Characteristics and treatment of Multiple Sclerosis-related trigeminal neuralgia: An Italian multi-centre study.

BACKGROUND: The prevalence of trigeminal neuralgia (TN) in Multiple Sclerosis (MS) patients is higher than in the general population and its management can be particularly challenging. Our aim is to describe the characteristics, treatment and prognostic factors of MS-related TN in a retrospective multicentre study. METHODS: Neurologists members of the RIREMS group (Rising Researchers in MS) enrolled MS patients with a TN diagnosis and filled out a spreadsheet comprising their clinical data. RESULTS: Population consisted of 298 patients. First-choice preventive treatments were carbamazepine and oxcarbazepine. A surgical procedure was performed in 81 (30%) patients, most commonly gamma knife stereotactic radiosurgery (37%), followed by microvascular decompression (22%) and radiofrequency thermocoagulation (21%); one third of patients underwent at least two procedures. Surgery was associated with higher disability, male sex and longer interval between MS and TN onset. Patients (77%) who stayed on at least one preventive medication at most recent follow-up, after a mean period of 8 years, had a higher disability compared to the untreated group. Furthermore, patients with higher disability at TN onset were less likely to discontinue their first preventive medication due to pain remission, had bilateral TN more frequently and underwent surgical interventions earlier. CONCLUSION: MS patients with a higher disability at TN onset and with a longer interval between MS and TN onset had differing clinical features and outcomes: pain was more frequently bilateral, surgery was more frequent and anticipated, and preventive medication discontinuation due to pain remission was less common.

Long-term pain relief at five years after medical, repeat surgical procedures or no management for recurrence of trigeminal neuralgia after microvascular decompression: analysis of a historical cohort.

BACKGROUND: Management strategies for the recurrence of trigeminal neuralgia after microvascular decompression include repeat procedures, medical management or no further therapy. No consensus exists as to which strategy is best for pain relief. The aim of this study was to determine the characteristics of patients with recurrences after microvascular decompression in the cohort, and to compare long-term pain relief between different management strategies. MATERIALS AND METHODS: A historical cohort of patients who underwent microvascular decompression at a neurosurgical institution between 1982-2002, followed up by postal survey at five years, was included. Characteristics of patients who experienced a recurrence were compared to those who were recurrence free, and pain relief was compared between each management strategy. RESULTS: From 169 responders who were included in the study, 28 (16.6%) experienced a recurrence after MVD. No characteristics were significantly different between patients who experienced a recurrence and those who did not. Repeat procedures, including repeat microvascular decompression, partial sensory rhizotomy or radiofrequency thermocoagulation, yielded the highest proportion of pain relief after recurrence (p = 0.031), with 63.6% of patients pain-free at five-years. There was no evidence to suggest that the choice of repeat procedure influenced the likelihood of pain relief after recurrence. No further treatment yielded 57.1% pain-free, whereas medical therapy had the lowest proportion of pain-free patients, at 10.0%. CONCLUSION: A variety of options are available to patients for recurrence of TN after microvascular decompression with repeat procedures yielding the greatest likelihood of long-term pain relief in this historical cohort. The choice of management should consider the mechanism of recurrence, the benefits and risks of each option and the severity of the pain. Regardless of the management strategy selected, careful phenotyping of patients before and after surgery is paramount.

Nationwide Shift From Percutaneous Rhizotomy to Microvascular Decompression for Treatment of Trigeminal and Other Cranial Nerve Neuralgias.

OBJECTIVE: The aim of this study was to report the trends in the use of common surgical interventions over the past decade to treat cranial nerve neuralgias. METHODS: The Centers for Medicare and Medicaid Services Part B National Summary Data File from 2000 to 2016 were studied. RESULTS: A total of 57.1 million persons were enrolled in 2016, up from 39.6 million persons in 2000. Suboccipital craniectomy done for cranial nerve decompressions (including cranial nerves V, VII, and IX) increased by 33.9 cases per year so that in 2016 the number of cases was 167% of what it was 17 years earlier (ie, from 655 cases in 2000 to 1096 cases in 2016). The less commonly used subtemporal approach craniectomy to treat trigeminal neuralgia (TN) increased by 1.13 cases per year (ie, from 25 cases in 2000 to 46 cases in 2016). The less invasive percutaneous rhizotomy procedures, including glycerol and radiofrequency ablation, for treatment of TN decreased by 42.9 cases per year (64%; ie, from 2578 cases in 2000 to 1206 cases in 2016). CONCLUSIONS: Overall trends show increased use of open surgery and decreased use of percutaneous rhizotomy, including destruction of the trigeminal nerve using balloon compression, glycerol injection, or thermal injury. These trends may be related to differences in outcomes between treatment modalities.

