Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

doi:10.1016/j.jocn.2014.11.028

Journal of Clinical Neuroscience

Volume 22, Issue 5, May 2015, Pages 818-822

https://doi.org/10.1016/j.jocn.2014.11.028 Get rights and content

Abstract

The aim of our study was to evaluate the long term efficacy of microvascular decompression (MVD) and gamma knife radiosurgery (GKRS) with respect to pain relief and patient satisfaction. Both these modalities are accepted modalities of treatment for intractable trigeminal neuralgia. We excluded deceased patients, those who had a prior intervention and those requiring an additional intervention following initial treatment. A total of 69 patients were included in the study. Of these, 49 patients underwent treatment by GKRS and 20 by MVD. Pain status was assessed using the Barrow Neurological Institute (BNI) pain scale. The median follow up was 5.3 years. There was no significant difference between the two groups with respect to initial pain relief (100% MVD, 84% GKRS; p = 0.055). There was no significant difference in pain recurrence between the two groups (39% GKRS, 20% MVD; p = 0.133). At last follow up, 85% of patients who underwent MVD had total pain relief (BNI scale I) compared to only 45% of GKRS patients (p = 0.002). There was no significant difference in the patient satisfaction with respect to undergoing the same procedure again (90% MVD, 69% GKRS; p = 0.1) and recommending it to family members (95% MVD, 84% GKRS; p = 0.2). MVD offered total pain relief in a significantly higher number of patients than GKRS. There was no significant difference in the patient satisfaction rate between the two groups.

Introduction

In one of the epidemiological studies conducted in the USA, the incidence rate of trigeminal neuralgia was 4.3 per 100,000 population and the age adjusted rate for women was significantly higher than that for men [1]. Medical management is the main stay of therapy for idiopathic trigeminal neuralgia and surgery is indicated when medical therapy fails. Various surgical treatment modalities include microvascular decompression (MVD), balloon compression, radiofrequency thermocoagulation, glycerol rhizolysis, partial sensory rhizotomy (posterior fossa), cryotherapy and neurectomy or alcohol injections. Of all these surgical modalities, MVD is more popular and it is the only non ablative technique. Gamma knife radiosurgery (GKRS) is gaining popularity for treating idiopathic trigeminal neuralgia not only due to its non-invasive nature but also because patients can be discharged on the same day with acceptable results.

We performed this study due to the lack of available literature with respect to efficacy of both MVD and GKRS treatment modalities and patient satisfaction. To our knowledge, there are only two prospective studies [2], [3] which have compared MVD and GKRS. In one study the results did not reach statistical significance [2]. In another study, [3] MVD was superior to GKRS in achieving pain free status. We also identified only two patient satisfaction surveys with regards to MVD or GKRS [3], [4]. Out of these, only one compares MVD and GKRS in terms of patient satisfaction [3]. Our study is the second such satisfaction survey.

MVD and GKRS are both accepted modalities of treatment for intractable trigeminal neuralgia. The aim of our study was to evaluate the long term efficacy of both these modalities with respect to pain relief and patient satisfaction. We attempted to evaluate the pain relief patterns after treatment for trigeminal neuralgia following GKRS and MVD.

Section snippets

Methods

The study was approved by our Institutional Review Board. Patients were briefed about the survey and after getting verbal consent from the patient, a telephone interview with a standardized questionnaire was conducted. Telephone interviews were conducted to assess the pain status and complete the patient satisfaction survey. Pain status was assessed using the Barrow Neurological Institute (BNI) pain scale. Patient satisfaction with respect to whether they would undergo the same procedure again

Results

A total of 69 patients with successful telephone interviews were included in the final analysis. Of these, 49 (71%) underwent GKS and 20 (29%) underwent MVD. There was no significant difference in the age between the two groups (MVD 61.3 years versus GKRS 63.39 years; independent sample t-test). The majority of the patients were women (66.7%). There was no difference in the gender distribution among the two groups. The median follow up period was 5.3 years.

