A recent Cochrane systematic review of surgical interventions for trigeminal neuralgia found not a single trial of what is becoming the most popular surgical intervention, namely microvascular decompression (MVD). With an increasing number of anticonvulsant drugs it is likely that patients may not be offered a surgical option for management of their trigeminal neuralgia for many years.
Current studies repeat much of what is already in the literature but there is an increasing appreciation of the value of preoperative imaging and the need to be more precise with the diagnosis. The search for prognosticators for good outcomes continues to dominate the literature.
Microvascular decompression in correctly diagnosed patients is probably the most effective therapy. However, high-quality prospective studies of MVD in a population that has been well phenotyped and which is assessed pre and postoperatively using psychometrically tested questions, administered at regular intervals by independent observers, are needed to provide clear evidence of its superiority over medical therapies.
"Oesman and Mooij  also reported good results of microvascular decompression, and that immediate resolution of symptoms postoperatively was the most important predictor of long-term relief of pain. Despite the encouraging results of individual studies, a recent Cochrane systematic review by Zakrzewska and Coakham  found that although microvascular decompression is likely the most effective therapy in correctly diagnosed patients, high-quality prospective studies are lacking. "
[Show abstract][Hide abstract] ABSTRACT: Whether arterial or venous compression or arachnoid adhesions are primarily responsible for compression of the trigeminal nerve in patients with trigeminal neuralgia is unclear. The aim of this study was to determine the causes of trigeminal nerve compression in patients with trigeminal neuralgia. The surgical findings in patients with trigeminal neuralgia who were treated by micro vascular decompression were compared to those in patients with hemifacial spasm without any signs or symptoms of trigeminal neuralgia who were treated with microvascular decompression. The study included 99 patients with trigeminal neuralgia (median age, 57 years) and 101 patients with hemifacial spasm (median age, 47 years). There were significant differences between the groups in the relationship of artery to nerve (p < 0.001) and the presence of arachnoid adhesions (p < 0.001) but no significant difference in relationship of vein to nerve. After adjustment for age, gender, and other factors, patients with vein compression of nerve or with artery compression of nerve were more likely to have trigeminal neuralgia (OR = 5.21 and 42.54, p = 0.026 and p < 0.001, respectively). Patients with arachnoid adhesions were less likely to have trigeminal neuralgia (OR = 0.15, p = 0.038). Arterial compression of the trigeminal nerve is the primary cause of trigeminal neuralgia and therefore, decompression of veins need not be a priority when performing microvascular dissection in patients with trigeminal neuralgia.
"There are very few RCTs of surgical treatments  and evidence is based mainly on cohort data [78,79]. Microvascular decompression is the only procedure that is non-destructive and gives the longest pain free interval 70% pain free at 10 years . For patients not suitable for this procedure ablative procedures include radiofrequency thermocoagulation glycerol rhizotomy, balloon compression or Gamma knife and these give 50% pain relief for four years but patients risk sensory changes which impact on quality of life [78,79]. "
[Show abstract][Hide abstract] ABSTRACT: Orofacial pain in its broadest definition can affect up to 7% of the population. Its diagnosis and initial management falls between dentists and doctors and in the secondary care sector among pain physicians, headache neurologists and oral physicians. Chronic facial pain is a long term condition and like all other chronic pain is associated with numerous co-morbidities and treatment outcomes are often related to the presenting co-morbidities such as depression, anxiety, catastrophising and presence of other chronic pain which must be addressed as part of management . The majority of orofacial pain is continuous so a history of episodic pain narrows down the differentials. There are specific oral conditions that rarely present extra orally such as atypical odontalgia and burning mouth syndrome whereas others will present in both areas. Musculoskeletal pain related to the muscles of mastication is very common and may also be associated with disc problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are specific diagnosis with defined care pathways. Other trigeminal neuropathic pain which can be associated with neuropathy is caused most frequently by trauma but secondary causes such as malignancy, infection and auto-immune causes need to be considered. Management is along the lines of other neuropathic pain using accepted pharmacotherapy with psychological support. If no other diagnostic criteria are fulfilled than a diagnosis of chronic or persistent idiopathic facial pain is made and often a combination of antidepressants and cognitive behaviour therapy is effective. Facial pain patients should be managed by a multidisciplinary team.
The Journal of Headache and Pain 04/2013; 14(1):37. DOI:10.1186/1129-2377-14-37 · 2.80 Impact Factor
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