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Original Article
1
Surgical Management of Trigeminal Neuralgia in Elderly Patients Using a Small Retrosigmoidal Approach: Analysis of Efficacy and Safety Jaime Jesus Martínez-Anda1Q1 Rogelio Revuelta-Gutierrez1 Q2
Juan Barges-Coll1
Juan Antonio Ponce-Gomez1
1 Department of Q2 Neurological Surgery, National Institute of
Neurology and Neurosurgery Manuel Velasco Suarez, Mexico City, Mexico J Neurol Surg A 2013;00:1–7.
Abstract
Keywords
► trigeminal neuralgia ► microvascular decompression ► elderly
Address for correspondence Jaime Jesus Martinez-Anda, MD, Department of Neurological Surgery, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Av. Insurgentes Sur #3877 Col. La Fama Mexico City Mexico City 14269, Mexico (e-mail:
[email protected]).
Background Trigeminal neuralgia is one of the most common causes of facial pain with the highest incidence in individuals > 60 years old. Despite the proven efficacy and safety of microvascular decompression (MVD) for the treatment of trigeminal neuralgia, some physicians are reluctant to perform the procedure in elderly patients because of potential complications. Material and Methods In the present study, we analyze the outcome of MVDs performed over a 10-year period in elderly patients and compare the results with those obtained in younger patients. A total of 32% of the patients were 65 years of age at the time of diagnosis. All of the patients were treated via a small retrosigmoidal approach because of reluctance for medical treatment. Overall, 87% of the patients exhibited microvascular compression of the fifth nerve in the root entry zone and were treated using MVD; the remainder of the patients were treated using a trigeminal root compression technique when a vessel was not compressing the fifth nerve. Results After the procedure, 93% reported complete relief of pain with a recurrence rate of 10.8% over a mean time of 43 months. A total of 10% of the patients experienced severe complications related to the operation with no mortality. Conclusion MVD continues to be the procedure of choice for the treatment of trigeminal neuralgia in patients reluctant to medical treatment, including elderly patients because age is not a contraindication.
Introduction Trigeminal neuralgia (TN) is one of the most common causes of facial pain. TN is defined by the International Headache Society as “unilateral disorder characterized by brief electric shock-like pains, abrupt in onset and termination, and limited to the distribution of one or more divisions of the trigeminal nerve.”1 TN is a debilitating condition that tends to occur in older patients with a mean age of 51.5 years at diagnosis.2
received May 2, 2012 accepted after revision June 28, 2013
Nadia Perez-Pena1
In 1934, Walter E. Dandy postulated that arterial compression and distortion of the trigeminal nerve might be the cause of TN,3 and Gardner confirmed this postulation in 1962.4 However, TN has not been satisfactorily described, and the current evidence shows that vascular compression alone is not the only cause of TN.5–8 Numerous studies have demonstrated the effectiveness of microvascular decompression (MVD) for treating TN.9–11 Despite the proven efficacy of MVD, some physicians are
© 2013 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1358608. ISSN 2193-6315.
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reluctant to perform posterior fossa procedures in elderly patients.12 The purpose of this study is to describe the outcome of a series of elderly patients diagnosed with TN who were reluctant to have medical treatment and underwent exploration of the cerebellopontine angle by a keyhole retrosigmoidal approach and MVD or nerve root compression of the affected fifth cranial nerve.
