Introduction
Methods
Patient cohort
Preoperative data collection
Surgical details of microvascular decompression
Postoperative evaluation
Statistical analysis
Ethical approval
Results
Patient cohort
Characteristics | Data |
---|---|
Ratio male:female, nPAT (%) | 77:88 (46.7%:53.3%) |
Age (yr) at TGN onset, median (range) | 49 (17–74) |
Duration of symptoms (years), mean (SD) | 7.6 ± 5.9 |
Reason of patient to undergo MVD, nPRO (%) | |
1 Uncontrollable pain | 123 (71.9%) |
2 Side effects of medication | 6 (3.5%) |
3 Combination of 1 and 2 | 40 (23.4%) |
4 Patients wish | 2 (1.2%) |
Age (yr) at MVD surgery, median (range) | 57 (21–78) |
Previous neurodestructive surgery, n (%) | 18 (10.5%) |
Previous MVD surgery, n (%) | 6 (3.5%) |
IHS classification of trigeminal pain - MRI, nPRO (%) | |
Classical | 67 (39.2%) |
Idiopathic | 102 (59.6%) |
Unknown | 2 (1.2%) |
Pain category, nPRO | |
Purely paroxysmal pain, n (%) | 94 (55%) |
Concomitant continuous pain 2, n (%) | 38 (22.2%) |
Not specified | 39 (22.8%) |
IHS classification of trigeminal pain - intraoperative finding, nPRO (%) | |
Classical | 129 (75.4%) |
Idiopathic | 41 (24%) |
Unknown | 1 (0.6%) |
Vessel causing neurovascular conflict at first surgery, nPAT (%) | |
Artery | 82 (49.7%) |
Vein | 22 (13.3%) |
Artery and vein | 55 (33.3%) |
No neurovascular conflict | 5 (3%) |
Unknown | 1 (0.6%) |
Most frequent arterial compressions, n = 135(%) | |
SCA | 93 (68.9%) |
AICA | 12 (8.9%) |
AICA and SCA | 11 (8.2%) |
BA | 1 (0.7%) |
Unspecified | 18 (13.3%) |
Affected nerve branch, nPRO (%) | |
V1 only | 1 (0.6%) |
V2 only | 32 (18.7%) |
V3 only | 33 (19.3%) |
V1 and V2 | 21 (12.3%) |
V1 and V3 | 2 (1.2%) |
V2 and V3 | 53 (31%) |
V1 and V2 and V3 | 29 (17%) |
Affected side, nPAT (%) | |
Left | 62 (37.6%) |
Right | 102 (61.8%) |
Bilateral | 1 (0.6%) |
Preoperative BNI score, nPRO | |
III | 5 (2.9%) |
IV | 24 (14%) |
V | 142 (83%) |
Preoperative facial numbness n (%) | 27 (15.8%) |
Classification of trigeminal neuralgia
Surgical procedure
Surgeon ID | Level of experience in CPA surgery | Caseload n (%) n = 171 | Major complications n (%) n = 14 | Pain recurrence n (%) n = 68 |
---|---|---|---|---|
S1 | High | 85 (49.7) | 6 (42.9) | 36 (52.9) |
S2 | Moderate | 20 (11.7) | 3 (21.4) | 6 (8.8) |
S3 | High | 14 (8.2) | 1 (7.1) | 4 (5.9) |
S4 | High | 12 (7) | 2 (14.3) | 5 (7.4) |
S5 | Moderate | 12 (7) | 0 (0) | 3 (4.4) |
S6 | High | 8 (4.7) | 0 (0) | 3 (4.4) |
S7 | Low | 5 (2.9) | 0 (0) | 3 (4.4) |
S8 | Low | 4 (2.3) | 2 (14.3) | 2 (2.9) |
S9 | Moderate | 3 (2) | 0 (0) | 3 (4.4) |
S10 | High | 2 (1.2) | 0 (0) | 1 (1.5) |
S11 | Low | 2 (1.2) | 0 (0) | 0 (0) |
S12 | High | 1 (0.6) | 0 (0) | 0 (0) |
S13 | High | 1 (0.6) | 0 (0) | 1 (1.5) |
S14 | Low | 1 (0.6) | 0 (0) | 0 (0) |
S15 | Moderate | 1 (0.6) | 0 (0) | 1 (1.5) |
Postoperative and long-term outcome after MVD
Characteristics | Favorable outcome (n = 103) | Unfavorable outcome (n = 60) | p value | n | |
---|---|---|---|---|---|
Age (yr) | 56.7 ± 11.7 | 54.9 ± 9.9 | 0.3158 | 163 | |
Sex | Male | 49 | 29 | 0.9253 | 163 |
Female | 54 | 31 | |||
Duration of symptoms (yr) | 6.4 ± 5.3 | 7.4 ± 4.4 | 0.0316* | 138 | |
Age at disease onset (yr) | 49.1 ± 11.1 | 47.4 ± 9.5 | 0.3314 | 161 | |
Pain category | Paroxysmal pain | 61 | 29 | 0.0228* | 125 |
Concomitant continuous pain | 16 | 19 | |||
Previous surgery for TGN | No | 89 | 51 | 0.8034 | 163 |
Yes | 14 | 9 | |||
Nerve branch involvement | Single | 37 | 24 | 0.6039 | 163 |
Multiple | 66 | 36 | |||
Side of TGN | Right | 63 | 34 | 0.5226 | 163 |
Left | 39 | 26 | |||
Bilateral | 1 | 0 | |||
Compression | Artery + Mixed | 89 | 46 | 0.3342 | 163 |
Vein | 11 | 12 | |||
No compression | 3 | 2 | |||
BNI facial numbness score | I | 84 | 42 | 0.1864 | 164 |
II | 12 | 10 | |||
III | 7 | 8 | |||
IV | 0 | 1 |
Complications
Complications and side effects | n (%) |
---|---|
Mortality | 0 (0%) |
Minor complications | 42 (24.6%) |
BNI facial numbness score II | 26 (15.2%) |
Tinnitus | 2 (1.2%) |
Vertigo | 2 (1.2%) |
Intermittent hearing deficit | 3 (1.8%) |
Wound healing problem | 1 (0.6%) |
Major complications | 14 (8.2%) |
CSF fistula | 4 (2.3%) |
Hygroma | 1 (0.6%) |
Cerebellar hemorrhage | 1 (0.6%) |
