Analysis of Failed Microvascular Decompression in Patients with Trigeminal Neuralgia

Abstract

Background Microvascular decompression (MVD) has been widely accepted as a definitive therapy for primary trigeminal neuralgia (TN). However, some patients may not experience relief of TN symptoms following surgery. In this study, the findings of redo MVD are discussed.

Methods Between 2015 and 2017, 205 patients with primary TN underwent MVD surgery in Shanghai Tongren Hospital. Among these patients, 187 had immediate complete relief of symptoms, 8 improved apparently, and 10 reported no symptom relief. Of the 10 patients without relief, 6 underwent reoperation within 5 days, 2 underwent reoperation 3 months after the first procedure, and 2 refused to undergo reoperation.

Results The symptoms of those patients who received reoperation disappeared immediately after the surgery. In the second operations, new conflict sites at the motor roots were found in five cases. The real offending vessels were the superior cerebellar artery (SCA) or branch of the SCA in seven cases and the petrosal vein in one case. The nerve was not decompressed completely in either of the two cases. At the 12-month follow-up, no recurrence was found. For the other two patients who did not have reoperation, their symptom persisted. Postoperative complications showed no significant differences between the first and second operations.

Conclusion Compression of the motor roots might be one of the causes of TN. Thorough exploration of both sensory and motor roots of the trigeminal nerve is essential to performing a successful MVD operation. Early reoperation for resistant TN after MVD does not increase the incidence of complications.

Keywords

trigeminal neuralgia - microvascular decompression - reoperation - motor root - offending vessel

• References

• 1 Sindou M, Leston JM, Decullier E, Chapuis F. Microvascular decompression for trigeminal neuralgia: the importance of a noncompressive technique--Kaplan-Meier analysis in a consecutive series of 330 patients. Neurosurgery 2008; 63 (04) (Suppl. 02) 341-350 , discussion 350–351
• 2 Sekula Jr RF, Frederickson AM, Jannetta PJ, Quigley MR, Aziz KM, Arnone GD. Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis. J Neurosurg 2011; 114 (01) 172-179
• 3 Zhong J, Li ST, Zhu J. et al. A clinical analysis on microvascular decompression surgery in a series of 3000 cases. Clin Neurol Neurosurg 2012; 114 (07) 846-851
• 4 Barker II FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996; 334 (17) 1077-1083
• 5 Zhang X, Xu L, Zhao H. et al. Long-term efficacy of nerve combing for patients with trigeminal neuralgia and failed prior microvascular decompression. World Neurosurg 2017; 108: 711-715
• 6 Xia L, Zhong J, Zhu J. et al. Effectiveness and safety of microvascular decompression surgery for treatment of trigeminal neuralgia: a systematic review. J Craniofac Surg 2014; 25 (04) 1413-1417
• 7 Chakravarthi PS, Ghanta R, Kattimani V. Microvascular decompression treatment for trigeminal neuralgia. J Craniofac Surg 2011; 22 (03) 894-898
• 8 Sandell T, Eide PK. Effect of microvascular decompression in trigeminal neuralgia patients with or without constant pain. Neurosurgery 2008; 63 (01) 93-99 , discussion 99–100
• 9 Rogers CL, Shetter AG, Fiedler JA, Smith KA, Han PP, Speiser BL. Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of the Barrow Neurological Institute. Int J Radiat Oncol Biol Phys 2000; 47 (04) 1013-1019
• 10 Jannetta PJ. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. 1967. J Neurosurg 2007; 107 (01) 216-219
• 11 Petty PG, Southby R, Siu K. Vascular compression: cause of trigeminal neuralgia. Med J Aust 1980; 1 (04) 166-167
• 12 Gu W, Zhao W. Microvascular decompression for recurrent trigeminal neuralgia. J Clin Neurosci 2014; 21 (09) 1549-1553
• 13 Matsushima T, Yamaguchi T, Inoue TK, Matsukado K, Fukui M. Recurrent trigeminal neuralgia after microvascular decompression using an interposing technique. Teflon felt adhesion and the sling retraction technique. Acta Neurochir (Wien) 2000; 142 (05) 557-561
• 14 Hussain MA, Konteas A, Sunderland G. et al. Re-exploration of microvascular decompression in recurrent trigeminal neuralgia and intraoperative management options. World Neurosurg 2018; 117: e67-e74
• 15 Lang J. [Neuroanatomy of the optic, trigeminal, facial, glossopharyngeal, vagus, accessory and hypoglossal nerves (author's transl)]. Arch Otorhinolaryngol 1981; 231 (01) 1-69
• 16 Saunders RL, Sachs Jr E. Relation of the accessory rootlets of the trigeminal nerve to its motor root. A microsurgical autopsy study. J Neurosurg 1970; 33 (03) 317-324
• 17 Gudmundsson K, Rhoton Jr AL, Rushton JG. Detailed anatomy of the intracranial portion of the trigeminal nerve. J Neurosurg 1971; 35 (05) 592-600
• 18 Young RF. Unmyelinated fibers in the trigeminal motor root. Possible relationship to the results of trigeminal rhizotomy. J Neurosurg 1978; 49 (04) 538-543
• 19 Young RF, Kruger L. Axonal transport studies of the trigeminal nerve roots of the cat. With special reference to afferent contributions to the portio minor. J Neurosurg 1981; 54 (02) 208-212
• 20 Yousry I, Moriggl B, Holtmannspoetter M, Schmid UD, Naidich TP, Yousry TA. Detailed anatomy of the motor and sensory roots of the trigeminal nerve and their neurovascular relationships: a magnetic resonance imaging study. J Neurosurg 2004; 101 (03) 427-434
• 21 Feng BH, Zheng XS, Liu M. et al. Microvascular decompression for trigeminal neuralgia: zone exploration and decompression techniques. J Craniofac Surg 2015; 26 (08) 2381-2384