Discussion

Current options for patients who have inadequate or only a transient relief with medications include MVD or several palliative destructive procedures like rhizotomy directed at the trigeminal nerve root or ganglion. Though MVD is currently the most frequently reported procedure, not a single randomized controlled trial was identified [5]. MVD like any other surgical procedure is associated with complications like mortality, infection or those related to general anesthesia, and the mortality

Conclusions

From our study, MVD offered total pain relief in significantly higher number of patients than GKRS. There was no significant difference in the rates of patient satisfaction between the two groups although there was a trend for greater satisfaction after MVD. Our observations regarding long term efficacy of MVD are similar to those published in the literature, but there is a lack of high quality evidence to support the clinical practice. Properly matched prospective studies or randomized

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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Cited by (35)

Microvascular Decompression and Trigeminal Neuralgia: Patient Sentiment Analysis Using Natural Language Processing
2023, World Neurosurgery
Microvascular decompression (MVD) as a treatment for trigeminal neuralgia (TGN) has high success rate but is associated with risks of complication. This study analyzes Twitter to provide insights into discussions surrounding MVD for patients with TGN.
A Twitter search performed in April 2022 yielded 491 tweets from 426 accounts. Tweets and accounts were classified thematically, and descriptive statistics were used for various social media metrics. Using a natural language processing machine learning algorithm, sentiment analysis (SA) was performed to evaluate patient perspectives before and after surgery, and a multivariate regression model was used to identify predictors of higher engagement metrics (likes, retweets, quote tweets, replies).
Most accounts were patients, caregivers, and other members of the public (70%). The most encountered themes were research (47%) and personal experiences (33.4%). SA of tweets about patient experiences showed that 40.2% of tweets were positive, 31.1% were neutral and 28.7% were negative. Negative tweets decreased significantly in postoperative tweets and mostly discussed complications or failure of surgery (63%). On multivariate analysis, only inclusion of media (photo or video) in a Tweet was associated with higher engagement metrics.
This study provides a comprehensive review of Twitter use discussing MVD in TGN and is the first to assess patient satisfaction after treatment using SA. The data presented on patient perspectives on social media could help physicians establish direct lines of communication with patients, fostering a more patient-focused care.
Microvascular Decompression Versus Gamma Knife Surgery in Patients with Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis
2022, World Neurosurgery
Citation Excerpt :
Another option is Gamma knife surgery (GKS), a non-invasive technique that delivers high-dose radiation to the fifth cranial nerve. This outpatient procedure does not need general anesthesia.6 The standard gold surgery is MVD nowadays, but it is still a challenge to choose between MVD and GKS.
There are 2 cardinal approaches for drug-resistant trigeminal neuralgia (TN), including microvascular decompression (MVD) and gamma knife surgery (GKS). This study aimed to compare the results of MVD versus GKS in the treatment of drug-resistant TN.
The search strategy was formulated in accordance with PRISMA recommendations for publications retrieved from electronic databases, such as PubMed, Scopus, and web of science. Inclusion and exclusion criteria were examined for relevant research. The meta-analysis was conducted by combining data using odds ratios.
Four papers were included in our study. 582 patients were treated with MVD, and 607 patients were treated with GKS for drug-resistant TN. Findings revealed that MVD related to higher rates of pain relief and lower rates of pain recurrence compared to GKS. It seems that GKS had lower post-procedural complications in our review.
MVD and GKS both reduce pain in patients with drug-resistant TN, but MVD was superior to GKS in pain relief. Furthermore, recurrence rate was lower. Post-operative complications except facial numbness were higher in MVD.
Teflon Granuloma: A Common Cause of Recurrent Trigeminal Neuralgia
2022, World Neurosurgery
Citation Excerpt :
In general, pain recurring within a month is deemed invalid. It has been reported that recurrence rate of TN was 3%–31%,5,9-13 improvement of diagnostic techniques and different medical levels may be responsible for such a huge cliff. Concerns about complications of re-do MVD14 and psychological rejections, many patients with recurrent TN opted for medications or some "minimally invasive operations".15-19
