Endoscope-assisted neurectomy and inferior alveolar nerve avulsion in treating trigeminal neuralgia

doi:10.1016/j.jcms.2017.06.008

Journal of Cranio-Maxillofacial Surgery

Volume 45, Issue 9, September 2017, Pages 1531-1534

https://doi.org/10.1016/j.jcms.2017.06.008 Get rights and content

Abstract

Objective

To explore endoscope-assisted surgical treatment for idiopathic trigeminal neuralgia (TN), with neurectomy and avulsion of the inferior alveolar nerve (IAN), when patients are not willing to undergo intracranial procedures.

Clinical materials and methods

Five TN patients with inferior alveolar neuralgia in the mandibular branch were admitted; endoscope-assisted inferior alveolar neurectomy and avulsion was performed for TN treatment. Clinical observation and postoperative follow-up were conducted.

Results

After the operation, all patients had complete relief of pain, with mild postoperative swelling, limited mouth opening, and fast recovery. Patients were followed up for 3–24 months. Facial numbness and paresthesia were felt in the IAN distribution area of the operated side, with no recurrence.

Conclusion

Endoscope-assisted neurectomy and avulsion of the IAN is a safe surgical method to treat TN in the mandibular branch when craniotomy is contraindicated or when patients decline neurosurgical options. It is effective in pain relief, with limited invasiveness and speedy recovery.

Introduction

Idiopathic trigeminal neuralgia (TN) mostly affects the maxillary and mandibular branches. Clinical manifestations typically include paroxysmal, lancinating, electric, and agonizing pain in the nerve distribution area. This is usually brief (for a few seconds), but can last up to minutes. This usually occurs among patients aged 40 years and over, and is more common among women (Manzoni and Torelli, 2005). Although clinical symptoms related to TN have been well characterized and documented in detail, the disease mechanism and etiopathogenesis are still not well understood. Current treatment of TN mainly involves medical treatment and surgical intervention. Drug therapy is usually the first line of treatment, but pain control becomes more challenging over time. Surgical options include a range of treatment modalities, including microvascular decompression (MVD), percutaneous radiofrequency thermocoagulation (PRT), peripheral neurectomy, radiofrequency rhizotomy, etc. – offering a wide choice. To date, however, there is yet to be a treatment method that can satisfactorily result in permanent remission without risks of severe adverse effects.

Currently, MVD is considered the optimal surgical method with the highest initial efficacy and durability (Sekula et al., 2011). Nevertheless, it is an open-skull operation and associated with severe, though rare, complications, such as diplopia, thromboembolism, cranial nerve injury, cerebellar syndrome, facial paralysis, and even death. The patient's fitness for surgery is a factor of concern in the decision-making process, and the surgeon's level of experience is of considerable importance in the success of this procedure (Xia et al., 2014).

Peripheral neurectomy – a destructive treatment option – is a common surgical approach for TN, especially in rural areas or regions without advanced medical facilities (Agrawal and Kambalimath, 2011, Ali et al., 2012). It is considered minimally invasive yet effective, but is often accompanied with swelling of the surgical area, limited mouth opening, slow recovery, and pain recurrence, in which case repeat surgeries are considered.

In this case series, we explored the endoscopic approach with neurectomy and avulsion of the IAN, and had satisfactory outcome, with postoperative follow-up over 3–24 months.

Section snippets

Clinical data

Five TN patients with inferior alveolar neuralgia, unwilling to consider neurosurgery options, were admitted to the surgical ward of the Department of Oral and Maxillofacial Surgery at the First Affiliated Hospital of Sun Yat-sen University, between February 2013 and February 2016 (see patient profile in Table 1). There were three female and two male patients, 51–73 years of age. The right IAN was operated on for three patients, and the left IAN for two patients. The average length of complaint

Results

All five patients reported complete relief of pain after the surgery, with numbness of the lower lip and paresthesia on the operated side, mild swelling at the external site of the pterygomandibular ligament incision, and limited mouth opening (4 cm). Normal mouth opening resumed 3 days after the operation.

All patients were followed up with return visits over 3–24 months and no recurrence of pain was reported. Postoperative numbness of the lower lip continued, but was gradually tolerated by the

Discussion

The etiology and pathogenesis of TN are not entirely clear, although the clinical features and presentations have been systematically documented and well recognized. Treatment considerations for TN mostly feature pharmacological treatment and surgical interventions. Medical treatment, often with oral carbamazepine, is initially an effective management of the condition; but patients often become non-responsive to the drug therapy over time, and require surgical options as pain becomes

Conclusion

Compared with conventional surgical methods, endoscope-assisted neurectomy and IAN avulsion to treat TN in the mandibular branch has the following advantages: 1) limited invasiveness, minimized incision and reduced surgical bleeding; 2) clear and stable surgical field vision to locate the IAN, the mandibular lingula, the mandibular foramen, and the mandibular canal in the very narrow pterygomandibular space; 3) reduced surgical time; 4) speedy postoperative recovery.

Conflicts of interest statement

None declared.

Acknowledgements

None.

References (11)

S. Zhu et al.
Pterygopalatine fossa segment neurectomy of maxillary nerve through maxillary sinus route in treating trigeminal neuralgia
J Craniomaxillofac Surg
(2013)
S.M. Agrawal et al.
Peripheral neurectomy: a minimally invasive treatment for trigeminal neuralgia. A retrospective study
J Maxillofac Oral Surg
(2011)
F.M. Ali et al.
Peripheral neurectomies: a treatment option for trigeminal neuralgia in rural practice
J Neurosci Rural Pract
(2012)
S. Chandan et al.
Peripheral neurectomy: minimally invasive surgical modality for trigeminal neuralgia in Indian population. A retrospective analysis of 20 cases
J Maxillofac Oral Surg
(2013)
J. Guo et al.
Treatment of a subtype of trigeminal neuralgia with descending palatine neurotomy in the pterygopalatine fossa via the greater palatine foramen-pterygopalatine canal approach
J Craniomaxillofac Surg
(2014)

There are more references available in the full text version of this article.

