Prognostic nomogram for microvascular decompression-treated trigeminal neuralgia.

This study aimed to establish an effective prognostic nomogram for microvascular decompression (MVD)-treated trigeminal neuralgia (TN). The nomogram was based on a retrospective cohort study of 1054 patients with TN. During the period 2005-2014, 845 patients at our department treated TN with MVD and served as a development cohort. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index) and calibration curve. The model was externally validated by 209 TN patients during 2014-2016. Multivariate cox analysis suggested that the patient's age, atypical pain, vascular type, number of offending vessels, and second MVD were significant factors influencing the prognosis of MVD-treated TN. The C index of nomogram in the development cohort was 0.767 (95% CI, 0.739-0.794), and 0.749 (95% CI, 0.688-0.810) in the validation cohort. We developed and validated a nomogram to predict 3-year overall remission rate after MVD treatment of TN. The nomogram can be used in clinical trials to determine the likelihood of pain recurrence in TN patients treated with MVD for 3 years to aid in the comprehensive treatment of TN.

Re-Exploration of Microvascular Decompression in Recurrent Trigeminal Neuralgia and Intraoperative Management Options.

BACKGROUND: Trigeminal neuralgia (TGN) is a debilitating disorder, and in patients for whom medical management is not sufficient, there are several therapeutic options. Microvascular decompression (MVD) for TGN has been shown to be highly effective; however, pain does recur after MVD in some patients. Therapeutic options for recurrent TGN are the same as those for primary TGN, including re-exploration of MVD (re-MVD). In this study we review our practice of re-MVD, comparing it with alternative options and assessing its safety and efficacy. METHODS: Retrospective analysis of prospectively collected data of patients undergoing re-MVD between 2007 and 2016. RESULTS: Thirty-two patients underwent re-MVD, all with a Barrow Neurosurgical Institute Pain Index (BNPI) of IV or V. Postoperatively, 87% of patients reported an improvement in their BNPI to III or better, with 50% being BNPI 1 or 2. Eleven patients without distortion or vascular conflict at the time of re-exploration underwent intraoperative neurolysis, and 90% reported improvement in their BNPI. Kaplan-Meier analysis showed a median pain-free period of 36 months after re-MVD. There were no significant complications. CONCLUSIONS: Re-MVD is a safe and effective method of treating recurrent TGN. Intraoperative neurolysis is an important tool in re-exploration and should be considered when there is no ongoing compression or distortion of the trigeminal nerve.

The Current Status of Microvascular Decompression for the Treatment of Trigeminal Neuralgia in Japan: An Analysis of 1619 Patients Using the Japanese Diagnosis Procedure Combination Database.

Microvascular decompression (MVD) is a widely used, safe, and effective treatment for trigeminal neuralgia (TGN). However, the extent of application of this therapeutic method and its outcomes in Japan are currently unclear. To address these questions, the authors analyzed the use of MVD for the treatment of TGN during the 33-month period from July 2010 to March 2013, using data contained in the Diagnosis Procedure Combination database. The analysis revealed that MVD was used for the treatment of TGN in 1619 cases (608 men, 1011 women), with approximately 1.66 times more women treated than men. MVD for TGN was most frequently performed in individuals 60 to 79 years of age; of particular note was the remarkable increase in the number of women in this particular category. The overall number of procedures performed per 100,000 population/year in Japan was 0.46. The number of procedures was larger in prefectures with higher populations, with a tendency toward a higher number of MVD procedures performed in the area designated West than in the East. Discharge outcomes indicated that cure and improvement were achieved in 97.6% of cases, with a mortality rate of 0.2%, and no differences in discharge outcomes between men and women. The mean length of hospital stay in patients undergoing MVD for TGN was 14.8 days. This analysis revealed discernable trends in the use of MVD for the treatment of TGN in Japan.

Increased risk of trigeminal neuralgia in patients with migraine: A nationwide population-based study.

