Archives

  • 2018-07
  • 2018-10
  • 2018-11
  • 2019-04
  • 2019-05
  • 2019-06
  • 2019-07
  • 2019-08
  • 2019-09
  • 2019-10
  • 2019-11
  • 2019-12
  • 2020-01
  • 2020-02
  • 2020-03
  • 2020-04
  • 2020-05
  • 2020-06
  • 2020-07
  • 2020-08
  • 2020-09
  • 2020-10
  • 2020-11
  • 2020-12
  • 2021-01
  • 2021-02
  • 2021-03
  • 2021-04
  • 2021-05
  • 2021-06
  • 2021-07
  • 2021-08
  • 2021-09
  • 2021-10
  • 2021-11
  • 2021-12
  • 2022-01
  • 2022-02
  • 2022-03
  • 2022-04
  • 2022-05
  • 2022-06
  • 2022-07
  • 2022-08
  • 2022-09
  • 2022-10
  • 2022-11
  • 2022-12
  • 2023-01
  • 2023-02
  • 2023-03
  • 2023-04
  • 2023-05
  • 2023-06
  • 2023-08
  • 2023-09
  • 2023-10
  • 2023-11
  • 2023-12
  • 2024-01
  • 2024-02
  • 2024-03
  • 2024-04

    • Complete immediate postoperative pain relief excellent outco

    2018-10-22

    Complete immediate postoperative pain relief (excellent outcome) was observed in 76.9% of the patients (n=20) and partial resolution (good outcome) in 3.8% (n=1). At 6 months postoperatively, 73.1% of the patients (n=19) reported an excellent outcome, whereas 7.7% (n=2) reported a good outcome. The proportion of excellent and good outcomes was 73.1% in patients (n=19) whose trigeminal nerves were compressed by, or in contact with, an artery and 100% in patients (n=2) with arachnoid thickening attached to the trigeminal nerve. When the trigeminal nerve was compressed by, or in contact with, an artery, 75% of the patients (n=9) in the artery-contact subgroup reported excellent or good outcomes, whereas the ratio of excellent and good outcomes was 100% in patients (n=10) belonging to the nerve distortion subgroup. In the nonartery-conflicting group, one patient reporting an excellent outcome and another reporting a good outcome were associated with the arachnoid-thickening subgroup, whereas one patient reporting a poor outcome and another with a failed procedure were associated with the patient group having venous contact with the trigeminal nerve. In the two patients revealing venous contact of the trigeminal nerve, the veins were left untouched during MVD, and a search was initiated for a nearby artery retracted from the trigeminal nerve. Such an artery was identified in one of the two patients, and the artery was subsequently relocated with a square Teflon with a cleft on one side. This patient experienced immediate and complete relief of facial pain; however, within 1 week postoperatively, the patient reported recurrence of pain that was 50% of the preoperative level. Another patient who continued to complain of persistent symptoms was found to have only venous contact (no arterial acetanilide or contact) with the trigeminal nerve. Table 4 shows the statistical differences in postoperative outcomes considering sex, age, pain location, type of structure contacting or compressing the trigeminal nerve, and type of arterial compression.
    Discussion The clinical application of therapy remains debated for patients in whom pure veins are in contact with the trigeminal nerve entry zone. Jannetta conducted a review of 1204 consecutive cases and reported that a vein was the sole vessel compressing the trigeminal nerve in 13% of the cases. Lee et al reported the development and regrowth of new veins in patients with recurrent TN in whom venous contact or compression had been observed during the original MVD procedure. Piatt and Wilkins addressed this concern by using coagulation and division of the veins in the first part of their study. Owing to poor outcomes, they discontinued this technique and subsequently subjected patients to percutaneous partial sensory rhizotomy (PSR) in the second part of the study. Sindou et al indicated the importance of carefully searching for a hidden additional offending artery when encountering an apparent conflicting vein to avoid possible surgical failure. One of our patients achieved an excellent outcome after the SCA distorting the trigeminal nerve was separated from the nerve without coagulation or division of the conflicting vein (Figure 2). Another patient having multiple small conflicting veins near the root entry zone (Figure 4) reported an immediate excellent outcome after an artery, away from the trigeminal nerve during cerebellar retraction, was bound with Teflon; moreover, those conflicting veins were not coagulated or divided. However, within a week, the patient reported recurrence of pain that was 50% of the preoperative level. One possible reason for this recurrence is the loosening of the Teflon surrounding the artery. These observations indicate that veins contacting the trigeminal nerve, in some cases, play a less crucial role in typical TN. The efficacy of intracranial PSR was reported to be equal to that of MVD in cases with conflicting vessels. Nonetheless, the recurrence rate was significantly higher after PSR than after MVD (49% vs. 6%). In addition, sensory loss after PSR was unavoidable and troublesome to the patient. The topographic divisions of the intracranial trigeminal nerve at the root entry zone are typically V1 at the caudal portion, V2 at the lateral or medial portion, and V3 at the cephalic portion. Implementation of selective PSR with limited coagulation ablation or resection of different portions of the trigeminal nerve according to the preoperative neuralgia distribution might be an option for treating TN with only a conflicting vein.