Patients and Methods A retrospective study of patients with TN who were surgically treated consecutively from January 2000 to August 2010 at the National Institute of Neurology and Neurosurgery at Mexico City was performed. All of the operations were performed by RRG. MVD was the procedure of choice unless no vessels were causing vascular compression of the trigeminal nerve root or the compression appeared to be minimal based on the surgeon’s judgment. Trigeminal nerve root compression was performed when MVD was not indicated. Medical records, operative videos, and protocols were reviewed, and the following information was recorded: age, sex, preoperative neurologic status, pain distribution and duration, preoperative physical status according to the American Society of Anesthesiologists (ASA) Physical Status Classification System, comorbidity, surgical findings, compressive vessel, and surgical procedure. The main outcome measures were immediate and long-term postoperative pain relief (need for medications), neurologic status focusing on trigeminal and facial nerve function using the House-Brackmann13 (HB) classification, hearing and surgical complications. Pain relief was evaluated using a questionnaire administered during the last neurologic examination with questions related to pain relief, the need for pain medications,
the duration of the pain-free period, the time to recurrence, pain severity, and the need for additional treatment. For analytical purposes, the clinical outcomes were classified into three groups: (1) patients with no pain and no medication needed, (2) patients with pain that was adequately controlled by medication, and (3) patients with pain that was not controlled by medication. Computed tomography or magnetic resonance imaging was performed before surgery in all of the patients. Patients with multiple sclerosis and patients with secondary neuralgia were excluded from the study. The patients were divided into younger (age < 65 years) and older (age 65 years) groups. The morbidity and complication rates in both groups and the functional outcome at early and late follow-up were compared. Mild complications included temporary facial hypoesthesia with conserved corneal sensitivity, temporary facial paresis HB 3, and temporary tinnitus. Severe complications included facial hypoesthesia with corneal ulcers, permanent facial paresis or paresis HB > 3, permanent hypacusis, compromised IX to XII cranial nerves, cerebrospinal fluid leakage, and cardiovascular or respiratory complications.
Operative Technique All of the operations were performed by the senior author (RRG) using a retrosigmoidal approach14 with park-bench positioning of the patient and the head fixed in a MayfieldKees headrest with rotation of 60 degrees and contralateral flexion of 10 degrees for a small retrosigmoidal craniotomy of 2.5 to 3 cm (►Fig. 1A). The dura was opened at the base of the sigmoid sinus, and an intradural dissection was performed at the cerebellopontine angle for cerebrospinal fluid release. In many cases, coagulation and sectioning of the tributaries of the superior petrosal veins was necessary without any
Fig. 1 Microvascular decompression of the trigeminal nerve. (A) Retrosigmoidal keyhole craniotomy. (B) Vascular compression of the right trigeminal root entry zone by the anteroinferior cerebellar artery (AICA). (C) Microvascular decompression separating cranial nerve (CN) V from the AICA with a Teflon sponge. (D) Absence of CN V vascular compression. Journal of Neurological Surgery—Part A
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Surgical Management of Trigeminal Neuralgia complication. In cases with evident vascular compression (►Fig. 1B), the procedure included the application of Teflon sponge fragments between the trigeminal nerve and the offending vessels (►Fig. 1C). When vascular compression was not present or was minimal according to the surgeon (►Fig. 1D), a trigeminal root compression of the nerve was performed; this procedure consists in dissection of the nerve from arachnoid attachments, with careful inspection to be sure that no offending vessels were present, and then a gentle compression on the cisternal segment of the nerve, and isolation of the nerve with Teflon sponge fragments without altering the root direction, as described by the senior author.15,16
Statistical Analysis A chi-square test was used to analyze statistically the difference between elderly and younger patients. A significant relationship was reported when the p value was < 0.05.
Results Clinical Characteristics Between January 2000 and August 2010, 301 patients were treated for primary TN; 271 of the patients were treated
Martínez-Anda et alQ10.
