 |
|
Predictive Model for Pain Recurrence After Posterior Fossa Surgery for Trigeminal Neuralgia
Philip V. Theodosopoulos, MD;
Elysa Marco, MD;
Carol Applebury, RN;
Kathleen R. Lamborn, PhD;
Charles B. Wilson, MD, MSHA
Arch Neurol. 2002;59:1297-1302.
ABSTRACT
| |
Background Surgical exploration of the posterior fossa is the definitive treatment
for trigeminal neuralgia refractory to medication, but predictors of its success
in effecting long-term pain relief have not been established.
Objective To develop a model that allows stratification of patients' risk of postoperative
recurrence of pain based on pretreatment factors.
Methods We reviewed the records of 420 consecutive patients who underwent posterior
fossa exploration by one of us (C.B.W.) for the treatment of idiopathic trigeminal
neuralgia. The primary outcome measure was recurrence of trigeminal pain.
The predictive value of preoperative and intraoperative factors was evaluated.
Multivariate analysis revealed the statistically significant predictors of
pain recurrence, permitting creation of a risk model for recurrence of pain.
Results After surgery, trigeminal pain had lessened in 98% of patients and completely
resolved in 87%. There were no perioperative deaths. After a mean follow-up
of 56.3 months, 93% of patients reported significant pain improvement and
72% continued to have no pain. The estimated likelihood of pain recurrence
at 8 years was 34%. Significant predictors of eventual recurrence of pain
were age younger than 53 years at the time of surgery, symptoms lasting longer
than 11 years, female sex, and pain on the left side in men. These
factors were weighted and incorporated into a risk model that revealed 4-year
pain-free survival of 89% ± 4% for the low-risk group, 80% ±
4% for the moderate-risk group, and 58% ± 6% for the high-risk group
(data are mean ± SD).
Conclusions We developed a predictive model that stratifies the risk for eventual
recurrence of pain after posterior fossa exploration for trigeminal neuralgia.
This information may be useful in counseling patients regarding treatment.
INTRODUCTION
TRIGEMINAL NEURALGIA is one of the most common causes of facial pain.
It is characterized by transient episodes of lancinating pain in the trigeminal
distribution, often precipitated by mild mechanical irritation from activities
such as brushing the teeth or chewing. Although the pathogenesis is controversial,
there are effective treatments. Once medical treatments fail, surgical intervention
may be advocated.1-3
Percutaneous lesions of the trigeminal nerve or ganglion, exploration of the
posterior fossa for microvascular decompression (MVD), partial sensory rhizotomy
(PSR) at the nerve root entry zone, and, more recently, stereotactic radiosurgery
have been shown to ameliorate symptoms.2, 4-47
Among the surgical treatments, posterior fossa exploration is often
the preferred initial treatment, because it affords the highest success rate
with the lowest complication rate.19-21,37
Several studies4, 6, 23, 25, 48-49
have assessed factors that predict pain relief after posterior fossa exploration
for trigeminal neuralgia. A short duration of symptoms, absence of prior destructive
procedures, male sex, and arterial compression of the nerve root entry zone,
either individually or in combination, are predictive of long-term pain relief.
Still, there is no consensus about predictors among the various studies, and
there is no model that incorporates predictors to stratify the risk of postoperative
recurrence based on pretreatment patient characteristics.
We performed this retrospective study to determine predictors of pain
relief after posterior fossa exploration and to create a model for predicting
the risk of pain recurrence.
PATIENTS AND METHODS
PATIENTS
All patients who consecutively underwent posterior fossa exploration
(n = 420) for the treatment of idiopathic trigeminal neuralgia by one of us
(C.B.W.) at our institution between June 1969 and September 1998 were eligible
for inclusion in the study. Patients who had multiple sclerosis, a posterior
fossa lesion (eg, tumor, aneurysm, or vascular malformation), or prior posterior
fossa exploration were excluded. Prior percutaneous procedures for the treatment
of trigeminal neuralgia were allowed.
All procedures were performed by using techniques described elsewhere.50-51 Based on operative findings, patients
were treated by MVD, PSR, or both. Microvascular decompression was performed
when nerve root distortion resulted from external vascular compression. Veins
were coagulated and divided, whereas arteries were dissected away from the
nerve and displaced with a Teflon sponge. In patients without vascular contact,
a PSR was performed. A combination of MVD and PSR was performed in patients
with vascular contact but without deformity of the nerve root.
DATA COLLECTION
After obtaining approval from The University of California, San Francisco,
Committee on Human Research, we reviewed the demographic and clinical characteristics
of all patients. Information about immediate postoperative and long-term trigeminal
pain status was obtained from hospital charts and from letters that patients
had been asked to write annually, after discharge from the hospital. When
no long-term follow-up information was on file, patients were interviewed
by telephone. Information about persistence or recurrence of pain, medication
use, timing of relapse, and additional procedures performed was collected.
STATISTICAL ANALYSIS
Two groups of patients were defined for the purpose of data analysis.
Group A included all patients (n = 420) whose immediate postoperative trigeminal
pain status was known. This group was used for the analysis of immediate postoperative
outcome. The subset of group A (n = 292) with immediate postoperative resolution
of trigeminal pain and follow-up for 12 months or longer was defined as group
B, which was used for the long-term outcome analysis and the development of
a predictive model for pain recurrence. To validate the proposed model, we
randomly divided group B into 2 subgroups in a two-thirds–one-third
ratio. The larger subgroup was used for an analysis that determined the statistically
significant factors for pain recurrence within each subgroup, whereas the
smaller subgroup was used to validate the results of this analysis. The validation
process consisted of 3 independent trials of group B division and analysis.
Predictive factors for immediate postoperative outcome were assessed
by logistic regression analysis. The predictive model for long-term outcome
was generated using Cox regression analysis and proportional hazard calculation.
Factors considered as predictors in all analyses were the patient's sex, age,
side and trigeminal distribution of pain, duration of symptoms, prior percutaneous
procedures, and presence of vascular compression as determined intraoperatively.
Age and duration of symptoms were assessed as dichotomous variables, divided
at a significant cutoff point to simplify the analysis. The logistic and Cox
regressions included univariate analyses, followed by multivariate analysis,
first looking at each pair of factors and their interaction and then including
all factors and any significant interactions. A Kaplan-Meier survival plot
was created for all patients with a postoperative follow-up of 12 months or
longer. Time to recurrence of pain after a successful postoperative outcome
was designated as the midpoint between the patient's latest follow-up evaluation
without pain and the next evaluation when recurrence of pain was reported.
Sensitivity analysis included time to recurrence of pain. Minimum time is defined as the latest follow-up evaluation without
pain and maximum time, as the first follow-up evaluation
with pain recurrence. The results were similar and are not presented. Statistical
significance for all analyses was defined as P =
.05 (2-tailed).
RESULTS
During the study, 648 posterior fossa explorations for trigeminal neuralgia
were performed in 586 patients. Eight patients had posterior fossa tumors,
12 had multiple sclerosis, and 106 had previously undergone 1 or more posterior
fossa explorations. There was insufficient follow-up information for 102 patients.
Group A consisted of 420 patients. The age and sex of the patients for whom
no follow-up information was available were similar to those of the patients
in group A. Group B consisted of 292 patients. Table 1 shows demographic and clinical characteristics for both
groups. There were no differences in baseline characteristics between patients
with and without long-term follow-up.
|
|
|
|
Table 1. Demographic and Clinical Characteristics of 420 Patients Undergoing
Surgical Exploration of the Posterior Fossa as Treatment for Idiopathic Trigeminal
Neuralgia*
|
|
|
There were 225 MVD, 81 PSR, and 114 combination MVD and PSR procedures
performed. After surgery, 98% (n = 411) reported lessening of their pain,
with 87% (n = 367) experiencing complete pain relief and 13% (n = 53) having
some pain persistence.
Univariate and multivariate logistic regression analyses for immediate
postoperative resolution of pain revealed pain on the left side (P = .007) and longer than 11 years' duration of symptoms (P = .04) as significant predictive factors. Involvement
of the V3 distribution of the trigeminal nerve was also a significant predictor
(P = .04) in univariate analysis but was not significant
in multivariate analysis (Table 2).
|
|
|
|
Table 2. Univariate and Multivariate Logistic Regression Analysis Results
for Immediate Postoperative Resolution of Trigeminal Pain*
|
|
|
In group B, 76% (n = 222) of the patients had complete pain relief and
90% (n = 264) had lessening of pain at their latest follow-up evaluation.
