Surgery for Tic Douloureux
[Show abstract] [Hide abstract] ABSTRACT: OBJECTIVE: Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of trigeminal nerve. The majority of these patients eventually requires surgical management to achieve remission of symptoms. Microvascular decompression addresses the root cause of the disease and is more effective than ablative procedures at preventing recurrence of symptoms. However, several long-term follow-up studies have disclosed that the efficacy of the procedure gradually decreases over time and have related recurrence to some clinical variables. Our objective is to study the impact of the type of interposing materials used for decompression on long-term success rate. MATERIALS and METHODS: We conducted a retrospective chart review of 65 patients with trigeminal neuralgia operated between 2007 and 2010 in an otology/base of skull tertiary referral center. Endoscopy-assisted microvascular decompression was used for all patients. Three types of interposing material were used: Teflon in 30 patients (Group I); muscle in 19 patients (Group II); and a combination of both in 16 patients (Group III). The minimum follow-up period was 3 years. RESULTS: In total, 17 (26.1%) of the 65 patients had recurrence of their symptoms. Average time for recurrence was 7.82+/-4.31 months; 95% of recurrences appeared within the first year. Recurrence rate was lower in Group II (5.2%) as compared to Group I (40%) and Group III (23%), and the difference was statistically significant (p <= 0.05). CONCLUSION: Microvascular decompression with interposition of a muscle pad carries a lower recurrence rate as compared to interposition of Teflon alone or in combination with muscle.
- "Nevertheless, Teflon is not such an inert material as presumed initially , and a neural tissue reaction to Teflon has recently been reported to be the cause of recurrent TN. Several reports of either Teflon felt fibrotic adhesion or Teflon-induced granuloma have increased in number [4, 26, 28, 29, 34, 52] . In three studies, histopathological examination of neural reaction to Teflon revealed microfragments of the Teflon felt surrounded by giant cells resembling a foreign body granuloma formation [26, 29, 53] . "
[Show abstract] [Hide abstract] ABSTRACT: Trigeminal neuralgia secondary to a posterior fossa AVM has been seldom reported in the literature. Most of the cases have been published on a case report basis, and there is not a general agreement about the best way of treatment. In this work, we analyze our experience with 5 cases of TN secondary to a posterior fossa AVM, treated at the Division of Neurosurgery from the National Institute of Neurology and Neurosurgery, "Manuel Velasco Suarez," Mexico City, Mexico, from January 1985 to December 2004. Trigeminal neuralgia associated with an AVM occurred in 1.3% of 375 brain AVMs and 9.8% of 37 posterior fossa AVMs. All had received drug therapy unsuccessfully, and 2 of them underwent a percutaneous thermocoagulation without solving the neuralgia. In 4 patients, a microvascular decompression was completed with excellent results. Even when different ways of treatment have been reported, it seems that percutaneous procedures (glycerol injection, thermocoagulation, or microcompression of the gasserian ganglia) give variable clinical results. The reported experience and our own results support the microvascular decompression of the trigeminal nerve as the best treatment whenever the total excision of the AVM cannot be accomplished.
- "In the same way as occurs with the typical TN, some factors should coexist to develop a tic douloureux. Perhaps, the most important is not only the presence of an AVM around or even inside the trigeminal nerve , but rather the compression of the trigeminal nerve at the REZ [1,12]. In this sense, the evidence points that the excision of an AVM without decompressing the REZ of the trigeminal nerve may perpetuate the neuralgia, but decompression of the REZ even without excision of the AVM (as occurred in most patients of our series) may be enough to solve the neuralgia . "
[Show abstract] [Hide abstract] ABSTRACT: There are few reports on the outcome of surgical treatment of TGN without vascular compression. Between 1984 and 2004, 668 patients underwent MVD for TGN. In 21 patients (3.1%), vascular compression was absent. The surgical strategy in these cases involved the following: (1) dissection and exposure of the entire trigeminal nerve root; (2) slight neurapraxia with bipolar tips at the trigeminal nerve root; and (3) isolation of trigeminal nerve with Teflon sponge fragments. The patients' (female/male, 20:1) ages ranged from 33 to 77 years. Their right side was the most frequently involved (61.9%). Their mean duration of pain before treatment was 7.6 years (range = 1-20 years). At surgical exploration, vascular compression or anatomical abnormalities were absent in 15 patients (71.4%), arachnoidal thickening was present in 5 (23.8%), and fiber dissociation of the trigeminal nerve was present in 1 (4.8%). Mean follow-up after surgery was 17.7 months (range = 4-65 months). Immediate relief from pain occurred in all 21 patients. On Kaplan-Meier analysis, recurrence was maintained at 14.8% for 12, 24, and 36 months, increasing to 43.2% at 48 months. Permanent hypoesthesia was present in 6 patients (28.6%), whereas loss of corneal reflex was observed transiently in 1 (4.8%). Motor function of the trigeminal nerve was intact in all patients. No other complication was found. The proposed surgical plan of standard MVD plus slight trigeminal nerve root neurapraxia is a safe and effective management option for TGN without vascular compression.
- "With such a mild surgical trauma, an early relapse of pain and a relatively high recurrence rate would be expected. Based on our experience in the treatment of TGN with radiofrequency-controlled thermocoagulation, it is found that the more dense the facial numbness created (with higher temperature or longer duration of lesion making), the longer the pain relief and the lesser the recurrence rate   . "
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