Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis

Broggi, Giovanni; Ferroli, Paolo; Franzini, Angelo; Servello, Domenico; Dones, Ivano

doi:10.1136/jnnp.68.1.59

Cited by 277 publications

(155 citation statements)

References 42 publications

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“…The major complications reported by the authors included 2 postoperative deaths (0.2%), 1 brainstem infarction (0.1%), 4 intracerebral hematomas, 4 cerebellar edemas, 2 cases of hydrocephalus, 12 cases of facial palsy (2 permanent), 15 cases of extraocular muscle palsy (2 permanent), 16 cases of ipsilateral hearing loss, 22 cases of severe facial numbness, 20 cases of CSF leakage, 4 cases of pseudomeningocele, 5 cases of bacterial meningitis, 225 cases of chemical meningitis, 2 cases of pneumonia, and 1 case each of septicemia, myocardial infarction, transverse sinus thrombosis, pulmonary embolus, and permanent contralateral hearing loss. 1 Few other reports 2,24,47,48 used independent outcome assessments after MVD. 5 These case series confirm the results of Barker et al, with a 75% chance of maintaining pain relief at 3 years and a risk of operative mortality of 0.2% (rising to 0.5% in other reports).…”

Section: Discussionmentioning

confidence: 99%

Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study

Régis

Tuleasca

Resseguier

et al. 2016

JNS

151

126

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OBJectiVe Gamma Knife surgery (GKS) is one of the surgical alternatives for the treatment of drug-resistant trigeminal neuralgia (TN). This study aims to evaluate the safety and efficacy of GKS in a large population of patients with TN with very long-term clinical follow-up. methOdS Between July 1992 and November 2010, 737 patients presenting with TN were treated using GKS. Data were collected prospectively and were further retrospectively evaluated at Timone University Hospital. The frequency and severity of pain, as well as trigeminal nerve function, were evaluated before GKS and regularly thereafter. Radiosurgery using the Gamma Knife (model B, C, 4C, or Perfexion) was performed with the help of both MR and CT targeting. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 85 Gy (range 70-90 Gy) was prescribed. reSultS The safety and efficacy are reported for 497 patients with medically refractory classical TN who were never previously treated by GKS and had a follow-up of at least 1 year. The median age in this series was 68.3 years (range 28.1-93.2 years). The median follow-up period was 43.8 months (range 12-174.4 months). Overall, 456 patients (91.75%) were initially pain free in a median time of 10 days (range 1-180 days). Their actuarial probabilities of remaining pain free without medication at 3, 5, 7, and 10 years were 71.8%, 64.9%, 59.7%, and 45.3%, respectively. One hundred fifty-seven patients (34.4%) who were initially pain free experienced at least 1 recurrence, with a median delay of onset of 24 months (range 0.6-150.1 months). However, the actuarial rate of maintaining pain relief without further surgery was 67.8% at 10 years. The hypesthesia actuarial rate at 5 years was 20.4% and at 7 years reached 21.1%, but remained stable until 14 years with a median delay of onset of 12 months (range 1-65 months). Very bothersome facial hypesthesia was reported in only 3 patients (0.6%). cONcluSiONS Retrogasserian GKS proved to be safe and effective in the long term and in a very large number of patients. Even if the probability of long-lasting effects may be modest compared with microvascular decompression, the rarity of complications prompts discussion of using GKS as the pragmatic surgical first- or second-intention alternative for classical TN. However, a randomized trial, or at least a case-matched control study, would be required to compare with microvascular decompression.http://thejns.org/doi/abs/10.3171/2015.2.JNS142144

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Section: Discussionmentioning

confidence: 99%

Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study

Régis

Tuleasca

Resseguier

et al. 2016

JNS

151

126

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“…There is no evidence in the literature to suggest increased major complication rates following MVD that are associated with increasing age. Previous studies have analyzed the results of MVD in elderly patients and demonstrated that the outcomes and morbidity rates are not related to age 2,5) . Broggi et al 5) , along with other physicians, consider MVD in the elderly to be easier and less time-consuming to accomplish than in younger patients, primarily due to brain atrophy and larger cisterns in the former, minimizing retractionrelated complications.…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies have analyzed the results of MVD in elderly patients and demonstrated that the outcomes and morbidity rates are not related to age 2,5) . Broggi et al 5) , along with other physicians, consider MVD in the elderly to be easier and less time-consuming to accomplish than in younger patients, primarily due to brain atrophy and larger cisterns in the former, minimizing retractionrelated complications. The routine application of neurophysiological monitoring, including brainstem auditory evoked potential and facial electromyography, also helps to control the retraction.…”

Section: Discussionmentioning

confidence: 99%

The Efficacy and Safety of Microvascular Decompression for Hemifacial Spasm in Elderly Patients

Jeon

Kong

Lee

et al. 2010

J Korean Neurosurg Soc

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Objective : The purpose of this study was to examine the efficacy and safety of microvascular decompression (MVD) for hemifacial spasm (HFS) in elderly patients. Methods : Between 1997 and June 2008, 1,174 patients had undergone MVD for HFS at our institute. Among these, 53 patients were older than 65 years. We retrospectively reviewed and compared the complication and the cure rates of these patients with those of younger patients. Results : There were 38 females and 15 males. The mean duration of symptoms of HFS of these patients was 94.6 months (range, 12-360 months), compared with 67.2 months (range, 3-360 months) in the younger group. The overall cure rate in elderly patients who underwent MVD for HFS during this period was 96.2%. Permanent cranial nerve dysfunctions, such as hearing loss and facial palsy, were seen in 2 patients (3.8%, 2/53) in the elderly group and 19 patients (1.7%, 19/1121) in the younger group. The difference in permanent cranial nerve dysfunction between the two groups was not statistically significant. There was no operative mortality in either group. Conclusion : Microvascular decompression is the most effective surgical modality available for the treatment of HFS. Results of this study indicate that such technique can be performed in the elderly without higher rates of morbidity or mortality. Any patient with HFS, whose general health is acceptable for undergoing general anesthesia, should be considered as a candidate for MVD.

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“…24 Also, MVD, which was previously contraindicated in patients with MS, has returned as a surgical option after recent evidence indicating the possible coexistence of vascular compression of the REZ concomitant with the presence of a demyelinating plaque. 7,13,17,19 Recurrence of symptoms varies widely. In patients with MS, the rate and frequency of recurrence is higher than in the general population with TN, with a more frequent need for repeated treatments.…”

Section: 15mentioning

confidence: 99%

Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis

Cheng¹,

Sanchez-Mejia²,

Limbo³

et al. 2005

FOC

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Object Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief. Methods Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V). Conclusions Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.

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Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis

Cited by 277 publications

References 42 publications

Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study

Long-term safety and efficacy of Gamma Knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study

The Efficacy and Safety of Microvascular Decompression for Hemifacial Spasm in Elderly Patients

Management of medically refractory trigeminal neuralgia in patients with multiple sclerosis

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