Vascular Decompression in Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing and recurrent pain within one or more branches of the trigeminal nerve. Although multiple mechanism involving peripheral pathologies at root (compression or traction), dysfunctions of brain stem, basal ganglion and cortical pain modulatory mechanisms could have role, neurovascular conflict (NCV) is most accepted theory. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, and glycerol rhizotomy and radiofrequency thermocoagulation procedures. Microvascular decompression (MVD) is surgical treatment of choice in TN resistant to medical management. There may be multiple NVC and entire course of root from pons to ganglion should be decompressed. Nerve combing or partial sensory root sectioning can be combined with MVD when no vascular conflict is detected intraoperative. Successful outcome after MVD in typical TN is 90-95%and 75% at 1and 5 years respectively. Immediate postoperative pain relief, shorter preoperative duration, older age, and typical features are good predictors of favorable outcome. Type 2 TN, presence of autonomic symptoms; multiple sclerosis is associated with poor prognosis. Compression or contact on the root by the prosthesis should be avoided to prevent recurrence. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict including ventral aspect. Effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.