Trigeminal neuralgia. Non-invasive techniques versus microvascular decompression. It is really available any further improvement?

Analysis of the results of the various methods for treatment of typical trigeminal neuralgia (TN) based on the literature and personal experience. The personal experience includes 847 cases: total thyzotomy in the posterior fossa 17 cases; rhyzotomy in the posterior fossa sparing the intermediate fibers 16 cases; microvascular decompression (MVD) 141 cases; controlled thermorhizotomy (PTR) 54 cases; Fogarty Balloon compression (FBC) 223 cases; glycerol ganglyolis (PGG) 12 cases; miscellaneous 48 case; medical treatment only 310 cases; cyberknife radiosurgery (CKR) 46 cases. The follow-up in this series is 1-32 years. MVD of the Vth cranial nerve in posterior fossa gives the best results in term of long-term pain relief without collateral effects in drug-resistant TN. Percutaneous techniques (PTR, PGG, FBC) are indicated in patients either without neurovascular conflict or with excessive surgical risk. Stereotactic radiosurgery (SRS) and CKR might be considered an improvement of percutaneous and surgical techniques, but contrary to the expectations, the rate of complete pain relief at long term is lower. SRS and CKR are less effective than MVD which, in spite of the risks it entails, remains the choice treatment for typical trigeminal neuralgia.