The Effect of Microvascular Decompression on Hemifacial Spasm With Atherosclerosis of Vertebral Artery.

BACKGROUND: Microvascular decompression (MVD) is the most useful treatment for hemifacial spasm (HFS). In patients of vertebral artery (VA) compression of the facial nerve, MVD is often difficult. Many of the VA are obviously atherosclerotic. In this study, the authors retrospectively compared the effect of MVD for HFS associated with the atherosclerosis of vertebral artery (aVA) with that of MVD for HFS with normal vertebral artery (nVA). METHODS: A retrospective study of HFS treated by MVD was conducted between January 2014 and October 2015. There were 186 patients with VA-associated HFS who underwent their first MVD at the authors' institution. Among them, 52 patients of HFS were associated with aVA and 134 patients were associated with nVA. RESULTS: At 1 day, 7 days, 1 month, 3 months, and 1 year after MVD surgery, in aVA group, the effective rate of MVD was 80.77%, 80.77%, 82.00%, 79.59%, and 82.61%, the incidence rate of complication was 15.83%, 13.46%, 14.00%, 12.24%, and 10.87%; in nVA group, the effective rate of operation was 94.03%, 94.78%, 95.42%, 94.53%, and 95.12% (P < 0.05), the incidence rate of complication was 4.48%, 4.48%, 3.82%, 3.13%, and 1.63% (P < 0.05). CONCLUSION: When the HFS was associated with the aVA, the effective rate of MVD was lower and the incidence of complication was higher than those associated with nVA. In MVD of HFS associated with aVA, the full decompression of the facial nerve and the minimal traction of surrounding tissue in the operation are the key to the success of MVD.

Outcome of Biomedical Glue Sling Technique in Microvascular Decompression for Hemifacial Spasm Involving the Vertebral Artery.

BACKGROUND: Microvascular decompression (MVD) is the most useful treatment for hemifacial spasm (HFS). In cases of vertebral artery (VA) compression of the facial nerve, MVD is often difficult. In this study, we compared the outcome of the biomedical glue sling technique with the traditional technique in MVD for HFS involving the VA. METHODS: A retrospective study of patients with HFS treated by MVD was conducted between January 2013 and December 2015. A total of 327 patients with VA-associated HFS underwent their first MVD at our institution. Among them, the traditional technique was performed in 153 patients and the biomedical glue sling technique was performed in 174 patients. We measured effectiveness at 1 day, 7 days, 1 month, 3 months, and 1 year after MVD surgery. RESULTS: In the traditional technique group, the effective rates of MVD were 89.54%, 88.89%, 89.40%, 88.44%, and 86.71%, and the incidence rates of complication were 5.23%, 4.58%, 3.97%, 2.72%, and 0.70%. In the biomedical glue sling technique group, the effective rates of operation were 96.55%, 96.55%, 97.66%, 95.86%, and 95.76% (P < 0.05), and the incidence rates of complication were 8.62%, 8.62%, 7.60%, 4.73%, and 2.42% (P > 0.05). CONCLUSION: When the HFS were associated with the VA, the effective rate of biomedical glue sling technique of MVD was higher than the traditional technique, and there was no statistical difference between the 2 groups about the incidence of complication.

The Current Status of Microvascular Decompression for the Treatment of Hemifacial Spasm in Japan: An Analysis of 2907 Patients Using the Japanese Diagnosis Procedure Combination Database.

