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The long-term outcome of nerve combing for trigeminal neuralgia

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

The purpose of our study was to describe and evaluate the long-term clinical outcome of nerve combing for idiopathic trigeminal neuralgia (TN) with and without vascular compression.

Methods

The study included 60 trigeminal neuralgia patients, 28 of which (Group A) had no visible vascular compression intraoperatively and 32 of which (Group B) had trigeminal nerve root entry zone (REZ) compressed by vascular structure. All patients were considered medical failures prior to the surgeries. All of them underwent trigeminal nerve combing. The following outcome measures were assessed: pain relief, recurrence, complication and time to pain relief.

Results

The median duration of follow-up was 52 months (range 48–96 months) in group A and 56 months (range 48–96 months) in group B. Excellent relief and good relief were noted in 23 patients (82.1 %) and two patients (7.1 %) from group A, respectively, and in 20 (62.5 %) and eight patients (25 %) from group B. The major complication of both groups was facial numbness. And the total complication rate was 15.8 % in group A and 18.8 % in group B. Recurrence was found in one patient in group A and in two in group B by the end of follow-up.

Conclusion

Trigeminal nerve combing is effective in treating TN, but has a much higher pain relief rate in patients without vascular compression than those with vascular compression.

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Abbreviations

TN:

Trigeminal neuralgia

REZ:

Root entry zone

MRI:

Magnetic resonance imaging

NVC:

Neurovascular compression

MVD:

Microvascular decompression

UCSF:

University of California at San Francisco

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Conflicts of interest

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Authors and Affiliations

  1. Department of Otorhinolaryngology Head and Neck Surgery, Shandong Provincial Hospital, Shandong University, Jinan, 250021, China

    Han Jie, Zhou Xuanchen, Luan Deheng, Gao Kun, Xie Fengyang, Cheng Xiang, Wang Xiaoting, Zong Guangxin & Liu Yiqing

Authors
  1. Han Jie
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  2. Zhou Xuanchen
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  3. Luan Deheng
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  4. Gao Kun
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  5. Xie Fengyang
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  6. Cheng Xiang
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  7. Wang Xiaoting
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  8. Zong Guangxin
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  9. Liu Yiqing
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Corresponding author

Correspondence to Liu Yiqing.

Additional information

Comment

The Shandong University’s article on combing of the trigeminal root for treating primary trigeminal neuralgias (TN)—a method currently performed on the facial nerve by ENT surgeons for hemifacial spasms— brings challenging insights. In the Authors’ series, when no vascular compression was found at cerebello-pontine angle exploration, combing of the root was revealed to be effective in 82.1 % of the patients, with a follow-up (FU) of 48 to 96 months (52 months on average). It must be noted, however, that combing provoked facial numbness in 15.8 % of the cases, which is a relatively high percentage of a superior to harmful side-effect. However, this is not superior to what is observed with percutaneous lesioning or stereotactic radiosurgical procedures. Thus, combing of the trigeminal nerve can be considered part of the surgical armamentarium for treating primary TN resistant to medications.

In the same article, the Authors report on combing alone in another group of patients; namely, patients in whom a neurovascular conflict was found at surgery. Relief, without associated microvascular decompression (MVD), was only 62.5 %, with a FU between 48 and 96 months (56 months on average). This logically pleads for performing MVD rather than simple combing in those patients, the more so, as facial numbness after MVD does not exceed 3–4 %, according to most literature publications, as well as our own study [3].

Although not directly addressed by the authors, the question of systematically performing combing is raised in association with root decompression, when a vascular conflict is present. We personally are not in favour of doing so, because of the 15 % rate of facial numbness created by combing. Most published series with long-term Kaplan-Meier analysis show that pure MVD achieves complete cure of the neuralgia in 85 % of the patients after 15 years of FU when a clearcut neurovascular conflict is found and the trigeminal nerve is properly decompressed [1, 3]. Associated combing could be considered if the role of a vascular compression—or better said, cont act—cannot be ascertained. In those cases, our current policy is to (only) free the root, from trigeminal root entry zone to porus of Meckel Cave, from all the (frequently-observed), arachnoidal adhesions.

Another problem would be the justification of an opened approach of the posterior fossa when probability of finding a neurovascular conflict is low to perform (only) combing. Recent studies showed that MRI with high resolution sequences, including 3D-T2, 3D-TOF-angio and 3D-T1 with Gadolinium in association, allow one to detect the presence or absence of a vascular compression. Sensitivity and specificity are of 96.7 % and 100 %, respectively [2]. High resolution 3D MRI also allows one to predict the degree of the vessel compression in 84.6 % of the cases (p < 0.01). It is therefore possible to offer the patients without clear-cut neurovascular conflict at MRI a percutaneous or a radiosurgical lesioning procedure.

Marc SINDOU

University of Lyon

References

1. Barker FG, Jannetta PJ, Bissonnette DJ, Larkins MV, Jho HD (1996) The long-term outcome of microvascular decompression for trigeminal neuralgia. N. Engl J Med 334:1077–108

2. Leal PRL, Hermier M, Froment JC, Souza MA, Cristino-Filho G, Sindou M (2010) Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: a prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia. Acta Neurochir 152:817–825

3. Sindou M; Leston J, Decullier E, Chapuis F (2007) Microvascular decompression for primary trigeminal neuralgia: long-term effectiveness and prognostic factors in a series of 362 consecutive patients with clear-cut neurovascular conflicts who underwent pure decompression. J. Neurosurg 107:1144–1153

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Jie, H., Xuanchen, Z., Deheng, L. et al. The long-term outcome of nerve combing for trigeminal neuralgia. Acta Neurochir 155, 1703–1708 (2013). https://doi.org/10.1007/s00701-013-1804-z

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  • DOI: https://doi.org/10.1007/s00701-013-1804-z

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