Objectives The objectives of this article are to evaluate the association between migraine and trigeminal neuralgia and to investigate the effects of age, sex, migraine subtype, and comorbid risk factors on trigeminal neuralgia development. Methods This population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database. Individuals aged ≥ 20 years with neurologist-diagnosed migraine between 2005 and 2009 were included. A non-headache age-, sex-, and propensity score-matched control cohort was selected for comparison. All participants were followed until the end of 2010, death, or the occurrence of trigeminal neuralgia. Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for comparison of the risk of trigeminal neuralgia between groups. Results Both cohorts ( n = 137,529 each) were followed for a mean of 3.1 years. During the follow-up period, 575 patients (421,581 person-years) in the migraine cohort and 88 matched controls (438,712 person-years) were newly diagnosed with trigeminal neuralgia (incidence rates, 136.39 and 20.06/100,000 person-years, respectively). The HR for trigeminal neuralgia was 6.72 (95% CI, 5.37-8.41; p < 0.001). The association between migraine and trigeminal neuralgia remained significant in sensitivity analyses. Among migraine subtypes, patients with migraine with aura were at greater risk of trigeminal neuralgia development. No other significant interaction was identified in subgroup analyses. Conclusions Migraine is a previously unidentified risk factor for trigeminal neuralgia. The association between these conditions suggests a linked underlying mechanism, which is worthy of further exploration.

First 1,000 Cases of Gamma Knife Surgery for Various Intracranial Disorders in LSU Health-Shreveport: Radiological and Clinical Outcome.

OBJECTIVE: Gamma knife radiosurgery (GKRS) has emerged as an important therapeutic alternative for different intracranial lesions. We have reviewed our institution's first 1,000 cases of radiosurgeries. MATERIALS AND METHODS: We performed a retrospective review (2000-2013) of 1,017 radiosurgeries in 911 patients with various intracranial lesions including vestibular schwannoma (82), meningioma (136), metastatic brain tumors (298), astrocytoma (49), pituitary adenoma (92), arteriovenous malformation (85) and trigeminal neuralgia (169). RESULTS: GKRS in different intracranial lesions showed significant variations in outcome and complications. Overall, the local tumor growth control for benign and malignant tumors was 89 percent and 70 percent respectively. The rate of obliteration of arteriovenous malformation nidus was 79 percent. The complete and partial relief of pain in the patients with trigeminal neuralgia was 55.6 percent and 22.4 percent respectively. CONCLUSION: At recent follow-up, GKRS showed good control of different tumor growth, obliteration of AVM nidus and remission of trigeminal neuralgia pain, good overall and progression free survival rate, possible preservation of neurological functions, lesser number of complications, and improvement of quality of life. Therefore, GKRS is an important treatment option for patients with different benign intracranial tumors, AVM and trigeminal neuralgia. However, GKRS is not effective for recurrent malignant tumors in the brain.

Increased risk of trigeminal neuralgia after hypertension: a population-based study.

OBJECTIVE: Very few studies have explored the temporal relationship between hypertension and trigeminal neuralgia (TN). The aim of this population-based follow-up study was to investigate whether hypertension is associated with a higher risk of developing TN. METHODS: A total of 138,492 persons with at least 2 ambulatory visits with the principal diagnosis of hypertension in 2001 were enrolled in the hypertension group. The nonhypertension group consisted of 276,984 age- and sex-matched, randomly sampled subjects without hypertension. The 3-year TN-free survival rate and the cumulative incidence of TN were calculated using the Kaplan-Meier method. Cox proportional hazard regression was used to estimate the hazard ratio of TN. RESULTS: In the hypertension group, 121 patients developed TN during follow-up, while, in the nonhypertension group, 167 subjects developed TN. The crude hazard ratio for the hypertension group was 1.52 (95% confidence interval [CI] 1.20-1.92; p = 0.0005), while, after adjustment for demographic characteristics and medical comorbidities, the adjusted hazard ratio was 1.51 (95% CI 1.19-1.90; p = 0.0006). CONCLUSIONS: This study shows a significantly increased risk of developing TN after hypertension. Further studies are needed to elucidate the underlying mechanism of the association between hypertension and TN.

Safety of microvascular decompression for trigeminal neuralgia in the elderly. Clinical article.

