Prospective comparison of posterior fossa exploration and stereotactic radiosurgery dorsal root entry zone target as primary surgery for patients with idiopathic trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) is the most common facial pain syndrome, with an incidence of approximately 27 per 100,000 patient-years. OBJECTIVE: To prospectively compare facial pain outcomes for patients having either a posterior fossa exploration (PFE) or stereotactic radiosurgery (SRS) as their first surgery for idiopathic TN. METHODS: Prospective cohort study of 140 patients with idiopathic TN who had either PFE (n = 91) or SRS (n = 49) from June 2001 until September 2007. The groups were similar with regard to sex, pain location, and pain duration. Patients who had SRS were older (67.1 vs 58.2 years; P < .001). The median follow-up after surgery was 38 months. RESULTS: Patients who had PFE more commonly were pain free off medications (84% at 1 year, 77% at 4 years) compared with the SRS patients (66% at 1 year, 56% at 4 years; hazard ratio = 2.5; 95% confidence interval, 1.4-4.6; P = .003). Additional surgery for persistent or recurrent face pain was performed in 14 patients after PFE (15%) compared with 17 patients after SRS (35%; P = .009). Nonbothersome facial numbness occurred more frequently in the SRS group (33% vs 18%; P = .04). No difference was noted in other complications between patients who had PFE (12%) (dysesthetic facial pain, n = 3; cerebrospinal fluid leakage, n = 3; hearing loss, n = 2; wound infection, n = 1; pneumonia, n = 1; deep vein thrombosis, n = 1) and patients who had SRS (8%) (dysesthetic facial pain, n = 4; P = .47). CONCLUSION: PFE is more effective than SRS as a primary surgical option for patients with idiopathic TN.

Natural history of tethered cord in patients with meningomyelocele.

OBJECTIVE: The purpose of this study was to describe the natural history of tethered cord in patients who have undergone meningomyelocele repair. METHODS: We performed a retrospective review of 45 patients with a history of neonatal meningomyelocele repair who subsequently developed symptoms of tethered cord. Symptoms of tethered cord in this cohort consisted of the development of bladder spasticity or orthopedic foot deformity. None of these patients were treated with cord untethering; instead, they were treated symptomatically. RESULTS: On follow-up, 40 (88.9%) of these patients subsequently required additional orthopedic or urological procedures because of further symptoms of tethered cord. The incidence of progression of tethered cord syndrome is 27.5, 40, and 60% at 1, 2, and 5 years, respectively. CONCLUSION: Although this study does not address the question whether cord untethering will prevent further symptom development, these results do provide a strong rationale for consideration of an untethering procedure in patients with repaired meningomyelocele at the time of the onset of symptoms of tethered cord.