Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression

Andrew L. Ko, Alp Ozpinar, Albert Lee, Ahmed Raslan, Shirley McCartney, Kim Burchiel

Research output: Contribution to journalArticle

56 Citations (Scopus)

Abstract

OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or "nerve combing," as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.

Original languageEnglish (US)
Pages (from-to)1048-1057
Number of pages10
JournalJournal of Neurosurgery
Volume122
Issue number5
DOIs
StatePublished - May 1 2015

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Trigeminal Neuralgia
Safety
Pain
Hypesthesia
Microvascular Decompression Surgery
Therapeutics
Facial Pain
Macrophage Colony-Stimulating Factor
Survival
Radiosurgery
Magnetic Resonance Angiography
Age Distribution
Kaplan-Meier Estimate
Telephone

Keywords

  • BAEP = brainstem auditory evoked potential
  • BNI = Barrow Neurological Institute
  • BPI = Brief Pain Inventory
  • functional neurosurgery
  • gangliolysis
  • GKS = Gamma Knife surgery
  • HR = hazard ratio
  • IN = internal neurolysis
  • internal neurolysis
  • microvascular decompression
  • MVD = microvascular decompression
  • neurovascular compression
  • NVC = neurovascular compression
  • pain
  • PSR = partial sensory rhizotomy
  • QOL = quality of life
  • REZ = root entry zone
  • RFL = radiofrequency gangliolysis
  • rhizotomy
  • TN = trigeminal neuralgia
  • trigeminal neuralgia

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression. / Ko, Andrew L.; Ozpinar, Alp; Lee, Albert; Raslan, Ahmed; McCartney, Shirley; Burchiel, Kim.

In: Journal of Neurosurgery, Vol. 122, No. 5, 01.05.2015, p. 1048-1057.

Research output: Contribution to journalArticle

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abstract = "OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or {"}nerve combing,{"} as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85{\%} of patients pain free and 96{\%} of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58{\%} and 47{\%}, respectively. Successful pain relief at those intervals was maintained in 77{\%} and 72{\%} of patients. Almost all patients experienced some degree of numbness or hypesthesia (96{\%}), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.",
keywords = "BAEP = brainstem auditory evoked potential, BNI = Barrow Neurological Institute, BPI = Brief Pain Inventory, functional neurosurgery, gangliolysis, GKS = Gamma Knife surgery, HR = hazard ratio, IN = internal neurolysis, internal neurolysis, microvascular decompression, MVD = microvascular decompression, neurovascular compression, NVC = neurovascular compression, pain, PSR = partial sensory rhizotomy, QOL = quality of life, REZ = root entry zone, RFL = radiofrequency gangliolysis, rhizotomy, TN = trigeminal neuralgia, trigeminal neuralgia",
author = "Ko, {Andrew L.} and Alp Ozpinar and Albert Lee and Ahmed Raslan and Shirley McCartney and Kim Burchiel",
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TY - JOUR

T1 - Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression

AU - Ko, Andrew L.

AU - Ozpinar, Alp

AU - Lee, Albert

AU - Raslan, Ahmed

AU - McCartney, Shirley

AU - Burchiel, Kim

PY - 2015/5/1

Y1 - 2015/5/1

N2 - OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or "nerve combing," as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.

AB - OBJECT Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or "nerve combing," as a treatment for TN without NVC. METHODS This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. RESULTS A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. CONCLUSIONS This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.

KW - BAEP = brainstem auditory evoked potential

KW - BNI = Barrow Neurological Institute

KW - BPI = Brief Pain Inventory

KW - functional neurosurgery

KW - gangliolysis

KW - GKS = Gamma Knife surgery

KW - HR = hazard ratio

KW - IN = internal neurolysis

KW - internal neurolysis

KW - microvascular decompression

KW - MVD = microvascular decompression

KW - neurovascular compression

KW - NVC = neurovascular compression

KW - pain

KW - PSR = partial sensory rhizotomy

KW - QOL = quality of life

KW - REZ = root entry zone

KW - RFL = radiofrequency gangliolysis

KW - rhizotomy

KW - TN = trigeminal neuralgia

KW - trigeminal neuralgia

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