Trigeminal neuralgia (TN) is a common pain syndrome of the nervous system,. Although about 90% patients who were refractory to medications could be free from pain after microvascular decompression (MVD), some patients did experience recurrence. The study aimed to analyze clinical characteristics of patients with recurrent TN, recurrence factors of TN, and prognosis after re-do MVD.
Clinical data and at least 12 months follow-up of patients with recurrent TN who underwent re-do MVD in our hospital from 2005 to 2020 were collected and analyzed.
A total of 14 patients with recurrent TN were enrolled eventually; adhesive arachnoid membranes were found in all patients. Teflon granuloma was found in 10 patients, new neurovascular compression (NVC) in 3 patients, and vascular displacement in 1 patient. Pain disappeared in 12 patients and relieved in 2 patients, but 4 patients experienced mild facial numbness and 1 patient suffered from incision infection after re-do MVC. No serious surgery-related complications and pain recurrences were recorded.
Teflon granuloma was the most common cause of TN recurrence in current study, new NVC was also saw in some patients. Patients with recurrent TN could get satisfactory results from re-do MVD.
Microvascular Decompression versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Single-Institution Experience
2020, World Neurosurgery
Citation Excerpt :
MVD is historically the most frequently reported procedure for medically intractable TN. Through univariate ordinal regression analysis, we found that MVD provides a more favorable outcome compared with SRS, similar to other studies reported in the literature.6,11,12,37 MVD is more prevalent in females; moreover, younger patients (age <65 years) tends to undergo MVD, whereas older patients (age >65 years) are more likely to undergo SRS.4
Microvascular decompression (MVD) is the standard surgical procedure for patients with medically refractory trigeminal neuralgia (TN). Stereotactic radiosurgery (SRS) has gained increasing popularity as a less invasive technique. We report our institution’s outcome in the surgical treatment of TN (MVD vs. SRS), taking patient’s age and gender into consideration.
We retrospectively reviewed a prospectively collected database of patients undergoing MVD or SRS for type 1 idiopathic TN between 2004 and 2019 at the University of Iowa. Standardized data collection focused on preoperative clinical characteristics and postoperative outcomes including the Barrow Neurological Institute (BNI) Pain Intensity Score.
A total of 111 patients underwent MVD and 103 patients underwent SRS for TN. Patients were younger in the MVD (median, 60 years) than SRS (median, 72 years) group. More females (58%) than males (42%) had TN. Multivariate ordinal regression analysis showed that an outcome of BNI score I–II (P = 0.365) and III (P = 0.736) can be achieved with either MVD or SRS; however, BNI score IV (P = 0.031) and V (P = 0.022) were more associated with SRS. Six percent of patients in the MVD group and 26% in the SRS group developed pain recurrence and required a second operation. Nine of 10 patients who underwent MVD after failed SRS had complete pain relief.
Factoring in patients’ age and gender, both MVD and SRS can achieve a favorable outcome for medically refractory TN, although BNI scores of IV and V were more common with SRS.
Treatment Outcomes in Trigeminal Neuralgia–A Systematic Review of Domains, Dimensions and Measures
2020, World Neurosurgery: X
Citation Excerpt :
The IMMPACT Outcome Domains are as follows: 1) Pain; 2) Physical functioning; 3) Emotional functioning; 4) Participant ratings of global improvement/satisfaction; 5) Symptoms and adverse events; and 6) Participant disposition. With the exception of 8 papers, all studies used pain as an outcome domain (Figure 2 and Table 1).13-459 Symptoms and adverse events also were described in a high number of papers (n = 386); however, the impact of treatment on physical and emotional functioning was significantly less evaluated, in 46 and 17 studies, respectively (Tables 2 and 3).460-464
Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock–like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measures. The aim of this systematic review was to summarize all the outcomes and outcomes measures that have been published to date and highlight variability in their use.
We have conducted a literature search using a wide range of databases (1946–2019 for medical and 2008–2019 for surgical treatment), for all intervention studies in TN. Four hundred and sixty-seven studies were selected for data extraction on TN classification, data collection method, intervention, and treatment outcomes mapped to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT guidelines).
Most studies collected data on pain (n = 459) and side effects (n = 386) domains; however, very few collected data on the impact of treatment on physical (n = 46) and emotional functioning (n = 17) and on patient satisfaction (n = 35). There was high variability on outcome measures used for pain relief (n = 10), pain intensity (n = 9), and frequency of pain episodes (n = 3).
