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Aggressive Management of Tic Douloureux
Abstract & Commentary
By Michael Rubin, MD, Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Rubin reports no financial relationships relevant to this field of study.
Synopsis: Neurosurgical interventions for trigeminal neuralgia have never been rigorously studied for efficacy and carry significant risks.
Source: Koopman JSHA, de Vries LM, Dieleman JP, et al. A nationwide study of three invasive treatments for trigeminal neuralgia. Pain 2011;152:507-513. Epub 2011 Jan 15.
Trigeminal neuralgia, when refractory to medical management, nevertheless may respond to a number of invasive therapies including percutaneous radiofrequency thermocoagulation, partial sensory rhizotomy, microvascular decompression (MVD), glycerol injections, gamma-knife radiosurgery, or balloon decompression. None has been proven beneficial in rigorous, randomized, controlled trials. Which method works best? To address this question, with respect to the first three methods noted, a cohort study was undertaken with the entire population of The Netherlands.
Using an electronic database encompassing hospital discharge records of all medical centers in The Netherlands from Jan. 1, 2001, to Dec. 31, 2005, information on all patients with trigeminal neuralgia who underwent percutaneous radiofrequency thermocoagulation, partial sensory rhizotomy, and microvascular decompression during the study period, Jan. 1, 2002, to Dec. 31, 2004, was captured and evaluated. Patients who had undergone a procedure in the year prior to the study period were excluded, and patients were followed for either 1 year, until a complication occurred, or until a repeat procedure was required, whichever came first. Primary outcome measures included readmission for a repeat procedure for trigeminal neuralgia or a known complication within 1 year, including but not limited to, hearing loss, cerebrospinal fluid leakage, meningitis, facial spasms or asymmetry, corneal hypesthesia, ataxia, keratitis, persistent neurological deficit, or death. Statistical analysis comprised conditional logistic regression and Kaplan–Meier analysis, with 95% confidence intervals calculated based on a binomial distribution.
During the study period, percutaneous radiofrequency thermocoagulation was performed on 672 patients, partial sensory rhizotomy on 39, and microvascular decompression on 87, with 33.8% of patients being readmitted within a year for a repeat procedure (2.4%) or complication (31.6%). Microvascular decompression carried the lowest risk of readmission at 1 year (9%), while percutaneous radiofrequency thermocoagulation carried the highest (38%). However, the latter also carried the lowest risk of complications (2%) compared to partial sensory rhizotomy (8%) or microvascular decompression (6%). Complications, which mostly occurred within the first month following the procedure (31.6%), included Bell's palsy (11%), infections (5%), anaphylactic shock, hemiplegia, aspiration, bleeding, and pulmonary issues (6% each). Percutaneous radiofrequency thermocoagulation is the most likely of the procedures studied to require a repeat procedure but is the least likely to result in a complication necessitating hospital readmission.
As noted in an accompanying editorial,1 the results of Koopman et al contrast with others2 reporting similar pain relief following partial sensory rhizotomy and MVD, but higher complication rates and lower patient satisfaction at 5 years, perhaps due to the shorter follow-up (1 year) in the Koopman study. Curiously, the latter also demonstrate a much higher repeat procedure rate than previously reported, particularly for percutaneous radiofrequency thermocoagulation, despite fewer complications, and notably, the sheer number of ablative procedures compared to microvascular decompression performed in The Netherlands stands in contrast to the trend toward decompression noted in the literature. Optimal treatment of medically refractory trigeminal neuralgia remains to be determined and further study is needed.
1. Zakrzewska JM. Surgery for trigeminal neuralgia? Pain 2011:152;469-470.
2. Zakrzewska JM, Lopez BC, Kim SE, et al. Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia. Neurosurgery 2005;56:1304-12.