ABSTRACT
Introduction Surgical intervention is most commonly considered when trigeminal neuralgia is refractory to medical management. Circumstances constituting failure of medical therapy should be determined by both doctor and patient. Certainly, persistence of pain despite rigorous trial of medications, either individually or in combination, should lead to a consideration of surgical options. Even a patient whose pain is initially well controlled medically may eventually become a surgical candidate if the condition becomes refractory to treatment. Furthermore, a significant number of patients whose pain is otherwise controlled become functionally incapacitated by the side effects of medication. The most common side effects from medication are often described as cognitive slowness or dullness that is unacceptable to patients. Thus, doctors medically managing trigeminal neuralgia need to carefully consider patients’ complaints regarding the side effects and be open to discuss the possibility of a surgical alternative. The ideal surgical procedure for the treatment of trigeminal neuralgia would produce long-lasting pain relief and minimal neurological deficit, and would be simple and safe to administer.1 Many procedures are currently available for trigeminal neuralgia and some of the more commonly used include: microvascular decompression, glycerol rhizotomy, balloon decompression, radio frequency rhizotomy, and gamma knife radiosurgery. There are no randomized controlled trials to guide comparisons of their relative safety and efficacy of the various surgical procedures.2 In the absence of randomized comparisons, the relative advantages and disadvantages of these various surgical procedures have been debated.3,4 Surgical intervention may generate a very powerful placebo response that ethically cannot be controlled for. Other major questions surrounding surgery concern which patients are likely to benefit most from which procedure and at what point over the course of their
disease. For example, the major predictors of recurrence in a large case series receiving microvascular decompression included female sex, symptoms lasting more than 8 years, and venous compression of the trigeminal root entry zone.5 What this suggests is the need for greater research on the mechanisms of trigeminal neuralgia, including gender-related mechanisms, research on more advanced preoperative imaging technology, and research on matching patients with treatment, including the timing of the procedure relative to the duration of symptoms.
