relief, 253 responders (23.6%) with pain recurrence and 720 responders (67.3%) without pain recurrence. The median pain-free survival (PFS) was 112.0 months (95% CI: 107.5, 116.5). The pain-free rates were 89.9% (95% CI: 88.0-91.8%) at 1 year, 83.8% (95% CI: 81.5-86.1%) at 2 years, 75.4% (95% CI: 72.7-78.1%) at 5 years and 70.2% (95% CI: 67.4-73.0%) at 10 years. Atypical facial pain (HR = 5.373, 95% CI: 2.623-11.004, p < .001), previous facial numbness (HR = 5.224, 95% CI: 3.107-8.784, p < .001) and poor initial response to medication (HR = 3.185, 95% CI: 2.087-4.860, p < .001) were independently associated with long-term pain recurrence. Patients with prognostic index (PI) > 0.25 were identified as high-risk for recurrent TN (HR = 5.575, 95% CI: 3.991-7.788, p < .001). New and worsen facial hypoesthesia was recorded in 77.9% of patients corresponding with BNI score II-IV, and 18.7% reported improved sensation. Severe complication incidence including troublesome dysesthaesia, keratitis and masseter weakness was higher in 80 °C group.

CONCLUSIONS

Favourable outcomes were achieved in terms of long-term pain relief and complications rate after RFT for maxillary TN. Patients with typical facial pain, normal facial sensation, and good initial response to medications may have favourable long-term outcomes.Key messagesThis is a retrospective analysis of radiofrequency thermocoagulation (RFT) targeted on Gasserian ganglion for the treatment of maxillary trigeminal neuralgia (TN) during long-term follow-up. Recurrence-free survival among a large sample was assessed and risk factors associated with long-term pain recurrence was identified. It has been verified that inadvertent damage of ophthalmic and mandibular division causes ophthalmic and masticatory complications. Therefore, a more precise needle tip position and thermocoagulation using a relatively low temperature was recommended.

CyberKnife Radiosurgery for refractory bilateral trigeminal neuralgia. Case report

Case description: A case of a 37-year-old female patient suffering from refractory bilateral trigeminal neuralgia is presented, who underwent various interventions such as acupuncture, block therapies and even microvascular decompression without effective pain relief.

Clinical findings

Paresthesias and shooting-like twinges of pain intensity 10/10 in bilateral maxillary and mandibular branches of the trigeminal nerve, with nasal and intraoral triggers that made eating impossible, becoming increasingly severe since refractoriness to microvascular decompression and carbamazepines, triggering the twinges even during sleep, generating somnolence, depressive mood and social isolation.

Treatment and results

The patient was evaluated by an interdisciplinary neuro-oncology team, where, in accordance with the analysis of the brain magnetic resonance imaging and the patient's history, it was indicated to perform Cyberknife® radiosurgery in monofraction on the left trigeminal and subsequently treat the contralateral trigeminal. When treated with Cyberknife® radiosurgery, the patient reported absolute improvement in her pain for 2 years.

Clinical relevance

Radiosurgery by CyberKnife is not yet the first line of management in trigeminal neuralgia, however, it should be considered since several studies have managed to demonstrate an increase in the quality of life of patients and pain relief in refractory or severe cases. of said pathology.

The practical limits of high-quality magnetic resonance imaging for the diagnosis and classification of trigeminal neuralgia

BACKGROUND

Neurovascular compression (NVC) has been the primary hypothesis for the underlying mechanism of classical trigeminal neuralgia (TN). However, a substantial body of literature has emerged highlighting notable exceptions to this hypothesis. The purpose of this study is to assess the reliability and diagnostic accuracy of high resolution, high contrast MRI-determined neurovascular contact for TN.

METHODS

We performed a retrospective, randomized, and blinded parallel characterization of neurovascular interaction and diagnosis in a population of TN patients and controls using four expert reviewers. Performance statistics were calculated, as well as assessments for generalizability using shuffled bootstraps.

RESULTS

Fair to moderate agreement (ICC: 0.32-0.68) about diagnosis between reviewers was observed using MRIs from 47 TN patients and 47 controls. On average reviewers performed no better than chance when diagnosing participants, with an accuracy of 0.57 (95% CI 0.40, 0.59) per patient.

CONCLUSION

While MRI is useful in determining structural causes in secondary TN, expert reviewers do no better to only slightly better than chance with distinguishing TN with MRI, despite moderate agreement. Further, the causal role of NVC for TN is not clear, limiting the applicability of MRI to diagnose or prognosticate treatment of TN.

