Acupuncture in the management of trigeminal neuralgia.

BACKGROUND: We aimed to assess the standing of acupuncture as a clinical tool in the management of trigeminal neuralgia against the current first-line drug treatment (carbamazepine) and the most effective surgery (microvascular decompression (MVD)). METHODS: Data regarding efficacy, side effects and cost were compiled for each of these three modalities from the PubMed and Cochrane Library databases. Patient stress was estimated according to Holmes and Rahe's Social Readjustment Rating Scale (SRRS). RESULTS: Acupuncture was not significantly more effective than its corresponding control (p = 0.088), but had the greatest efficacy (mean ± 95% confidence interval) of the modalities considered (86.5% ± 5.6% compared to surgery (79.3% ± 7.7%) and pharmacotherapy (71.7% ± 2.5%), respectively). Acupuncture also had fewer mean reported side effects (22.7% ± 5.9%) compared with surgery (25.3% ± 12.6%) and pharmacotherapy (88.8% ± 25.0%), and the lowest cost; after 5 years, the cost of acupuncture was estimated to be £750, compared to £1507.73 for carbamazepine and £4878.42 for MVD. Acupuncture was the least stressful according to the SRRS (53 points), whereas surgery was second most stressful (153 points) and pharmacotherapy was the most stressful intervention to patients (217 points). CONCLUSION: Acupuncture appears more effective than pharmacotherapy or surgery. Statistical analysis of side effects was not possible due to inconsistent reporting protocols, but the data suggest that acupuncture is considerably safer than pharmacotherapy or surgery. Acupuncture also appears to be the least expensive therapeutic modality to deliver long-term (65 weeks onwards), and our analysis indicated that it was less stressful to patients than pharmacotherapy or surgery. Further study into these areas and the practicality of its availability in the UK National Health Service (NHS) and other health systems is recommended.

Burden of illness of trigeminal neuralgia among patients managed in a specialist center in England.

BACKGROUND: Trigeminal neuralgia (TN) causes severe episodic, unilateral facial pain and is initially treated with antiepileptic medications. For patients not responding or intolerant to medications, surgery is an option. METHODS: In order to expand understanding of the pain-related burden of illness associated with TN, a cross-sectional survey was conducted of patients at a specialist center that utilizes a multidisciplinary care pathway. Participants provided information regarding their pain experience and treatment history, and completed several patient-reported outcome (PRO) measures. RESULTS: Of 129 respondents, 69/128 (54%; 1 missing) reported no pain in the past 4 weeks. However, 84 (65%) respondents were on medications, including 49 (38%) on monotherapy and 35 (27%) on polytherapy. A proportion of patients had discontinued at least one medication in the past, mostly due to lack of efficacy (n = 62, 48%) and side effects (n = 51, 40%). A total of 52 (40%) patients had undergone surgery, of whom 30 had microvascular decompression (MVD). Although surgery, especially MVD, provided satisfactory pain control in many patients, 29% of post-surgical patients reported complications, 19% had pain worsen or stay the same, 48% were still taking pain medications for TN, and 33% reported new and different facial pain. CONCLUSIONS: In most PRO measures, respondents with current pain interference had poorer scores than those without pain interference. In the Patient Global Impression of Change, 79% expressed improvement since beginning of treatment at this clinic. These results indicate that while the multidisciplinary approach can substantially alleviate the impact of TN, there remains an unmet medical need for additional treatment options.

Comparing Microvascular Decompression with Gamma Knife Radiosurgery for Trigeminal Neuralgia. A Cost-Effectiveness Analysis.

BACKGROUND AND OBJECTIVE: Both microvascular decompression (MVD) and Gamma Knife radiosurgery (GKRS) are time-tested treatment modalities for trigeminal neuralgia (TN). There is little evidence in the literature studying these modalities head to head in a cost-effectiveness comparison. OBJECTIVE: To evaluate the cost-effectiveness of MVD compared with GKRS for treating patients with TN. METHODS: We developed a Markov cost-effectiveness model for the U.S. health care system to account for all costs related to MVD and GKRS as treatment modalities for TN, from the health care system perspective, over a patient lifetime horizon. A base case was estimated using data from previous studies, from our own GKRS experience, and from a current data analysis of patients undergoing MVD. We derived model inputs, including health care costs, survival, and utility estimates, from the literature. We used age-specific, sex-specific, and race-specific mortality from national registries. Costs studied included those for MVD, for GKRS, for treating complications from either procedure, and for medications throughout patient lifetimes. We performed multiple 1-way, 2-way, and probabilistic sensitivity analyses to confirm the robustness of model assumptions and results. The incremental cost-effectiveness ratio (ICER), with a threshold of $50,000 per quality-adjusted life-year (QALY) gained, defined cost-effectiveness. RESULTS: The base case had an ICER of $12,154 per QALY for MVD compared with GKRS. Probabilistic sensitivity (Monte Carlo) analysis showed that MVD was cost-effective in 70% of model iterations. GKRS was favored when the willingness to pay threshold was <$12,000 per QALY gained. CONCLUSIONS: In patients medically eligible for either procedure, we found MVD to be the most cost-effective modality to treat TN, primarily because of its reported greater durability. MVD remained the most cost-effective strategy across a broad range of model input values in sensitivity analyses.

