This article provides a summary of the operative techniques available for treating patients with trigeminal neuralgia who have medication resistant pain or medication intolerance. Microvascular decompression is performed via suboccipital craniotomy to find and resolve the underlying nerve compression. The authors found 80.3-96% of patients report good initial response rate for pain and 72-85% at five years. Factors associated with better outcomes include: type 1 neuralgias, a greater degree of neuromuscular compression, presence of preoperative trigger points, patients with immediate postoperative pain relief, male gender, absence of venous compression and shorter disease duration. This technique is the most invasive procedure for trigeminal neuralgia with a 4% rate of serious complication and mortality rate of 0.15-0.8%. Complications include trigeminal nerve deficit, facial weakness, hearing loss, aseptic meningitis, hydrocephalus, CSF leak, cerebellar infarct or haematoma and anaesthesia dolorosa. Other treatment modalities include percutaneous treatments which use a needle to access the gasserian ganglion and introduce heat (radiofrequency rhizotomy), chemical injury (glycerol rhizotomy) or mechanical compression (balloon). Radiofrequency rhizotomy has a 97.6-99% initial response rate but percutaneous techniques have poorer long-term response 43.5-80%. They have generally less serious complications than microvascular decompression. Sterotactic radiosurgery can also be of use in patients with multiple failed operative procedures or patients with multiple sclerosis-associated trigeminal neuralgia. The authors found that microvasuclar decompression offers the best long-term outcomes but has associated highest rates of serious complications. They found that percutaneous radiofrequency rhizotomy is the best option for patients who have failed microvascular decompression or are poor operative candidates as it is cost effective with good pain response outcomes and has an advantage over other techniques in being able to selectively target affected trigeminal divisions. This paper has given an informative overview of the varying modalities of interventional approach to trigeminal neuralgia, care for patients is ultimately tailored for their specific needs and associated factors.

Surgical treatment of trigeminal neuralgia.
Bick SKB, Eskandar EN.
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Aaron SJ Ferguson

Victoria Hospital, Kirkcaldy, NHS Fife, UK.

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