Xper-CT combined with laser-assisted navigation radiofrequency thermocoagulation in the treatment of trigeminal neuralgia

Objective

Our objective was to study the clinical feasibility of Xper-CT combined with laser-assisted radiofrequency thermocoagulation in the treatment of trigeminal neuralgia.

Materials and methods

A retrospective analysis was made of 60 patients with trigeminal neuralgia who visited the Affiliated Hospital of Binzhou Medical University from January 2019 to May 2021. According to the different surgical methods, we were divided into C-arm X-ray group and laser navigation group. The operation time, operative complications, post-operative 24 h, post-operative 3 and 6 months Barrow Neurotics Institute (BNI) score were recorded and compared.

Results

Compared with the C-arm X-ray-guided puncture group, Xper-CT combined with laser-assisted navigation has the obvious advantages of shorter total puncture time, shorter surgical time, higher success rate of first puncture, and better surgical effect.

Conclusion

Radiofrequency therapy of trigeminal neuralgia with Xper-CT combined with laser-assisted navigation has a good clinical effect and can be promoted and applied.

Unilateral Approach to Primary Bilateral Trigeminal Neuralgia Via Bilateral Microvascular Decompression

Primary bilateral trigeminal neuralgia is a rare disease characterized by paroxysmal bilateral facial pain confined to the somatosensory distribution of the trigeminal nerve. Nonetheless, while treatment of bilateral trigeminal neuralgia with microvascular decompression (MVD) has been reported, there have been no trials of a unilateral approach for bilateral MVD.

Inhibitory Effects of Palmatine on P2X7 Receptor Expression in Trigeminal Ganglion and Facial Pain in Trigeminal Neuralgia Rats

Trigeminal Neuralgia (TN) refers to recurrent severe paroxysmal pain in the distribution area of the trigeminal nerve, which seriously affects the quality of life of patients. This research applied the chronic constriction injury of the infraorbital nerve (CCI—ION) approach to induce an animal model of TN in rats. The mechanical pain threshold of each group of rats was determined postoperatively; the expression of P2X7 receptor in trigeminal ganglion (TG) was assessed by qRT-PCR, immunofluorescence and Western blot; and the changes of the proinflammatory cytokines IL-1β and TNF-α in serum of rats were detected by ELISA. The results showed that the administration of palmatine in the TN rats could reduce the mechanical pain threshold, significantly decrease the expression of P2X7 receptor in TG, and lower the serum concentrations of IL-1β and TNF-α, compared to the sham group. In addition, the phosphorylation level of p38 in TG of TN rats was significantly decreased after treatment with palmatine. Likewise, inhibition of P2X7 expression by shRNA treatment could effectively counteract the adversary changes of pain sensitivity, IL-1β and TNF-α production, and p38 phosphorylation in TN rats. Our data suggest that palmatine may alleviate mechanical facial pain in TN rats possibly by reducing the expression of P2X7 receptor in TG of TN rats, which may be attributable to inhibiting p38 phosphorylation and reducing the release of IL-1β and TNF-α.

Balloon compression vs radiofrequency for primary trigeminal neuralgia: a randomized, controlled trial

ABSTRACT

Surgical procedures are necessary in up to 50% of trigeminal neuralgia patients. Although radiofrequency (RF) is more widely used, it is associated with high intraprocedural costs and long technical learning time. Other simpler procedures such as balloon compression (BC) require a lower training period and have significant lower costs. We evaluated the effects of BC and RF in pain control in primary trigeminal neuralgia in a randomized, double-blinded, head-to-head trial. Individuals were randomly allocated in 1 of 2 groups: BC and RF. Throughout pain, psychological and quality of life measurements were performed at baseline and after surgery. The main outcome was the worst pain in the last 24 hours (0-10) at 6 months postoperatively. After the inclusion of half of the estimated sample, a preplanned interim analysis was performed when 33 patients (62.1 ± 9.4 y.) completed the study. Pain intensity (confidence interval [CI] 95% 0.6 to 3.8, and -0.6 to 2.2, for BC and RF) did not significantly differ. Complications, interference of pain in daily life (CI 95% -0.1 to 2.3 and -0.4 to 2.3, for BC and RF), neuropathic pain symptoms (CI 95% 1.7 to 3.6 and 3.0 to 5.7, for BC and RF), mood (CI 95% 4.8 to 11.5 and 5.5 to 15.1, BC and RF, respectively), medication use, and quality of life (CI 95% 80.4 to 93.1 and 83.9 to 94.2, for BC and RF) were also not different. Radiofrequency presented more paresthetic symptoms than BC at 30 days after intervention. Based on these results, the study was halted due to futility because BC was not superior to RF.