surgically, and 30 patients were referred to the radiosurgery unit after declining surgery. Of the 89 patients who were 65 years of age (32.8%), 25 patients were male, 64 patients were female, the female-to-male ratio was 2.6:1, 76 patients were between 65 and 75 years of age, 13 patients were > 75 years, and the oldest patient was 82 years at the time of diagnosis. The mean time of course of neuralgia was 6.5 years (range: 4 months to 40 years). The pain was lateralized on the right side in 68 cases (76.4%) and the left side in 21 cases (23.59%). The pain was most commonly distributed in the V2 to V3 region (42.69%). One of the patients reported combined trigeminal pain with glossopharyngeal neuralgia on the same side. A statistically significant difference was observed between both groups with regard to the laterality of pain and the V2 to V3 region distribution (►Table 1). The preoperative physical status was ASA I in 26 patients (29.2%) , ASA II in 51 patients (57.3%), ASA III in 11 patients (12.35%), and ASA IV in 1 patient (1.1%). Forty-three patients exhibited one comorbidity (48.31%), and 13 patients exhibited two or more comorbidities (14.6%). Eleven patients had type 2 diabetes mellitus (12.35%), 49 patients had systemic arterial hypertension (55%), three patients had chronic obstructive pulmonary disease (3.3%), three patients had ischemic heart disease (3.3%), and three patients had dyslipidemia (3.3%). A
Table 1 Clinical characteristics < 65 y n ¼ 182
> 65 y n ¼ 89Q3
p value
2.25:1
2.6:1
0.650
Right
112/182 (61.53)
68/89 (76.4)
0.01
Left
70/182 (38.46)
21/89 (23.59)
0.01
V1
6/182 (3.2)
3/89 (3.33)
0.955
V1 þ V2
33/182 (18.13)
12/89 (13.4)
0.334
V2
36/182 (19.78)
15/89 (16.85)
0.562
Q3 Gender ratio (F:M) Laterality (%)
Distribution (%)
V2 þ V3
55/182 (30.21)
38/89 (42.69)
0.042
V3
39/182 (21.4)
16/89 (17.97)
0.440
V1 þ V2 þ V3
13/182 (7.14)
5/89 (5.6)
0.635
DM
18/182 (9.8)
11/89 (12.35)
0.536
SAH
37/182 (20.3)
49/89 (55.05)
< 0.0001
Others
12/182 (6.5)
9/89 (10.11)
0.308
ASA I
115/182 (63.18)
26/89 (29.21)
< 0.0001
ASA II
61/182 (33.5)
51/89 (57.3)
0.0002
Comorbidity (%)
ASA
ASA III
6/182 (3.2)
11/89 (12.35)
0.0039
ASA IV
–
1/89 (1.1)
–
Abbreviations: ASA, American Society of Anesthesiologists Physical Status Classification System; DM, diabetes mellitus; F:M, female-to-male ratio; SAH, systemic arterial hypertension. Journal of Neurological Surgery—Part A
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Table 2 Surgical findings < 65 y n ¼ 182
Q5
> 65 y n ¼ 189Q5
p value
Vascular structure PICA
6/182 (3.2%)
3/89 (3.3%)
0.974
AICA
23/182 (12.6%)
19/89 (21.3%)
0.627
SUCA
98/182 (53.84%)
42/89 (47.1%)
0.303
Basilar artery
2/182 (1%)
3/89 (3.3%)
0.191
Superior petrosal vein
10/182 (5.5%)
3/89 (3.3%)
0.442
More than one vascular structure
10/182 (5.5%)
8/89 (8.9%)
0.278
Minimal vascular contact
12/182 (6.5%)
3/89 (3.3%)
0.275
No vascular contact
11/182 (6%)
8/89 (8.9%)
0.372
Abbreviations: AICA, anteroinferior cerebellar artery; PICA, posteroinferior cerebellar artery; SUCA, superior cerebellar artery.
statistically significant difference was observed with regard to the comorbidities and the ASA classification between the groups, with older patients exhibiting worse ASA ratings (►Table 1).
Medical Treatment All of the patients underwent at least 6 months of medical management with carbamazepine and/or gabapentin before surgical treatment was indicated; six patients reported adverse effects of carbamazepine and were treated only with gabapentin and nonsteroidal anti-inflammatory drugs. Only 39 patients (43%) reported some relief with medical treatment, but the pain was not controlled in any of the patients; therefore, all of the patients were classified in group 3.
Surgical Findings Of the 89 elderly patients, 78 (87.6%) had a vessel compressing the trigeminal nerve at or near the root entry zone (►Fig. 1B), 3 patients had a vessel with minimal contact with the trigeminal nerve, and 8 patients had no vessels contacting the nerve (►Fig. 1D) (►Table 2). The 78 patients with vascular compression of the trigeminal nerve were treated with a standard microvascular decompression procedure to isolate the nerve from the compressing vessel with Teflon sponge fragments. The 11 patients without vascular compression or with minimal contact of a vessel underwent a trigeminal root compression with isolation of the nerve from the surrounding structures with Teflon sponge fragments. There was no
statistically significant difference in the surgical findings between the groups (►Table 2).
