Microvascular Transposition Without Teflon: A Single Institution's 17-Year Experience Treating Trigeminal Neuralgia

Abstract

BACKGROUND Trigeminal neuralgia (TN) refractory to medical management is often treated with microvascular decompression (MVD) involving the intracranial placement of Teflon. The placement of Teflon is an effective treatment, but does apply distributed pressure to the nerve and has been associated with pain recurrence. OBJECTIVE To report the rate of postoperative pain recurrence in TN patients who underwent MVD surgery using a transposition technique with fibrin glue without Teflon. METHODS Patients were eligible for our study if they were diagnosed with TN, did not have multiple sclerosis, and had an offending vessel that was identified and transposed with fibrin glue at our institution. All eligible patients were given a follow-up survey. We used a Kaplan-Meier (KM) model to estimate overall pain recurrence. RESULTS A total of 102 patients met inclusion criteria, of which 85 (83%) responded to our survey. Overall, 76 (89.4%) participants responded as having no pain recurrence. Approximately 1-yr pain-free KM estimates were 94.1% (n = 83), 5-yr pain-free KM estimates were 94.1% (n = 53), and 10-yr pain-free KM estimates were 83.0% (n = 23). CONCLUSION Treatment for TN with an MVD transposition technique using fibrin glue may avoid some cases of pain recurrence. The percentage of patients in our cohort who remained pain free at a maximum of 17 yr follow-up is on the high end of pain-free rates reported by MVD studies using Teflon. These results indicate that a transposition technique that emphasizes removing any compression near the trigeminal nerve root provides long-term pain-free rates for patients with TN.

Surgical Treatment for Trigeminal Neuralgia

“…Recently, several studies have suggested that the offending vessel should be removed reliably and thoroughly from the neurovascular compression site rather than inserting a decompression material between the culprit vessel and trigeminal nerve ( Fig. 2 ) [ 12 , 35 , 37 , 48 , 67 ]. This method, first proposed by Fukushima [ 22 ], completely separates the trigeminal nerve and the offending vessel.…”

Trigeminal Nerve Isolation Application in Microvascular Decompression for Treating Trigeminal Neuralgia: A Retrospective Study

“…Indeed, a tentorial sling technique was proposed a few years ago, which aimed to generate offending vessel transposition without the use of foreign materials 7 . Other techniques have also been used, including using biological glue 8 or a vascular clip 9 . Moreover, several doctors claim that the cranial nerve V could be split into 6 to 8 bundles longitudinally by its fibers, which requires lower rates of pain relief, and recurrence are lower than CMVD technique.…”

Commentary: Microvascular Decompression for Treatment of Simultaneous Arterial and Venous Conflict Causing Trigeminal Neuralgia: 2-Dimensional Operative Video

“…In most cases, we prefer to perform a "Teflon-free MVD" using fibrin glue to attach the superior cerebellar artery to the tentorium, as well as a fenestrated clip and/or sling in selected cases. 12,13 This technique does require additional distal dissection of the superior cerebellar artery to allow for atraumatic mobilization of the artery to the tentorial surface. Our team has observed that 89.3% of patients who have undergone transposition of the superior cerebellar artery with fibrin glue remain pain free at 3 to 17 years of follow-up.…”

“…Our team has observed that 89.3% of patients who have undergone transposition of the superior cerebellar artery with fibrin glue remain pain free at 3 to 17 years of follow-up. 13 This technique also eliminates Teflon-associated granuloma formation and gliosis. 14 During microvascular decompression of the trigeminal nerve, it can be more difficult to mobilize a vein than an artery based on their anatomy.…”

“…Our team has observed that 89.3% of patients who have undergone transposition of the superior cerebellar artery with fibrin glue remain pain free at 3 to 17 years of follow-up. 13 This technique also eliminates Teflon-associated granuloma formation and gliosis. 14…”