Cited by (5)

Endoscopic Infraorbital Microdissection for Localized V2 Trigeminal Neuralgia
2020, Journal of Oral and Maxillofacial Surgery
Trigeminal neuralgia is a chronic and debilitating syndrome characterized by short paroxysms of lancinating facial pain. Patients may be medically managed; however, in cases of medically refractory trigeminal neuralgia, surgical management is often required. Our objective was to present and describe a technique for endoscopic microdissection of the infraorbital nerve, a peripheral method of management for refractory V2 trigeminal neuralgia in patients without evidence of neurovascular compression. The technique is designed to spare sensation in unaffected portions of the V2 distribution. We present 2 patients with medically refractory V2 trigeminal neuralgia localized to the lateral midface who underwent infraorbital microdissection. After first confirming that there was no neurovascular compression on imaging in these patients, we administered infraorbital bupivacaine injections to localize the symptomatic nerve. The nerve was then accessed via a 1.5-cm buccogingival incision, and the connective tissue sheath was incised. The nerve fascicles were bluntly separated, and the symptomatic branches were cauterized with fine-tipped monopolar cautery. Both patients reported complete resolution of their pain postoperatively and were pain free at last follow-up. They reported some hypoesthesia in the lateral face; however, they retained some sensation in the medial upper lip, midface, and nose. Infraorbital microdissection is a safe and effective technique for symptomatic management of V2 trigeminal neuralgia while sparing sensation in asymptomatic portions of the dermatome.
Minimally Invasive Trigeminal Ablation: Transoral Approach for Targeting V2
2018, World Neurosurgery
Citation Excerpt :
Five-year pain-free survival was 47%; however, prior surgical therapy for TN is a poor prognostic factor.13 Though a transoral technique has previously been reported with complete nerve transection,14 minimally invasive partial trigeminal ablation (MITA) has been shown to provide significant pain relief without complete nerve transection.15 Unmyelinated pain (type C) fibers appear to have increased sensitivity to thermal injury when compared with myelinated general sensory nerves, possibly explaining their increased amenity to ablation via thermal cautery without causing severe postoperative numbness.16
Trigeminal neuralgia (TN) is a chronic orofacial pain syndrome, which manifests as severe pain in the distribution of any trigeminal nerve branch. Though traditionally responsive to anticonvulsant therapy, TN can become refractory to medications and require surgical intervention.
We present a case of V2 TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of type 1 TN and had failed the maximum tolerated doses of carbamazepine and gabapentin. There was no evidence of vascular compression on neuroimaging. After the patient refused stereotactic radiosurgery, she was offered minimally invasive trigeminal ablation. At 5 months postoperatively the patient reported complete alleviation of pain with tolerable sensorineural numbness.
The endoscopic approach allows for precise targeting of V2, which is ideal in patients undergoing targeted neuroablation for pain. This is the first documented case of a transoral endoscopic approach toward ablative V2 TN management.
Minimally Invasive Trigeminal Ablation: Novel Transoral Technique for Targeted Treatment of V3
2018, World Neurosurgery
Citation Excerpt :
The approach, when compared with more invasive procedures, may provide equivalent pain relief while being an outpatient procedure with lower risk profiles and shorter operative time. An endoscopic transoral approach has been previously described; however, the trigeminal nerve was completely transected.8 Alternative surgical approaches for TN can be classified into nondestructive or destructive categories.
Trigeminal neuralgia (TN) is a chronic orofacial pain syndrome that presents with debilitating shooting pains in the V3 nerve distribution. The condition is traditionally responsive to anticonvulsant therapy; however, cases that become refractory to medications often require surgical intervention.
We present a case of TN that was treated with minimally invasive trigeminal ablation. The patient presented with a 6-year history of TN that had been resistant to medical management. The patient opted for minimally invasive management, refused stereotactic radiosurgery, and was treated using the minimally invasive trigeminal ablation approach. At 16 weeks postoperatively, the patient reported complete alleviation of pain with minimal sensorineural numbness.
The endoscopic approach allows for precise targeting through visual guidance, which is ideal in patients undergoing neuroablation for pain within specific nerve distributions. This is the first documented case of an endoscopic minimally invasive transoral approach toward ablative TN management.
Peripheral Neurectomy: Minimally Invasive Surgical Modality for Trigeminal Neuralgia: A Retrospective Study
2023, Medical Forum Monthly
Treatment of Facial Pain with i Ching Balance Acupuncture
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¹: These authors contributed equally to this work.

View full text

Endoscope-assisted neurectomy and inferior alveolar nerve avulsion in treating trigeminal neuralgia

Abstract

Objective

Clinical materials and methods

Results

Conclusion

Introduction

Section snippets

Clinical data

Results

Discussion

Conclusion

Conflicts of interest statement

Acknowledgements

J Craniomaxillofac Surg

Peripheral neurectomy: a minimally invasive treatment for trigeminal neuralgia. A retrospective study

J Maxillofac Oral Surg

Peripheral neurectomies: a treatment option for trigeminal neuralgia in rural practice

J Neurosci Rural Pract

Peripheral neurectomy: minimally invasive surgical modality for trigeminal neuralgia in Indian population. A retrospective analysis of 20 cases

J Maxillofac Oral Surg

Treatment of a subtype of trigeminal neuralgia with descending palatine neurotomy in the pterygopalatine fossa via the greater palatine foramen-pterygopalatine canal approach

J Craniomaxillofac Surg