Clinical Outcome Complete pain relief after the procedure (group 1) was reported in 83 (93%) of the 89 elderly patients subjected to the surgical procedure. The mean follow-up time was 36 months (range: 3 months to 10 years). Recurrence was reported in 9 (10.8%) of the 83 patients with pain remission; the mean time of recurrence was 43 months (range: 15 days to 7 years). Three of the six patients without pain remission experienced no improvement (group 3), and the other three improved to group 2 because their pain was controlled with medication. Three of the nine patients with pain recurrence experienced recurrence to group 3; pain was adequately controlled with medication in the remainder of the patients (group 2). The patient with trigeminal and glossopharyngeal neuralgia and no recurrence of TN required reoperation for recurrence of glossopharyngeal neuralgia and was included in group 1. No statistically significant difference was noted in the surgical outcome between the groups, as seen in ►Table 3.
Reoperation Five patients were reoperated with exploration and microvascular decompression immediately after the procedure Q6or after pain recurrence; all of these patients were in group 3. Three of
Table 3 Surgical outcome < 65 y n ¼ 182
Q5
> 65 y n ¼ 89Q5
p value
Remission (%)
172/182 (94.5)
83/89 (93)
0.682
Recurrence (%)
35/182 (20.3)
9/89 (10.8)
0.055
Mild complications (%)
30/182 (16.4)
18/89 (20.2)
0.4487
Severe complications (%)
14/182 (7.6)
9/89 (10.1)
0.502
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Surgical Management of Trigeminal Neuralgia the patients experienced complete pain relief (group 1) after the procedure, and the other two patients experienced no improvement. One patient who experienced recurrence to group 3 was referred to radiosurgery with improvement to group 2.
Complications The complication rate was 30.3% (27 patients) including 18 patients with mild complications (20.2%) and 9 patients with severe complications (10.1%). The most common complication was postoperative mild facial hypoesthesia (14.6%); three patients experienced temporary facial paresis HB 3. Only one patient had postoperative facial paresis HB > 3 with facial hypoesthesia; the patient also developed a corneal ulcer. Three patients developed a cerebrospinal fluid leak that remitted with conservative maneuvers (lumbar drainage). One patient experienced dysphagia in the postoperative period, which remitted after 1 month and required no further treatment. Only one patient experienced a cardiovascular complication in the postoperative period after developing a hypertensive crisis in the first hours after the procedure, which was adequately controlled. No statistically significant difference was noted with regard to the mild and severe complication rates between elderly and younger patients.
Discussion The incidence of TN increases with age. Therefore, neurosurgeons frequently encounter older patients with TN. TN involves incapacitating pain that impairs daily functioning, quality of life, well-being, sleep, mood, and overall health status.17
Therapeutic Options
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Many pharmacologic options are currently available including carbamazepine as a first–line therapy. Even with maximal medical treatment, only 69% of the patients reported acceptable pain control, and after prolonged use, the percentage decreased to 50%.18 Several options are available for patients who are refractory to medical treatment. MVD for TN was first reported by Gardner4 in 1962 and was subsequently popularized by McLaughlin et al19 and by Jannetta.20 Numerous studies have demonstrated the effectiveness and durability of MVD for patients with primary TN. MVD achieves the most effective results, with published studies showing that pain is completely relieved in 70 to 91% of patients and reduced in another 6 to 7.6%.9–11,19 Alternative treatments have been proposed for the management of elderly patients with TN because of the assumed risk associated with surgery and the shorter remaining life expectancy.21 Radiosurgery is the least invasive option available, and its advantages include short procedure duration and the need for only local anesthesia. However, radiosurgery is associated with poorer long-term pain control and a higher incidence of recurrences compared with MVD.22 Percutaneous procedures are associated with high recurrence rates (17.4–46%) primarily related to thermocoagulationQ7.23