Cerebellar infarction | 2 (1.2%) |
Facial palsy | 2 (1.2%) |
Permanent ipsilateral hearing loss | 2 (1.2%) |
Trochlear palsy | 2 (1.2%) |
BNI facial numbness score III | 15 (8.8%) |
BNI facial numbness score IV | 1 (0.6%) |
Expected side effects | |
Intraoperative bradycardia treated with atropine | 19 (11.1%) |
Patient ID | Age at MVD | ASA Score | Sufficient surgical experience | Patient positioning | Prior ipsilateral posterior fossa surgery | Description of complication | Length of hospital stay | Transfer to another clinic | Long-term Pain outcome |
---|---|---|---|---|---|---|---|---|---|
TN00156 | 64 | 2 | Yes | Lateral | No | Displacement of the trochlear nerve together with the SCA during decompression resulted in a 1-year-long trochlear nerve palsy with double vision | 8 | No | Good; BNI III |
TN00183 | 67 | 2 | Yes | Lateral | Yes | CSF fistula after second posterior fossa surgery without bone replacement and atrophic neck muscles makes revision surgery necessary | 16 | No | Bad; BNI IV |
TN00224 | 68 | 2 | Yes | Lateral | no | Intraoperative coagulation of multiple draining veins causes venous cerebellar congestive bleeding that does not require any surgical intervention. Increased hospitalization due to postoperative decompensation of a pre-existing bilateral vocal cord paralysis after resection of a squamous cell carcinoma, neck dissection and radiation which necessitates a tracheostomy | 45 | ENT | Good; BNI I |
TN00272 | 59 | 2 | Yes | Lateral | No | Development of a right hemispheric hygroma with pronounced mid-line shift 3 weeks after discharge led to a soporous condition and an emergency operation with emptying via a burr hole | 8 | No | Good; BNI I |
TN00273 | 62 | 2 | No | Prone | No | Intraoperatively confusing situation with unintentional opening of the sigmoid sinus. The vestibulocochlear nerve was mistaken for the trigeminal nerve. MVD lead to a left-sided AICA infarction with accompanying facial palsy (House-Brackmann Grade III, ipsilateral hearing loss, dizziness and a tendency to fall to the right | 10 | Neurorehabilitation | Good; BNI I |
TN00283 | 59 | 2 | Yes | Lateral | No | Insufficient patient positioning causes massive venous congestion and brain swelling that cannot be controlled by intraoperative cerebellopontine CSF drainage and repositioning of the head. Abort of the operation. No neurologic deficits | 6 | No | Bad; BNI III |
TN00290 | 51 | 2 | Yes | Lateral | Yes | CSF fistula that heals after a lumbar drain has been placed for five days | 14 | No | Bad; BNI V |
TN00322 | 59 | 2 | Yes | Supine | No | Opening of mastoid cells leads to rhinoliquorrhea and consecutive revision surgery despite covering with muscle and fibrin glue | 18 | No | Good; BNI I |
TN00333 | 57 | 1 | Yes | Prone | No | No NVC. Combing of the trigeminal nerve root results in a BNI facial numbness score of IV | 8 | No | Bad; BNI V |
TN00340 | 51 | 1 | Yes | Lateral | No | Postoperative temporary trochlear palsy which makes it necessary to wear prism glasses for a short time. The nerve was not seen intraoperatively. No abnormal findings in postoperative imaging | 8 | No | Good; BNI I |
TN00344 | 42 | 1 | Yes | Lateral | No | Postoperative ipsilateral hearing loss. No abnormal intraoperative findings. No abnormal findings in postoperative imaging | 8 | No | Good; BNI I |
TN00366 | 38 | 1 | Yes | Lateral | Yes | Successful treatment of CSF fistula after a lumbar drain had been placed for six days | 17 | No | Good; BNI I |
TN00399 | 40 | 1 | No | Lateral | Yes | Second MVD makes it necessary to loosen scarring with otherwise normal operative course. Postoperative facial paralysis (House-Brackmann Grade II) without abnormal findings in the postoperative CT scan. Clinical deterioration on the fifth postoperative day with pronounced ataxia and a wide-legged gait. The MRI examination showed a small, demarcated, subacute infarct area pontocerebellar without bleeding | 8 | Neurorehabilitation | Good; BNI I |
TN00406 | 34 | 2 | Yes | Lateral | No | Opening of mastoid cells leads despite covering with muscle, fibrin glue and TachoSil® to rhinoliquorrhea at postoperative day three. Lumbar drain was successfully placed for 7 days | 11 | No | Bad; BNI IV |