Treatment of recurrent trigeminal neuralgia due to Teflon granuloma

Abstract

Recurrent trigeminal neuralgia after microvascular decompression (MVD) may be due to insufficient decompression, dislocation of the implant to pad the neurovascular contact, or the development of granuloma. Here, we report on our experience with Teflon granuloma including its treatment and histopathological examination. In a series of 200 patients with trigeminal neuralgia MVD was performed with Teflon felt according to Jannetta’s technique. In three patients with recurrent facial pain Teflon granuloma was found to be the cause for recurrence. In each instance, the granuloma was removed for histopathological examination. Mean age at the first procedure was 62.3 years and at the second procedure 66.3 years. Recurrence of pain occurred between 1 and 8.5 years after the first procedure. MRI scans demonstrated local gadolineum enhancement in the cerebellopontine angle, and CT scans showed local calcification. Intraoperatively dense fibrous tissue was found at the site of the Teflon granuloma. Histopathological examination revealed foreign body granuloma with multinuclear giant cells, collagen-rich hyalinized scar tissue, focal hemosiderin depositions, and microcalcifications. The Teflon granuloma was completely removed, and a new Teflon felt was used for re-decompression. Patients were free of pain after the second procedure at a mean of 40.3 months of follow-up. Teflon granuloma is a rare cause for recurrent facial pain after MVD. Small bleeding into the Teflon felt at surgery might trigger its development. A feasible treatment option is surgical re-exploration, nerve preserving removal of the granuloma, and repeat MVD.

Teflon granulomas mimicking cerebellopontine angle tumors following microvascular decompression

“…Aseptic meningitis, brain abscess, and intracranial cysts leading to neurologic deficits have been described in isolated cases . TG may grow and become symptomatic at variable intervals, ranging from within 1 month to over 8 years following primary surgery . Our cases reflect this variable and potentially protracted natural history, as one patient developed symptoms within 1 year, whereas the other remained asymptomatic for 9 years after the initial operation.…”

“…TGs characteristically adhere to nerves (as seen in Fig. A), vessels, and the brainstem, and may exert mass effect as they grow, precipitating recurrent facial pain, new‐onset facial numbness, facial paralysis, or hearing loss . Aseptic meningitis, brain abscess, and intracranial cysts leading to neurologic deficits have been described in isolated cases .…”

“…Prevention of TG via surgical technique modification is unproven, but previous authors have recommended limiting contact between Teflon with the tentorium or dura, as well as restricting pledget positioning such that the Teflon is completely contained within the cisterns . Minimizing the volume of Teflon implanted and maintaining a hemostatic surgical field may also lower the incidence of this rare complication …”

A Clinical Analysis of Secondary Surgery in Trigeminal Neuralgia Patients Who Failed Prior Treatment

“…Unfortunately, despite surgical intervention, some patients still have recurrent symptoms, with an annual recurrence risk of 1–4%291430). Although neurodestructive procedures such as glycerol injection provide short-term relief, their long-term results are unsatisfactory; only 40–50% are successful1738).…”

MR Imaging of Teflon Induced Granuloma as a Cause of Recurrent Trigeminal Neuralgia Following Microvascular Decompression

“…Vascular compression of TGN at its root entry zone (REZ) which was first recognised as a cause of TN by Jannetta in 1967 and found in 80-90% of patients TN [1,2]. Microvascular decompression (MVD) is considered to be the effective and relatively safe surgery in which a piece of polytetrafluoroethylene (PTFE) is usually placed between the trigeminal nerve and the culprit blood vessel.…”