Efficacy and safety of radiofrequency in the treatment of trigeminal neuralgia: a systematic review and meta-analysis

To assess the effectiveness of radiofrequency (RF) versus other percutaneous strategies (balloon compression, glycerol rhizotomy [GR], and microvascular decompression [MVD]) in patients with trigeminal neuralgia. We systematically searched the electronic databases of PubMed, Embase, and the Cochrane Library to identify eligible studies throughout October 2020. The odds ratio (OR) with 95% confidence interval (CI) was applied to assess effect estimates using the random-effects model. Eighteen retrospective cohort studies that enrolled 6391 patients with trigeminal neuralgia were included. We noted that RF was associated with an increased incidence of immediate pain relief compared with GR (OR 2.65; 95% CI 1.29-5.44; P = 0.008). Moreover, RF was associated with an increased risk of pain recurrence compared with MVD (OR 3.80; 95% CI 2.00-7.20; P < 0.001). Furthermore, RF was associated with an increased incidence of postoperative anesthesia compared with GR (OR 3.01; 95% CI 1.11-8.13; P = 0.030) or MVD (OR 4.62; 95% CI 2.15-9.93; P < 0.001). This study found that RF was superior to GR for the improvement in immediate pain relief; whereas, RF yielded an excess risk of pain recurrence compared with MVD. Moreover, the incidence of postoperative anesthesia in patients treated with RF significantly increased compared with the incidence after treatment with GR and MVD.

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

OBJECTIVE

The safety and efficacy of surgical microvascular decompression (MVD) in elderly patients with trigeminal neuralgia (TN) is controversially discussed in the literature. A widespread reluctance to expose this cohort to major intracranial surgery persists. Our aim was to compare the efficacy and safety between older and younger patients with TN.

METHODS

In this cross-sectional study, 139 MVD procedures (103 patients < 70 and 36 patients ≥ 70) were included. Surgical fitness was assessed by the American Society of Anesthesiology (ASA) grade. The pain-free interval was evaluated using Kaplan-Meier analysis only in patients with a recent follow-up visit. Independent risk factors for recurrence in patients with a minimum 12-month follow-up were determined.

RESULTS

Patients ≥ 70 showed a significantly higher number of comorbidities. Pain intensity, affection of trigeminal branches and symptom duration was similar between groups. No significant difference in treatment associated complications and permanent neurological deficits was shown. There was no treatment-related mortality. A tendency towards a lower recurrence rate in patients < 70 did not reach statistical significance (17.6% vs. 28.6%, P = 0.274). Pain-free interval was not different between both cohorts (78.7 vs. 73.5 months, P = 0.391).

CONCLUSION

Despite a higher prevalence of comorbidities in elderly patients, complication rates and neurological deficits after MVD were comparable to younger patients. Rates of immediate and long-term pain relief compared favorably to previous studies and were similar between elderly and younger patients. These data endorse MVD as a safe and effective first-line surgical procedure for elderly patients with TN and neurovascular conflict on MRI.

Comparison of efficacy and safety of complementary and alternative therapies for primary trigeminal neuralgia: A protocol for a Bayesian network meta analysis

BACKGROUND

Primary trigeminal neuralgia (PTN) is a type of peripheral neuralgia that seriously affects people's lives. In recent years, complementary therapies and alternative therapies have played a significant role in treating PTN. However, there is a lack of comparison among all the complementary and alternative therapies at present. Thus, the aim of this study is to discuss the efficacy and safety of diverse complementary and alternative therapies by Bayesian network meta-analysis (NMA).

METHODS

We will retrieve the Chinese and English databases to gather related randomized controlled trials (RCTs) of complementary and alternative therapies for treating PTN. The deadline is November 2020. Two independent researchers will be in charge of screening qualified literature, extracting data, and independently evaluating bias risks involved in the research. Pairwise meta-analysis and Bayesian network meta-analysis will be performed to assess all evidence. Then, we will use STATA16.0 as well as WinBUGS1.4.3 software for data analysis. Besides, the quality of NMA evidence will be classified by grading of recommendations assessment development and evaluation (GRADE).

RESULTS

This study will compare and rank the efficacy and safety of different complementary and alternative therapies in treating primary trigeminal neuralgia.

CONCLUSION

Complementary and alternative therapies play an essential role in treating primary trigeminal neuralgia. We expect our study will furnish meaningful evidence support for clinicians and patients.

PROTOCOL REGISTRATION NUMBER

INPLASY2020120026.

ETHICAL APPROVAL

Since the study is based on published or registered RCTs, ethical approval and patient informed consent are abandoned.