Stereotactic radio surgery and radio frequency rhizotomy for trigeminal neuralgia in multiple sclerosis: A single institution experience.

OBJECTIVES: For patients with medically unresponsive trigeminal neuralgia (TN), surgical options include micro vascular decompression (MVD), radiofrequency rhizotomy (RF), and stereotactic radio surgery (SRS). Multiple sclerosis (MS) is a demyelinating condition that can be associated with TN, but is not amenable to treatment with MVD. We sought to identify the outcome differences of patients with TN in MS undergoing SRS or RFR in an attempt to identify factors that may influence outcomes. We also evaluated cost outcomes, both initially and over time, based on the index procedure. We performed a retrospective review of our experience with 17 cases. PATIENTS AND METHODS: A single institution retrospective chart review was performed. Since 1997, 17 patients with TN and MS have been treated at our institution. All patients underwent a preoperative MRI to rule out a compressive lesion. Patients either underwent SRS (n=7) or RFR (n=10) as their index procedure and were evaluated as a group based on this first procedure. Outcome measures included preoperative Expand Disability Status Score (EDSS) scores, pre- and postoperative facial pain and medication use, post-intervention facial numbness, need for subsequent procedures, and duration of follow-up. Charges for the index procedure, subsequent interventions, and total costs were tabulated and analyzed in 2017 US dollars, adjusting for inflation. RESULTS: The median age of patients at first operation in each group was 58.5±10.9 and 63.5±7.5 for SRS and RFR respectively. There were no significant differences in basic demographics. Overall, 71% of these patients had an excellent or good initial pain outcome. Over time, 60% of RFR and 29% of SRS patients required additional procedures to obtain satisfactory pain relief. The patients who underwent RFR as their index procedure required a significantly higher number of procedures to achieve adequate pain relief (RFR=2.7 vs SRS=2.0 [p=0.04]). The average index procedure costs in US dollars were significantly different (SRS=53,300±5257 vs RFR=12,315±3387). The average subsequent costs (costs incurred following the initial intervention) (SRS=8320±17,842, RFR=36,002±46,767) and total costs (SRS=61,620±16,087, RFR=48,317±48,475) were not statistically significantly different. CONCLUSION: TN in the setting of MS is highly difficult to treat medically with SRS and RFR being offered as options for these patients. Both can provide good initial pain relief. For patients who have RFR as their initial procedure, a larger number of procedures are required for relief compared to patients who initially underwent SRS. While there is a significant difference in the cost of the initial procedure, over time, with the cost of required subsequent interventions, there is no significant difference in total costs between the two groups.

The cost-effectiveness of surgery for trigeminal neuralgia in surgically naïve patients: a retrospective study.

OBJECTIVE: For 75% of patients with trigeminal neuralgia (TN), the pain can be controlled with medication. For those who fail medication therapy, surgical options include microvascular decompression (MVD), percutaneous radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS). Few studies have explored the relative cost-effectiveness of these interventions, particularly in surgically naïve patients. METHODS: A retrospective chart review performed between January 2003 and January 2013 identified a total of 89 patients who underwent surgical treatment for TN (MVD=27, RFR=23, SRS=39). Outcome measures included facial pain (excellent=no pain, no medications; good=no pain, medications required; fair=>50% decrease in pain; and poor=<50% decrease in pain/secondary surgery), numbness, cost, and the need for a subsequent procedure. RESULTS: The average age of patients for each procedure was MVD=53.9±16, RFR=76.2±16, and SRS=74.5±12 (p<0.001 MVD vs. other modalities). Total charges for the procedures (US dollars) were MVD=50,100±9600, RFR=4700±2200, and SRS=39,300±6000 (p<0.001). Actual collections varied by insurance. Percentages of postoperative facial numbness were MVD=11%, RFR=52%, and SRS=28% (p<0.01). At two years, the rates of recurrence requiring a second procedure were MVD=22%, RFR=74%, and SRS=31% (p<0.01). Average times to secondary procedure in months were MVD=26±29, RFR=59±76, and SRS=35±25. Mean quality adjusted pain-free years were MVD=1.58, RFR=2.28, and SRS=0.99. Cost-effectiveness calculations in US dollars showed MVD=31,800, RFR=2100, and SRS=39,600 (p<0.001). CONCLUSION: There are significant cost differences among the three most common surgical procedures for TN. MVD was the most expensive procedure, was more likely to be performed on younger patients, had the lowest rate of facial numbness, and had the lowest rate of recurrence requiring a secondary procedure. SRS was slightly less costly, more likely to be performed on an older population, and had a rate of recurrence similar to MVD. RFR was the least expensive procedure, provided immediate relief, but was associated with the highest rates of facial numbness and recurrence. Based on cost-effectiveness, considering both cost and outcome, RFR was the most cost-effective, followed by MVD, and finally SRS.

