Surgical management of trigeminal neuralgia patients with recurrent or persistent pain despite three or more prior operations.

OBJECTIVE: To compare facial pain outcomes from different surgical techniques for patients with idiopathic trigeminal neuralgia (TN) who continue to have persistent or recurrent TN despite multiple operations.
METHODS: Review of a prospective surgical database identified 62 TN patients with ongoing facial pain despite having undergone three or more prior operations (mean = 3.4) from July 1999 to March 2008. The mean patient age was 66.5 years and the mean pain duration was 11.8 years. Twenty-six patients (42%) underwent 33 additional procedures during the follow-up period. In total, 95 operations were performed: posterior fossa exploration (PFE; n = 37, 39%), stereotactic radiosurgery (n = 31, 33%), glycerol rhizotomy (n = 18, 19%), and balloon compression (n = 9, 10%). Follow-up (median = 35 months; range = 1 day to 103 months) was censored at time of subsequent surgery, last patient contact, or death.
RESULTS: Complete pain relief after surgery (no pain, no medications) was 66% at 1 year and 50% at 3 years. Patients having PFE had better facial pain outcomes (70% complete relief at 3 years) compared to other procedures (36% at 3 years) (hazard ratio = 2.6, 95% CI = 1.3-5.1, P < .01). No difference was noted between radiosurgery and the percutaneous techniques. Additional surgery was performed in 8 patients after PFE (22%) compared to 25 patients (48%) after radiosurgery (n = 16), glycerol rhizotomy (n = 7), or balloon compression (n = 2; P = .02).
CONCLUSIONS: Although no procedure is best for all patients, PFE gives the operating surgeon the option of performing either a nondestructive (microvascular decompression) or destructive (partial sensory rhizotomy) procedure and is associated with better facial pain outcomes for this difficult patient group.