Bilateral trigeminal neuralgia: a therapeutic dilemma.

In order to illustrate the inherent problems of managing bilateral trigeminal neuralgia a retrospective study of the 16 cases of bilateral trigeminal neuralgia, out of just over 300 cases of trigeminal neuralgia, treated over a 14-year period, has been performed. All the patients, presented with a typical history of trigeminal neuralgia and underwent surgical exploration. Pain relief was initially achieved in all cases; however, only four remained cured, three have become pain free after additional rhizotomy, a further one after peripheral cryotherapy and four with medical treatment. Four patients have had bilateral operations for trigeminal neuralgia, but in two cases the pain was relieved on one side only. Bilateral trigeminal neuralgia presents special problems of management with respect to underlying neuropathology (e.g. multiple sclerosis), the need for the limitation of the use of ablative techniques in order to minimise the disability of bilateral sensory and motor dysfunction, and the relatively poor response to microvascular decompression. These factors emphasize the multifactorial nature of the cause of trigeminal neuralgia. Magnetic resonance tomographic angiography is now available and is important in determining the range of therapeutic options for this group of patients.