Surgical management of trigeminal neuralgia: use and cost-effectiveness from an analysis of the Medicare Claims Database.

BACKGROUND: Trigeminal neuralgia is a relatively common neurosurgical pathology with multiple management options. Microvascular decompression (MVD) is nonablative and is considered the gold standard. However, stereotaxic radiosurgery (SRS) and percutaneous stereotaxic rhizotomy (PSR) are 2 noninvasive but ablative options that have rapidly gained support. OBJECTIVE: To use Medicare claims data in conjunction with a literature review to assess the usage, effectiveness, and cost-effectiveness of the 3 different invasive treatments for trigeminal neuralgia. METHODS: All of the claims of trigeminal neuralgia treatment were extracted from the 2011 5% Inpatient and Outpatient Limited Data Set. Current Procedural Terminology, 4th Edition/International Classification of Diseases, Ninth Revision codes for the 3 different surgical treatment modalities were used to further classify these claims. Kaplan-Meier survival curves in key articles were used to calculate quality-adjusted life years and cost-effectiveness for each procedure. RESULTS: A total of 1582 claims of trigeminal neuralgia were collected. Ninety-four (6%) patients underwent surgical intervention. Forty-eight (51.1%) surgical patients underwent MVD, 39 (41.5%) underwent SRS, and 7 (7.4%) underwent PSR. The average weighted costs for MVD, SRS, and PSR were $40 434.95, $38 062.27, and $3910.64, respectively. The quality-adjusted life years were 8.2 for MVD, 4.9 for SRS, and 6.5 for PSR. The cost per quality-adjusted life year was calculated as $4931.1, $7767.8, and $601.64 for MVD, SRS, and PSR, respectively. CONCLUSION: This study shows that the most frequently used surgical management of trigeminal neuralgia is MVD, followed closely by SRS. PSR, despite being the most cost-effective, is by far the least utilized treatment modality.

Value-based neurosurgery: the example of microvascular decompression surgery.

OBJECT: Value of care is emerging as a promising framework to restructure health care, emphasizing the importance of reporting multiple outcomes that encompass the entire care episode instead of isolated outcomes specific to care points during a patient's care. The authors assessed the impact of coordinated implementation of processes across the episode of surgical care on value of neurosurgical care, using microvascular decompression (MVD) as an example. METHODS: This study is a retrospective review of consecutive cases involving patients with either trigeminal neuralgia or hemifacial spasm undergoing first-time MVD. Patients were divided into 2 groups: Group 1 included patients who underwent surgery between February 2008 and November 2009 and Group 2 included those who underwent surgery between January 2011 and October 2012. The authors collected data on outcome measures spanning the entire surgical episode of care according to the Outcome Measures Hierarchy. RESULTS: Forty-nine patients were included: 20 patients in Group 1 and 29 patients in Group 2. Thirty-one patients underwent MVD for trigeminal neuralgia and 18 for hemifacial spasm. A zero mortality rate and high degree of symptom resolution were achieved in both groups. Group 2 benefited from a reduction in the average total operating room time, a decrease in the mean and median postoperative length of hospital stay, a decrease in the mean length of stay on the floor, and a reduction in the rates of complications and readmissions. CONCLUSIONS: Comprehensive implementation of improvement processes throughout the continuum of care resulted in improved global outcome and greater value of delivered care. Enhanced-recovery perioperative protocols and diagnosis-specific clinical pathways are two avenues built around global care delivery that can help achieve an "optimal episode of surgical care" in every case.

Cost-effectiveness in the surgical treatments for trigeminal neuralgia.