A clear definition of what are the important outcomes for patients with TN is essential. The choice of standardized outcome measures allowing for consistent reporting in TN treatment will allow for comparison of studies and facilitate treatment choice for patients and clinicians thus, improving health outcomes and reducing health care cost.
Predictive value of magnetic resonance for identifying neurovascular compressions in trigeminal neuralgia
2019, Neurologia
La descompresión microvascular (DMV) es aceptada como único tratamiento quirúrgico etiológico para la neuralgia del trigémino (NT) clásica refractaria al tratamiento médico. Por ello existe un creciente interés por establecer el valor diagnóstico y pronóstico de la identificación de compresiones neurovasculares (CNV) mediante resonancia magnética (RM) con secuencias tridimensionales de alta resolución en pacientes con NT clásica candidatos a cirugía.
Este estudio observacional incluye una serie consecutiva de 74 pacientes con NT clásica refractaria intervenidos mediante DMV. En todos los pacientes se realizó una RM tridimensional de alta resolución con secuencias DRIVE preoperatoria para diagnosticar la existencia de una CNV, así como su grado, origen y localización. Los resultados de la RM fueron analizados de forma «ciega» para los hallazgos de la exploración quirúrgica y posteriormente comparados con estos. Se realizó un seguimiento mínimo de 6 meses para comprobar los resultados quirúrgicos, que se clasificaron según la escala de dolor facial del Barrow Neurological Institute (BNI score). El valor pronóstico de la RM preoperatoria se analizó mediante una regresión logística binaria.
La RM preoperatoria con secuencias DRIVE demostró una sensibilidad del 95% y una especificidad del 87%, con un valor predictivo positivo del 98% y un valor predictivo negativo del 70%. Además se evidenció un buen grado de concordancia mediante el coeficiente kappa (CK) entre los hallazgos radiológicos y quirúrgicos respecto a la existencia de CNV (CK 0,75), al tipo de compresión (CK 0,74) y a la localización (CK 0,72), siendo del grado de concordancia moderado para el grado de compresión (CK 0,48).
Tras un seguimiento medio de 29 meses (rango 6-100 meses), el 81% de los pacientes presentaban un control del dolor sin o con medicación (BNI score i-iii). Los pacientes con un resultado excelente del tratamiento, es decir aquellos sin dolor trigeminal y sin medicación (BNI score i) fueron el 66% al final del seguimiento. El análisis univariante mediante regresión logística binaria demostró que el diagnóstico de una CNV en la RM preoperatoria era un factor pronóstico favorable que incrementaba significativamente la probabilidad de obtener un resultado excelente (OR 0,17, IC del 95%, 0,04-0,72; p 0,02) o aceptable (OR 0,16, IC del 95%, 0,04-0,68; p 0,01) tras la DMV.
La RM DRIVE presenta una elevada sensibilidad y especificidad para el diagnóstico preoperatorio de CNV en pacientes con NT clásica refractaria candidatos a tratamiento mediante DMV. El hallazgo de una CNV en el estudio de RM preoperatorio es un factor de buen pronóstico para la obtención de alivio del dolor a largo plazo con la DMV.
Microvascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery.
This observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression.
Preoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48).
After a mean follow-up of 29 months (range 6-100 months), 81% of the patients reported pain control with or without medication (BNI score i-iiiI). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score i), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favorable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P=.01) after MVD.
DRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD.

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Clinical StudyLong term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflicts of Interest/Disclosures

Surg Neurol

J Clin Neurosci

Int J Radiat Oncol Biol Phys

Neurochirurgie

Surg Neurol

Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945–1984

Ann Neurol

Microvascular decompression vs. gamma knife radiosurgery for typical trigeminal neuralgia: preliminary findings

Stereotact Funct Neurosurg

A prospective cohort study of microvascular decompression and Gamma Knife surgery in patients with trigeminal neuralgia

J Neurosurg

Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia

Neurosurgery

Neurosurgical interventions for the treatment of classical trigeminal neuralgia

Cochrane Database Syst Rev

Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis

J Neurosurg

The long-term outcome of microvascular decompression for trigeminal neuralgia

N Engl J Med

Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis

J Neurol Neurosurg Psychiatry

Clinical Study
Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia