William H. Sweet Young Investigator Award - Microvascular Decompression for Type I Trigeminal Neuralgia: Outcomes Based on a 23-year Cohort Utilizing Vein Sacrifice and Teflon Transposition Technique

Introduction:

Introduction: Microvascular decompression (MVD) is accepted as the most effective surgery for patients with classic trigeminal neuralgia (TN), but controversy remains regarding operative technique.

Methods:

Methods: A prospective registry of 523 patients undergoing MVD for unilateral Type I TN (July 1999-September 2022) was reviewed. Patients with secondary TN, Type II TN, bilateral TN, vertebrobasilar compression, or prior MVD were excluded. The goal at surgery was to have nothing contacting the trigeminal nerve: the superior petrosal vein and veins in contact with the trigeminal nerve were sacrificed, and arteries in contact with the trigeminal nerve were mobilized away from the nerve root whenever possible and secured with Teflon. Partial sensory rhizotomy (PSR) was performed if the vacular compression was insignificant or no vascular compression was noted. Follow-up (median, 7.0 years) was censored at the time additional surgery (n=99, 18.9%) or last clinical contact (n=424, 81.1%). The primary outcome was pain-free survival without medications.

Results:

Results: Most patients were women (n=310, 59.3%), the median age was 63 years, the median pain duration was 5 years, and 109 patients (20.8%) had prior ablative procedures. Operative technique was arterial transposition (n=255, 48.8%), arterial transposition and vein sacrifice (n=182, 34.8%), vein sacrifice (n=64, 12.2%), and PSR (n=22, 4.2%). Initially, 485 patients (92.7%) were pain-free without medications. Pain-free survival estimates at 5, 10, and 15 years were 77.6%, 72.5%, and 69.7%, respectively. Women (HR=1.48, p=0.03) and patients without any venous compression (HR=1.55, p=0.01) had a lower rate of pain-free survival. Thirty-five patients (6.7%) had complications; the most common was wound leakage/infection (n=16, 3.1%) requiring operative revision. Three patients (0.6%) had venous infarctions, and 2 patients (0.4%) had possible Teflon granulomas.

Conclusion :

Conclusions: A non-compressive (no-touch) MVD utilizing venous sacrifice and Teflon implantation provided long-term pain relief for most patients with Type I TN with a low-risk of venous infarction or Teflon granuloma formation.