Increasing costs of healthcare call for rational approaches based on cost-effectiveness of the surgical procedures. When treating trigeminal neuralgia, therapeutic options vary widely as does their cost. We have compared microvascular decompression (MVD), radiofrequency rhizotomy (RFR), percutaneous balloon compression of the Gasser ganglion (PBC) and gamma knife rhizotomy (GKR) for length of stay, cost of the stay, of the procedure, of disposable material and of specific hospital investments. This was compared to the immediate and long-term (>5 years) efficacy of the procedures. The evaluated total cost were 1,014 for PBC and RFR, 3,360 for MVD with a 2-day hospital stay, 4,560 for MVD with a 5-day hospital stay, and 3,424 for GKR. In addition, RFR requires investing in a generator (10,000 ) and GKR requires a gamma knife suite (3,000,000 ). MVD, PBC and RFR allow immediate relief of the pain, GKS having a more progressive effect. Long-term results, however, are comparable, all techniques having at least a 25% recurrence rate between 5 and 10 years postoperatively. Although all surgical techniques allow pain relief in trigeminal neuralgia, from an economical point of view, percutaneous techniques are more cost-effective than MVD and GKR. They should be considered as the first therapeutical option, keeping the more expensive procedures for percutaneous treatment failures or for medically justified indications.

Trigeminal neuralgia treated with pregabalin in family medicine settings: its effect on pain alleviation and cost reduction.

The purpose of this study is to analyze the effect of pregabalin (PGB) on pain alleviation, use of health care and non-health care resources, and associated costs in patients with trigeminal neuralgia under usual clinical practice in primary care settings. Sixty-five PGB-naïve patients receiving PGB as monotherapy (n = 36, 55%) or combined with other drugs (n = 29, 45%) fulfill criteria for inclusion in a secondary analysis from a 12-week, multicenter, observational prospective study aimed to ascertain the cost of illness in subjects with neuropathic pain. Pain is evaluated using the Short Form McGill Pain Questionnaire. Use of health care and non-health care resources and lost workdays equivalents (LWDEs) are also recorded. PGB significantly reduces pain scores, use of health care resources (ancillary tests and unscheduled medical visits), and number of LWDEs. Additional cost of PGB treatment (+euro 174 +/- 106) is broadly compensated for by a reduction in both health care costs (-euro 621 +/-1211, P < .001) and indirect costs (-euro 1210 +/- 1141, P < .001). It is concluded that PGB as monotherapy or combined with other drugs is effective in pain management in patients with trigeminal neuralgia and reduces the cost of illness.

A prospective cost-effectiveness study of trigeminal neuralgia surgery.

OBJECTIVES: Approximately 8000 patients with trigeminal neuralgia undergo surgery each year in the United States at an estimated cost exceeding $100 million. We compared 3 commonly performed surgeries (microvascular decompression, glycerol rhizotomy, and stereotactic radiosurgery) to evaluate the relative cost-effectiveness of these operations for patients with idiopathic trigeminal neuralgia. METHODS: Prospective nonrandomized trial at a tertiary referral center from July 1999 to December 2001. One hundred twenty-six consecutive patients underwent 153 operations (microvascular decompression, n=33; glycerol rhizotomy, n=51; stereotactic radiosurgery, n=69). Preoperative characteristics were similar between the groups with respect to sex, pain location, duration of pain, and atypical features. Facial pain outcomes were classified as excellent (no pain, no medications), good (no pain, reduced medications), fair (>50% pain reduction), and poor. The cost per quality adjusted pain-free year was compared between the groups. Mean follow-up was 20.6 months. RESULTS: Patients having microvascular decompression more commonly achieved and maintained an excellent outcome (85% and 78% at 6 and 24 months) compared with glycerol rhizotomy (61% and 55%, P=0.01) and stereotactic radiosurgery (60% and 52%, P<0.01). No difference was detected between glycerol rhizotomy and stereotactic radiosurgery (P=0.61). The cost per quality adjusted pain-free year was $6,342, $8,174, and $8,269 for glycerol rhizotomy, microvascular decompression, and stereotactic radiosurgery, respectively. Reduction in the average cost of morbidity and additional surgeries to zero did not make either microvascular decompression or stereotactic radiosurgery more cost-effective than glycerol rhizotomy. Both microvascular decompression and stereotactic radiosurgery would be more cost-effective than glycerol rhizotomy if the cost of additional surgeries after glycerol rhizotomy increased 79% and 83%, respectively. DISCUSSION: This analysis supports the practice of percutaneous surgeries for older patients with medically unresponsive trigeminal neuralgia. At longer follow-up intervals, microvascular decompression is predicted to be the most cost-effective surgery and should be considered the preferred operation for patients if their risk for general anesthesia is acceptable. More data are needed to assess the role that radiosurgery should play in the management of patients with trigeminal neuralgia.