OBJECT: Microvascular decompression (MVD) offers an effective and durable treatment for patients suffering from trigeminal neuralgia (TN). Because the disorder has a tendency to occur in older persons, the risks of surgical treatment in the elderly have been a topic of recent interest. To date, evidence derived from several small retrospective and a single prospective case series has suggested that age does not increase the complication rate associated with surgery. Using a large national database, the authors aimed to study the impact of age on in-hospital complications following MVD for TN. METHODS: Using the Nationwide Inpatient Sample (NIS) for the 10-year period from 1999 to 2008, the authors selected all patients who underwent MVD for TN. The primary outcome of interest was the in-hospital mortality rate. Secondary outcomes of interest were cardiac, pulmonary, thromboembolic, cerebrovascular, and wound complications as well as the duration of hospital stay, total hospital charges, and discharge location. An elderly cohort of patients was first defined as those 65 years of age and older and then redefined as those 75 years and older. RESULTS: A total of 3273 patients who underwent MVD for TN were identified, having a median age of 57 years. Within this sample, 31.5% were 65 years and older and 10.7% were 75 years and older. The in-hospital mortality rate was 0.68% for patients 65 years or older (p = 0.0087) and 1.16% for those 75 years or older (p = 0.0026). In patients younger than 65 years, the in-hospital mortality rate was 0.13% (3 deaths among 2241 patients). As analyzed using the chi-square test (for both 65 and 75 years as the age cutoff) and the Pearson rank correlation coefficient, the risk of cardiac, pulmonary, thromboembolic, and cerebrovascular complications was higher in older patients (that is, those 65 and older and those 75 and older), but the risks of wound complications and CNS infection were not. The risk of any in-hospital complication occurring in a patient 65 years and older was 7.36% (p < 0.0001) and 10.0% in those 75 years and older (p < 0.0001). There was no difference in the total hospital charges associated with age. The duration of the hospital stay was longer in older patients, and the likelihood of discharge home was lower in older patients. CONCLUSIONS: Microvascular decompression for TN in the elderly population remains a reasonable surgical option. However, based on data from a large national database, authors of the present study suggest that complications do tend to gradually increase in tandem with an advanced age. While age does not act as a risk factor in isolation, it may serve as a convenient surrogate for complication rates. The authors hope that this information can be of use in guiding older patients through decisions for the surgical treatment of TN.

Microvascular decompression for trigeminal neuralgia in the elderly: long-term treatment outcome and comparison with younger patients.

OBJECTIVE: Multiple studies have proved that microvascular decompression (MVD) is the treatment of choice in cases of medically refractory trigeminal neuralgia (TN). In the elderly, however, the surgical risks related to MVD are assumed to be unacceptably high and various alternative therapies have been proposed. We evaluated the outcomes of MVD in patients aged older than 65 years of age and compared them with the outcomes in a matched group of younger patients. The focus was on procedure-related morbidity rate and long-term outcome. METHODS: This was a retrospective study of 112 patients with TN operated on consecutively over 22 years. The main outcome measures were immediate and long-term postoperative pain relief and neurological status, especially function of trigeminal, facial, and cochlear nerves, as well as surgical complications. A questionnaire was used to assess long-term outcome: pain relief, duration of a pain-free period, need for pain medications, time to recurrence, pain severity, and need for additional treatment. RESULTS: The mean age was 70.35 years. The second and third branches of the trigeminal nerve were most frequently affected (37.3%). The mean follow-up period was 90 months (range, 48-295 months). Seventy-five percent of the patients were completely pain free, 11% were never pain free, and 14% experienced recurrences. No statistically significant differences existed in the outcome between the younger and older patient groups. Postoperative morbidity included trigeminal hypesthesia in 6.25%, hypacusis in 5.4%, and complete hearing loss, vertigo, and partial facial nerve palsy in 0.89% each. Cerebrospinal fluid leak and meningitis occurred in 1 patient each. There were no mortalities in both groups. CONCLUSION: MVD for TN is a safe procedure even in the elderly. The risk of serious morbidity or mortality is similar to that in younger patients. Furthermore, no significant differences in short- and long-term outcome were found. Thus, MVD is the treatment of choice in patients with medically refractory TN, unless their general condition prohibits it.

Radiosurgery for trigeminal neuralgia.

Radiosurgery has recently emerged as a suitable treatment of pharmacologically resistant idiopathic trigeminal neuralgia. Results and complications of this treatment are related to parameters of the dosimetry, i.e. the dose and the target. We found that the irradiation dose delivered to the brainstem, the distance between the target and the brainstem, and the occurrence of facial numbness after radiosurgery are related to a better pain outcome.