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Efficacy of Microvascular Decompression in Elderly Patients Because MVD is the first-line of treatment, and the world population is aging, increasing interest has been paid to evaluating the safety and efficacy of MVD in older patients.24–29 MVD treatment in elderly patients has been examined in several small case series summarized in a meta-analysis by Sekula and colleagues30 and a recent meta-analysis published by Rughani et al.31 Both meta-analyses independently reported that the efficacy of MVD was not statistically significantly different between younger and older patients. The authors established an age cut-off of 65 years because the in-hospital mortality rate rises, as does the risk of cardiac, pulmonary, thromboembolic, and cerebrovascular complications, in elderly patients. In the present study, we report the outcome of patients treated in a single institution over 10 years by a single surgeon. We found that treatment efficacy was similar in the elderly and younger patients. The rates of remission after the procedure were not significantly different between the groups and were consistent with the results reported in the literature.24,28,29,32,33 Other therapeutic options are available for TN that are less invasive but not as effective as MVD, which thus remains the procedure of choice.24 Patients reluctant to undergo MVD can be reoperated with good resultsQ8. Five patients were reoperated in this series, including three patients with pain remissionQ9. Radiosurgery is also an option for patients who do not accept reoperation or with pain that persists after a second surgery. We referred one patient to radiosurgery, and this patient then experienced pain improvement. The TN treatment algorithm should ensure that all of the options are explained to the patient before the first surgery. The patients in this study were operated on over a 10-year period and were followed up for varying periods of time. We observed a 10% recurrence rate in elderly patients and a 20% recurrence rate in younger patients, but these rates were not significantly different between the groups. The rates we observed were similar to the rates reported in previous articles. The recurrence of pain has been reported to occur from several days to 20 years after surgery. The risk of recurrence appears to decrease over time, with higher rates in the first 5 years after treatment. The treatment options include reoperation and radiosurgery. When both procedures fail, the best option is controversial.32,33
Safety of Microvascular Decompression in Elderly Patients The increased surgical risk in elderly patients is theoretically inferred from statistics showing increased hospital morbidity and mortality in elderly patients. MVD usually requires the patient to be admitted the day before the procedure and discharged 1 or 2 days after the procedure. We found that the safety of the MVD procedure was similar in the elderly and younger patients, with no statistically significant difference in the complication rates between the groups. The complication rates appear to be high compared with the results of previously published papers27,32,33; 20% of the Journal of Neurological Surgery—Part A
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patients developed mild, and 10% severe complications. In only one patient the neurologic deficit persisted, whereas the other patients experienced only transient deficits. Facial hypesthesia is the most common complication, followed by facial paresis. Both complications can result from simple surgical manipulation of the nerves or vasculature and are transient in most cases. Thus, facial hypesthesia and facial paresis mostly require no treatment because they resolve within 1 month after surgery. Cerebrospinal fluid leakage after surgery can be hazardous if it is not detected and properly treated. All of the patients who presented with cerebrospinal fluid leakage responded to a 3- to 5-day trial of a lumbar drain. If the patients do not respond within this period, re-operations for dural closure should be considered because of the risk of infection. Cardiovascular status and comorbidities do not appear to increase the surgical risk in elderly patients, as shown in ►Table 1. A statistically significant difference was observed between the elderly and younger patients with regard to the ASA classification and comorbidities, including SAH. The older patients typically had poorer preoperative statuses. However, the poorer preoperative status did not affect the surgical safety of MVD. The short duration of the procedure, nol bleeding, appropriate preoperative evaluation, and teamwork between the anesthesiologist and the surgeon all contribute to the high safety profile of the operation. The risk of coagulation of the petrosal vein of Dandy should also be considered because it is sometimes required for adequate exposure of the cerebellopontine angle. Ischemic complications occasionally have been associated with this maneuver,34 although we experienced no complications related to petrosal vein coagulation. We believe that coagulation of the petrosal vein can be performed safely if required, as reported previously by McLaughlin et al.19
Conclusions MVD is a safe and effective procedure for TN, even in elderly patients. No difference was observed in the results compared with the younger patients, and the risk of serious morbidities or death was not increased. Thus MVD continues to be the treatment of choice in patients with medically refractory TN irrespective of age.