Microvascular decompression (MVD) is widely used as a safe and effective treatment for hemifacial spasm (HFS). However, the extent of application of this therapeutic method and its outcomes in Japan are currently unclear. To address these questions, we analyzed the utilization of MVD for the treatment of HFS during the 33- month period from July 2010 to March 2013. We conducted an analysis on data contained in the Diagnosis Procedure Combination database in Japan. This analysis showed that MVD was used for the treatment of HFS in 2907 cases (men, 916; women, 1991) with 2.2 times more women treated than men. MVD for HFS was most frequently performed in women aged 50 to 69 years; however, most men were aged between 40 and 59 years at the time of the procedure. The numbers of procedures performed per 100,000 population/year were 0.83 overall in Japan, with the numbers larger in prefectures with larger populations. Regarding discharge outcomes, the mortality rate was 0.1%. The mean length of hospital stay in patients undergoing MVD for HFS was 14.7 days. This analysis provides preliminary information regarding the trends in the performance of MVD for the treatment of HFS in Japan. Further studies on other registries that contain data obtained by standardized assessment methods and that include long-term outcomes and postoperative complications are required.

Options in treating trigeminal neuralgia: Experience with 195 patients.

OBJECTIVE: For patients with medically unresponsive trigeminal neuralgia (TN), surgical options include microvascular decompression (MVD), radiofrequency rhizotomy (RF), and stereotactic radiosurgery (SRS). In an attempt to identify the risks and benefits and cost inherent with each of the three modalities, we performed a retrospective review of our experience with 195 cases of TN treated over the past 15 years. METHODS: Since 2001, 195 patients with previously untreated TN were managed: with MVD in 79, RF in 36, and SRS in 80. All patients reported herein underwent preoperative MRI. Women outnumbered men 122/73 (p=0.045). Follow-up after surgery was 32±46months. RESULTS: The patients qualifying for MVD were generally healthier and younger, with a mean age±SD of 57±14, compared to those undergoing RF (75±15) or SRS (73±13, p<0.0001). In case of relapse, medical treatment was always tried and failed prior to consideration of surgical intervention. A second surgical procedure was necessary in 2, 23, and 18 patients initially treated with MVD, RF, and SRS respectively (p<0.0001). In the patients treated with MVD, RF, and SRS, the average number of procedures per patient necessary to achieve pain control was 1.1, 2.0, and 1.3 respectively (p=0.001). There were 7 complications in the patients treated with MVD but no deaths. Numbness was present in 13, 18, and 29 patients treated with MVD, RF, and SRS respectively (p=0.008). CONCLUSION: MVD for TN is the treatment least likely to fail or require additional treatment. Patients who underwent MVD were younger than those undergoing RF or SRS. The highest rate of recurrence of TN was encountered in patients undergoing RF (64%). Facial numbness was least likely to occur with MVD (16%) compared to RF and SRS (50% and 36% respectively).

Microvascular decompression for elderly patients with trigeminal neuralgia.

Microvascular decompression (MVD) has been demonstrated to be an excellent surgical treatment approach in younger patients with trigeminal neuralgia (TN). However, it is not clear whether there are additional morbidity and mortality risks for MVD in the elderly population. We performed a systematic literature review using six electronic databases for studies that compared outcomes for MVD for TN in elderly (cut-off ⩾60, 65, 70years) versus younger populations. Outcomes examined included success rate, deaths, strokes, thromboembolism, meningitis, cranial nerve deficits and cerebrospinal fluid leaks. There were 1524 patients in the elderly cohort and 3488 patients in the younger cohort. There was no significant difference in success rates in elderly versus younger patients (87.5% versus 84.8%; P=0.47). However, recurrence rates were lower in the elderly (11.9% versus 15.6%; P=0.03). The number of deaths in the elderly cohort was higher (0.9% versus 0.1%; P=0.003). Rates of stroke (2.5% versus 1%) and thromboembolism (1.1% versus 0%) were also higher for elderly TN patients. No differences were found for rates of meningitis, cranial nerve deficits or cerebrospinal fluid leak. MVD remains an effective and reasonable strategy in the elderly population. There is evidence to suggest that rates of complications such as death, stroke, and thromboembolism may be significantly higher in the elderly population. The presented results may be useful in the decision-making process for MVD in elderly patients with TN.