Neuronavigator-guided percutaneous radiofrequency thermocoagulation in the treatment of intractable trigeminal neuralgia.

BACKGROUND: Percutaneous radiofrequency thermocoagulation of the trigeminal ganglion (PRTTG) is regarded as the first choice for most patients with trigeminal neuralgia (TN) because of its safety and feasibility. However, neuronavigator-guided PRTTG has been seldom reported. The purpose of this study was to assess the safety and efficacy of neuronavigator-guided PRTTG for the treatment of intractable TN. METHODS: Between January 2000 and December 2004, 54 patients with intractable TN were enrolled into this study and were randomly divided into two groups. The patients in navigation group (n = 26) underwent PRTTG with frameless neuronavigation, and those in control group (n = 28) received PRTTG without neuronavigation. Three months after the operation, the efficacy, side effects, and complications of the surgery were recorded. The patients in the control group were followed up for 10 to 54 months (mean, 34 +/- 5), and those in the navigation group were followed up for 13 to 58 months (mean, 36 +/- 7). Kaplan-Meier analyses of the pain-free survival curves were used for the censored survival data, and the log-rank test was used to compare survival curves of the two groups. RESULTS: The immediate complete pain-relief rate of the navigation group was 100%, whereas it was 95% in the control. The proportion of sustained pain-relief rates at 12, 24 and 36 months after the procedure were 85%, 77%, and 62% in the navigation group, and 54%, 40%, and 35% in the control. Recurrences in the control group were more common than that in the navigation group. Annual recurrence rate in the first and second years were 15% and 23% in the navigation group, and 46%, 60% in the control group. No side-effect and complication was noted in the navigation group except minimal facial hypesthesia. CONCLUSION: Neuronavigator-guided PRTTG is a safe and promising method for treatment of intractable TN with better short- and long-term outcomes and lower complication rate than PRTTG without neuronavigation.

Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes.

OBJECTIVE: Microvascular decompression (MVD) is associated with low mortality and morbidity rates at specialized centers, but many MVD procedures are performed outside such centers. We studied short-term end points after MVD in a national hospital discharge database sample. METHODS: A retrospective cohort study was performed by using the Nationwide Inpatient Sample, 1996 to 2000. RESULTS: The sample included 1326 MVD procedures for treatment of trigeminal neuralgia, 237 for treatment of hemifacial spasm, and 27 for treatment of glossopharyngeal neuralgia, performed at 305 hospitals by 277 identified surgeons. The mortality rate was 0.3%, and the rate of discharge other than to home was 3.8%. Neurological complications were coded in 1.7% of cases, hematomas in 0.5%, and facial palsies in 0.6%, with 0.4% of patients requiring ventriculostomies and 0.7% postoperative ventilation. Trigeminal nerve section was also coded for 3.4% of patients with trigeminal neuralgia, more commonly among older patients (P = 0.08), among female patients (P = 0.03), and at teaching hospitals (P = 0.02). The median annual caseloads were 5 cases per hospital (range, 1-195 cases) and 3 cases per surgeon (range, 1-107 cases). With adjustment for age, sex, race, primary insurance, diagnosis (trigeminal neuralgia versus hemifacial spasm versus glossopharyngeal neuralgia), geographic region, admission type and source, and medical comorbidities, outcomes at discharge were superior at higher-volume hospitals (P = 0.006) and with higher-volume surgeons (P = 0.02). Complications were less frequent after surgery performed at high-volume hospitals (P = 0.04) or by high-volume surgeons (P = 0.01). The rate of discharge other than to home was 5.1% for the lowest-volume-quartile hospitals, compared with 1.6% for the highest-volume-quartile hospitals. Volume and mortality rate were not significantly related, but three of the four deaths in the series followed procedures performed by surgeons who had performed only one MVD procedure that year. Length of stay (median, 3 d) and hospital volume were not significantly related. Hospital charges were slightly higher at higher-volume hospitals (P = 0.007). CONCLUSION: Although most MVD procedures in the United States are performed at low-volume centers, mortality rates remain low. Morbidity rates are significantly lower at high-volume hospitals and with high-volume surgeons.