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Díaz-Molina J, Orduna J, Rivero D, Alcázar P, González LM. Partial sensory rhizotomy in recurrent trigeminal neuralgia. Our experience and literature review. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00038-8. [PMID: 38972389 DOI: 10.1016/j.neucie.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 05/06/2024] [Accepted: 06/03/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND AND OBJECTIVE Trigeminal Neuralgia (NT) is a common pathology in Neurosurgery. It can be classified as idiopathic or secondary to other pathologies, such as Multiple Sclerosis (MS). Several surgical treatments have been described, some of them being replaced by more modern techniques. Partial sensory rhizotomy (PSR), described by Dandy is a technique replaced by other techniques due to its permanent side effects. We present our experience with this technique in patients with recurrent NT. METHODS AND MATERIALS A retrospective review is carried out on five patients who underwent surgery at our center from 2018 to 2023 using the PSR technique. RESULTS All the patients intervened showed significant clinical improvement, except one patient who required reintervention due to uncontrolled pain. According to the Barrow Neurological Institute (BNI) scale, 80% (4/5) of patients showed improvement from grade V to grades I/II except for one of them. This patient suffered from MS. Additionally, one patient presented a corneal ulcer after surgery due to impairment of the corneal reflex. CONCLUSION In our experience, PSR is a valid treatment option in selected patients with recurrent TN. It has a low incidence of complications with an adequate surgical technique and anatomical knowledge of the region. To the best of our knowledge, we are one of the few centers in Spain to publish our results with PSR in the last ten years. We report good results in pain control withdrawing medication in 80% (4/5) of the operated patients.
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Affiliation(s)
| | | | - David Rivero
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Paula Alcázar
- Hospital Universitario Miguel Servet, Zaragoza, Spain
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Montano N, Menna G, Musarra A, Martinelli R, Izzo A, D'Alessandris QG, D'Ercole M, Olivi A. A systematic review on the efficacy of adjunctive surgical strategies during microvascular decompression for trigeminal neuralgia without intraoperative evidence of neurovascular conflict. Neurosurg Rev 2024; 47:276. [PMID: 38884812 DOI: 10.1007/s10143-024-02498-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/11/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024]
Abstract
Aim of the present study was to conduct a comprehensive review of surgical strategies that can be offered to patients with trigeminal neuralgia undergoing microvascular decompression (MVD) surgery and without intraoperative evidence of neurovascular conflict, with a high pre-operative suspicion of conflict lacking intraoperative confirmation, or individuals experiencing recurrence after previous treatment. This systematic review followed established guidelines (PRISMA) to identify and critically appraise relevant studies. The review question was formulated according to the PICO (P: patients; I: intervention; C: comparison; O: outcomes) framework as follows. For patients with trigeminal neuralgia (P) undergoing MVD surgery (I) without demonstrable preoperative neurovascular conflict, high suspicion of conflict but no intraoperative confirmation or recurrence after previous treatment (C), do additional surgical techniques (nerve combing, neurapraxia, arachnoid lysis) (O) improve pain relief outcomes (O)? The search of the literature yielded a total of 221 results. Duplicate records were then removed (n = [76]). A total of 143 papers was screened, and 117 records were excluded via title and abstract screening; 26 studies were found to be relevant to our research question and were assessed for eligibility. Upon full-text review, 17 articles were included in the review, describing the following techniques; (1) internal neurolysis (n = 6) (2) arachnoid lysis/adhesiolysis (n = 2) (3) neurapraxia (n = 3) (4) partial rhizotomy of the sensory root (n = 4) (5) pontine descending tractotomy (n = 2). The risk of bias was assessed using the ROBINS-I (Risk of Bias in Non-randomized Studies - of Interventions) assessment tool. While the described techniques hold promise, further research is warranted to establish standardized protocols, refine surgical approaches, and comprehensively evaluate long-term outcomes.