References 1 International Classification Subcommittee of the International
2
3 4 5
6
7
8 9
10
The Role of the Trigeminal Root Compression Procedure Previous works report that no vascular compression or other etiology can be found in 3.1 to 17% of cases of TN.14 These cases represent a medical and surgical challenge because of the empirical nature of the treatment.35 Manipulation with minimal trauma has been reported to be the only therapeutic effect in patients with TN treated by MVD.36 Currently, most surgeons prefer partial sensory rhizotomy,37 and “nerve combing” may be an effective surgical method for some cranial nerve dysfunction syndromes including TN and hemifacial spasms.38 Inspection of the trigeminal nerve in a circumferential fashion allowed us to detect a compressing vessel at or near the root entry zone in 78 patients (87.6%). A vessel with minimal contact with the trigeminal nerve was observed in three patients (3.3%), and no vessel contacted the nerve in eight patients (8.9%). For the cases in which vessel contact was minimal or no vascular compression was observed, we performed a trigeminal root compression procedure, which was previously described by the senior author (RRG) to exhibit efficacy and safety results similar to MVD in patients with a vessel compressing the trigeminal nerve.15,16 Journal of Neurological Surgery—Part A
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12
13 14
15
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Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24(Suppl 1):9–160 Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC. Incidence of facial pain in the general population. Pain 2009;147(1–3):122–127 Dandy WE. The treatment of trigeminal neuralgia by the cerebellar route. Ann Surg 1932;96(4):787–795 Gardner WJ. Concerning the mechanism of trigeminal neuralgia and hemifacial spasm. J Neurosurg 1962;19:947–958 Devor M, Amir R, Rappaport ZH. Pathophysiology of trigeminal neuralgia: the ignition hypothesis. Clin J Pain 2002;18(1): 4–13 Love S, Hilton DA, Coakham HB. Central demyelination of the Vth nerve root in trigeminal neuralgia associated with vascular compression. Brain Pathol 1998;8(1):1–11; discussion 11–12 Marinković S, Gibo H, Todorović V, et al. Ultrastructure and immunohistochemistry of the trigeminal peripheral myelinated axons in patients with neuralgia. Clin Neurol Neurosurg 2009; 111(10):795–800 Møller AR. Vascular compression of cranial nerves: II: pathophysiology. Neurol Res 1999;21(5):439–443 Broggi G, Ferroli P, Franzini A, Servello D, Dones I. Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2000;68(1):59–64 Mendoza N, Illingworth RD. Trigeminal neuralgia treated by microvascular decompression: a long-term follow-up study. Br J Neurosurg 1995;9(1):13–19 Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71(15): 1183–1190 van Loveren HR, Tew JM Jr, Keller JT, Nurre MA. A 10-year experience in the treatment of trigeminal neuralgia. Comparison of percutaneous stereotaxic rhizotomy and posterior fossa exploration. J Neurosurg 1982;57(6):757–764 House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93(2):146–147 Van Rompaey J, Bush C, McKinnon B, Solares AC. Minimally invasive access to the posterior cranial fossa: an anatomical study comparing a retrosigmoidal endoscopic approach to a microscopic approach. J Neurol Surg A Cent Eur Neurosurg 2013;74(1):1–6 Revuelta-Gutiérrez R, López-González MA, Soto-Hernández JL. Surgical treatment of trigeminal neuralgia without vascular compression: 20 years of experience. Surg Neurol 2006;66(1):32–36; discussion 36 Revuelta-Gutierrez R, Martinez-Anda JJ, Coll JB, Campos Romo A, Perez-Peña N. Efficacy and safety of root compression of trigeminal nerve for trigeminal neuralgia without evidence of vascular compression. World Neurosurg 2012; August 10 (Epub ahead of print)
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Vol. 00
No. 00/2013
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Author Query Form (JNLSA/120679oa) Special Instructions: Author please write responses to queries directly on proofs and then return back. Q1: AU: As per the latest Thieme guidelines, to make searching authors online easier, a standard rule of disallowing diacritical marks in authors’/contributors’ names has been put into effect. Please confirm your approval on changing the spelling of the author’s name from “Jesús” to “Jesus” here and in the citation of the corresponding author; from Gómez to Gomez; and from Peña to Pena. Q2: AU: Please check the affiliation for accuracy. Q3: AU: What you are doing with a patient of 65 years? There must be either > or or or
