Surgical management of trigeminal neuralgia patients with recurrent or persistent pain despite three or more prior operations.

Abstract

To compare facial pain outcomes from different surgical techniques for patients with idiopathic trigeminal neuralgia (TN) who continue to have persistent or recurrent TN despite multiple operations. Review of a prospective surgical database identified 62 TN patients with ongoing facial pain despite having undergone three or more prior operations (mean = 3.4) from July 1999 to March 2008. The mean patient age was 66.5 years and the mean pain duration was 11.8 years. Twenty-six patients (42%) underwent 33 additional procedures during the follow-up period. In total, 95 operations were performed: posterior fossa exploration (PFE; n = 37, 39%), stereotactic radiosurgery (n = 31, 33%), glycerol rhizotomy (n = 18, 19%), and balloon compression (n = 9, 10%). Follow-up (median = 35 months; range = 1 day to 103 months) was censored at time of subsequent surgery, last patient contact, or death. Complete pain relief after surgery (no pain, no medications) was 66% at 1 year and 50% at 3 years. Patients having PFE had better facial pain outcomes (70% complete relief at 3 years) compared to other procedures (36% at 3 years) (hazard ratio = 2.6, 95% CI = 1.3-5.1, P < .01). No difference was noted between radiosurgery and the percutaneous techniques. Additional surgery was performed in 8 patients after PFE (22%) compared to 25 patients (48%) after radiosurgery (n = 16), glycerol rhizotomy (n = 7), or balloon compression (n = 2; P = .02). Although no procedure is best for all patients, PFE gives the operating surgeon the option of performing either a nondestructive (microvascular decompression) or destructive (partial sensory rhizotomy) procedure and is associated with better facial pain outcomes for this difficult patient group.