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Affiliation(s)
- Nicola Montano
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Grazia Menna
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Alessandra Musarra
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Renata Martinelli
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Olivi
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Sousa MP, Fukunaga CK, Ferreira MY, da Silva Semione G, Borges PGLB, Silva GM, Verly G, Oliveira LB, Batista S, Andreão FF, Brito HN, Bertani R, da Cunha PHM. Efficacy and safety of microvascular decompression with or without partial sensory rhizotomy: a comprehensive meta-analysis and systematic review in treating trigeminal neuralgia. Neurosurg Rev 2024; 47:229. [PMID: 38787487 DOI: 10.1007/s10143-024-02463-4] [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: 01/25/2024] [Revised: 05/07/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient's quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47%. We aimed to assess the efficacy and safety profile of MVD + PSR when compared to standalone MVD for TN. We searched Medline, Embase, and Web of Science following PRISMA guidelines. Eligible studies included those with ≥ 4 patients, in English, published between January 1980 and December 2023, comparing MVD vs. MVD + PSR for TN. Endpoints were pain cure, immediate post-operative pain improvement, long-term effectiveness, long-term recurrence, and complications (facial numbness, hearing loss, and intracranial bleeding). We pooled odds ratios (OR) with 95% confidence intervals with a random-effects model. I2 was used to assess heterogeneity, and sensitivity and Baujat analysis were conducted to address high heterogeneity. Eight studies were included, comprising a total of 1,338 patients, of whom 1,011 were treated with MVD and 327 with MVD + PSR. Pain cure analysis revealed a lower likelihood of pain cure in patients treated with MVD when compared to patients treated with MVD + PSR (OR = 0.30, 95% CI: 0.13 to 0.72). Immediate postoperative pain improvement assessment revealed a lower likelihood of improvement in the MVD group when compared with the MVD + PSR group (OR = 0.31, 95% CI: 0.10 to 0.95). Facial numbness assessment revealed a lower likelihood of occurrence in MVD alone when compared to MVD + PSR (OR = 0.08, 95% CI: 0.04 to 0.15). Long-term effectiveness, long-term recurrence, hearing loss, and intracranial bleeding analyses revealed no difference between both approaches. Our meta-analysis identified that MVD + PSR was superior to MVD for pain cure and immediate postoperative pain improvement for treating TN. However, MVD + PSR demonstrated a higher likelihood of facial numbness complications. Furthermore, identified that hearing loss and intracranial bleeding complications appear comparable between the two treatments, and no difference between long-term effectiveness and recurrence.
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Affiliation(s)
- Marcelo Porto Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Guilherme Melo Silva
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gabriel Verly
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo B Oliveira
- Department of Neurosurgery, State University of Ponta Grossa, Paraná, Brazil
| | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Raphael Bertani
- Department Neurosurgery, University of São Paulo, São Paulo, Brazil
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Xu R, Materi J, Raj D, Alomari S, Xia Y, Nair SK, Shah PP, Kannapadi N, Kim T, Huang J, Bettegowda C, Lim M. Internal neurolysis versus intraoperative glycerin rhizotomy for trigeminal neuralgia. J Neurosurg 2023; 138:270-275. [PMID: 35523261 DOI: 10.3171/2022.3.jns212956] [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: 12/26/2021] [Accepted: 03/21/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Internal neurolysis (IN) and intraoperative glycerin rhizotomy (ioGR) are emerging surgical options for patients with trigeminal neuralgia without neurovascular contact. The objective of this study was to compare the neurological outcomes of patients who underwent IN with those of patients who underwent ioGR. METHODS The authors retrospectively reviewed all patients who underwent IN or ioGR for trigeminal neuralgia at our institution. Patient demographic characteristics and immediate postoperative outcomes, as well as long-term neurological outcomes, were compared. RESULTS Of 1044 patients who underwent open surgical treatment for trigeminal neuralgia, 56 patients underwent IN and 91 underwent ioGR. Of these 147 patients, 37 had no evidence of intraoperative neurovascular conflict. All patients who underwent IN and 96.7% of patients who underwent ioGR had immediate postoperative pain relief. At last follow-up, patients who underwent IN had lower Barrow Neurological Institute (BNI) pain intensity scores (p = 0.05), better BNI facial numbness scores (p < 0.01), and a greater degree of pain improvement (p = 0.05) compared with those who underwent ioGR. Patients who underwent IN also had significantly lower rates of symptomatic pain recurrence (p < 0.01) at last follow-up over an average of 9.5 months. CONCLUSIONS IN appears to provide patients with a greater degree of pain relief, lower rates of facial numbness, and lower rates of pain recurrence compared with ioGR. Future prospective studies will better characterize long-term pain recurrence and outcomes.
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Affiliation(s)
- Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Joshua Materi
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Divyaansh Raj
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Safwan Alomari
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Yuanxuan Xia
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Sumil K Nair
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Pavan P Shah
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Nivedha Kannapadi
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Timothy Kim
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Chetan Bettegowda
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Michael Lim
- 2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Clinical outcomes of partial sensory root rhizotomy on patients with recurrence of multiple sclerosing trigeminal neuralgia after percutaneous balloon compression. Mult Scler Relat Disord 2022; 63:103883. [DOI: 10.1016/j.msard.2022.103883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/16/2022] [Accepted: 05/13/2022] [Indexed: 11/22/2022]
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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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