Microvascular decompression is the only surgical option that allows for long-term pain relief while avoiding any sensory disturbance. In our opinion it remains the treatment of choice for all patients with drug-resistant typical TN.

1. DR AMIT KUMAR GHOSH
Consultant Neurosurgeon
Institute of Neurosciences Kolkata

2. Clinical Neurology and
Neurosurgery
Volume 182, May 2019,
Pages 171-176
Patrick W.HitchonaGirishBathlabToshioMoritanibMarshall
T.HollandaJenniferNoelleraKirill V.Nourskia
a
Department of Neurosurgery, University of Iowa Carver College
of Medicine, Iowa City, IA, USA
b
Department of Radiology, University of Iowa Carver College of
Medicine, Iowa City, IA, USA

3. Diagnosis History
Spontaneous onset
Trigeminal neuralgia, type 1 episodic lancinating pain
Trigeminal neuralgia, type 2 constant pain
Trigeminal injury
Trigeminal neuropathic pain Unintentional, incidental trauma
Trigeminal deafferentation pain Intentional
deafferentation(Radiation,RF etc)
Symptomatic trigeminal
neuralgia
Multiple sclerosis, tumours,
vascular lesions
Postherpetic neuralgia Trigeminal Herpes
zoster outbreak
Atypical facial paina Somatoform pain disorder
From Burchiel KJ. A classification for trigeminal
pain. Neurosurgery. 2003;53:1164–1167.

4. Microvascular decompression is the only surgical option that allows
for long-term pain relief while avoiding any sensory disturbance. In
our opinion it remains the treatment of choice for all patients with
drug-resistant typical TN.
Although the results of microvascular decompression in
patients affected by MS (as well as the results of percutaneous
methods: Broggi et al., 1990) are less satisfactory, about 40%
of MS TN patients were found to be pain-free at long-
term follow-up.
TN1 is the most responsive to microvascular decompression;
however, MVD results in long-term pain control in most patients
with both types 1 and 2 TN.

5. Sixty-nine patients withTN, MRI images,
operative reports, and intraoperative
photographs were retrospectively
reviewed.
Magnetic resonance imaging (MRI)
has been investigated extensively in
its success or failure to identify
preoperative vascular compression in
patients with trigeminal neuralgia
(TN)

6. Review shows that MRI predicted conflict (arterial or venous) in 58
cases that was confirmed at surgery in 55 cases
3 cases--- No conflict found at surgery though MRI
predicted
MRI predicted no conflict in 11 cases, whereas surgery revealed no
conflict in a total of 6 cases.
4 cases--- Conflict present, Though not shown in
MRI
Statiscally, MRI had a sensitivity of 87%, and specificity of 50%,
respectively.
MRI accurately predicted intraoperative conflict (positive predictive
value) in 95% of cases, and the absence of conflict (negative
predictive value) in 27%.
These results reveal that MRI is more accurate in predicting conflict
than the absence of conflict at surgery.

7. Results support the reliance on the clinical diagnosis of TN to
recommend microvascular decompression (MVD) when intractable.
The presence of vascular compression by MRI should encourage the
surgeon to persevere in search of the offending vessel when it
proves elusive
The absence of neurovascular conflict
on high-resolution MRI should not
negate MVD in the treatment of a
patient with classic TN.

8. Thank you