Invasive and Non-Invasive Electrical Neuromodulation in Trigeminal Nerve Neuralgia: A Systematic Review and Meta-Analysis

BACKGROUND

Trigeminal neuralgia is a chronic disease characterized by intense facial pain that is caused by trigeminal nerve affectation. It usually affects adults from 50 years of age, and is more frequent in women. Additionally, it presents serious psychological effects that often lead to depression, which is why it is considered highly disabling. The therapeutic approach is based on the modification of nerve activity through electrical, surgical or chemical stimulation in specific regions of the nervous system.

OBJECTIVE

To perform a meta-analysis of the scientific literature related to invasive and non-invasive electrical neuromodulation of trigeminal neuralgia, in order to assess their effects over pain and adverse effects.

METHODS

A literature search was conducted in 4 databases, followed by a manual search of articles on invasive or non-invasive electrical neuromodulation to control the pain of trigeminal neuralgia, including the last 15 years.

RESULTS

Regarding non-invasive methods, clinical trials did not present enough results in order to perform a meta-analysis. Regarding invasive methods, clinical trials meta-analysis showed no statistical differences between different treatment methods. In all cases, improvements in patients' pain were reported, although results regarding adverse effects were variable.

CONCLUSION

In the treatment of trigeminal neuralgia, the continuous radiofrequency provides better short and medium-term results, but pulsed radiofrequency shows less adverse effects after treatment, and has better results in the long-term.

Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis

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.

The fifth cranial nerve in headaches

The fifth cranial nerve is the common denominator for many headaches and facial pain pathologies currently known. Projecting from the trigeminal ganglion, in a bipolar manner, it connects to the brainstem and supplies various parts of the head and face with sensory innervation. In this review, we describe the neuroanatomical structures and pathways implicated in the sensation of the trigeminal system. Furthermore, we present the current understanding of several primary headaches, painful neuropathies and their pharmacological treatments. We hope that this overview can elucidate the complex field of headache pathologies, and their link to the trigeminal nerve, to a broader field of young scientists.

Long-Term Efficacy and Complications of Radiofrequency Thermocoagulation at Different Temperatures for the Treatment of Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a common neuropathic pain that seriously affects the daily life of patients. Many invasive treatments are currently available for patients who respond poorly to oral carbamazepine or oxcarbazepine. Among them, radiofrequency (RF) treatment is a viable option with reliable initial and long-term clinical efficacy. The long-term analgesic effects of radiofrequency thermocoagulation (RFT) at high temperatures (≥80°C) are not superior to those at relatively low temperatures (60–75°C). In contrast, the higher the temperature, the greater the risk of complications, especially facial numbness, masticatory muscles weakness, and corneal hypoesthesia. Some patients even experience irreversible lethal complications. Therefore, we recommend low-temperature RFT (60–75°C) for treatment of TN. The therapeutic effects of pulsed radiofrequency (PRF) are controversial, whereas PRF (≤75°C) combined with RFT can improve long-term effects and decrease the incidence of complications. However, large-scale clinical trials are needed to verify the efficacy of the combination of PRF and RFT.

Long-Term Beneficial Effects of Acupuncture with Reduced Risk of Depression Development Following Trigeminal Neuralgia: A Nationwide Population-Based Cohort Study

BACKGROUND

Existing evidence has shown that patients with trigeminal neuralgia (TN) have a higher risk of developing depression than the normal population. Clinically, acupuncture has been widely used to alleviate pain in TN. However, few studies have explored the use of acupuncture to prevent depression in TN. Therefore, this study aimed to apply national real-world data to investigate the long-term effect of acupuncture on the risk of depression in patients with TN.

METHODS

We recruited participants with newly diagnosed TN from the Taiwanese National Health Insurance Research Database between January 1, 2000 and December 31, 2010, and categorized them into either the acupuncture cohort or non-acupuncture cohort using the 1:1 propensity score-matched method. All patients in the two cohorts were followed up until the end of 2013. Cox proportional hazards regression analysis was used to compare the incidence of depression between the two cohorts.

RESULTS

In total, 776 patients with newly diagnosed TN in each cohort with similar baseline characteristics were enrolled in the study. The acupuncture cohort had a reduced risk of depression compared to the non-acupuncture cohort (adjusted hazard ratio, 0.47; 95% confidence interval, 0.31-0.70). Kaplan-Meier analysis also revealed that the cumulative incidence of depression was significantly lower in the acupuncture cohort during the 13-year follow-up period (Log rank test, p < 0.001). In particular, the beneficial effect of acupuncture was a decrease in the risk of depression among TN patients aged 50-69 years who had also used carbamazepine.

CONCLUSION

This study demonstrated that acupuncture is associated with a reduction in the risk of depression during long-term follow-up in patients with TN. The results provide new insights for clinical practitioners as well as for health resource allocation.