The mean duration of follow-up was 56.3 months for all patients followed up
for longer than 12 months and 65.7 months for the subgroup that had no residual
pain at their latest follow-up evaluation. The estimated likelihood of pain
recurrence by 8 years was 34% (Figure 1).
|
|
|
|
Figure 1. Kaplan-Meier curve depicting all
patients with pain recurrence and follow-up for 12 months or longer.
|
|
|
Multivariate analysis revealed age younger than 53 years at the time
of surgery (P<.001), duration of symptoms longer
than 11 years (P = .04), and female sex and
pain on the left side in men (P = .02) as predictors
of long-term pain recurrence (Table 3).
These factors remained significant in all 3 subgroup iterations (results not
shown).
|
|
|
|
Table 3. Univariate and Multivariate Cox Regression Analysis Results
for Long-term Trigeminal Pain Recurrence
|
|
|
Based on the results of the multivariate analysis of long-term outcome
predictors, we developed a model for predicting the risk of eventual recurrence
of pain. Three risk groups were identified—high, moderate, and low risk—depending
on the risk factors each patient possessed. Based on the hazard ratios, we
defined female sex and pain on the left side in men as major risk factors,
and symptom duration of 11 years or longer and age younger than 53
years at the time of surgery as minor risk factors. The low-risk group included
patients with only 1 minor risk factor (n = 65). The moderate-risk group included
patients with only 1 major risk factor (n = 143). The high-risk group included
patients with any combination of 2 or more risk factors (n = 84) (Table 4). A survival curve according to
risk group was then created, including all patients followed up for 12 months
or longer (Figure 2).
|
|
|
|
Table 4. Risk Factors and Their Hazard Ratios Included in the Model
of Long-term Trigeminal Pain Recurrence
|
|
|
|
|
|
|
Figure 2. Kaplan-Meier curve depicting pain
recurrence, stratified according to risk group, for all patients with immediate
postoperative resolution of pain and follow-up for 12 months or longer.
|
|
|
For patients with immediate postoperative pain resolution, pain-free
survival at 4 and 10 years, respectively, after surgery was 89% ± 4%
at both end points for the low-risk group, 80% ± 4% and 71% ±
5% for the moderate-risk group, and 58% ± 6% and 47% ± 7% for
the high-risk group (data are given as mean ± SD). For all patients
followed up for 12 months or longer, regardless of initial pain resolution,
the mean pain-free survival at 4 and 10 years, respectively, was 87% ±
4% at both end points for the low-risk group, 77% ± 4% and 68% ±
5% for the moderate-risk group, and 56% ± 5% and 47% ± 6% for
the high-risk group.
There were no perioperative deaths in this series. Major complications
included hearing loss, hydrocephalus requiring a procedure to divert cerebrospinal
fluid, anesthesia dolorosa, and intracranial hemorrhage (Table 5).
|
|
|
|
Table 5. Rates of Complications in the Perioperative Period for All
420 Patients Undergoing Surgical Exploration of the Posterior Fossa as Treatment
for Trigeminal Neuralgia
|
|
|
COMMENT
Posterior fossa exploration lessened trigeminal pain in 98% of patients
and provided complete pain relief in 87% immediately after surgery. After
a mean follow-up of 56.3 months, 76% of the patients in this series reported
complete pain resolution, while 90% reported significant pain improvement.
These results compare favorably with the results of studies4, 6
of MVD alone in the treatment of idiopathic trigeminal neuralgia, which reveal
a 70% pain resolution rate.
The recurrence of trigeminal pain after initial complete resolution
is an issue that is often raised in the literature and in clinical practice.
For patients who were pain free after surgery, the model of risk for the recurrence
of pain described in this report predicts long-term pain status for low-,
moderate-, and high-risk groups. Younger age,23
duration of symptoms,4-5,12
and female sex4-5,52
have been reported as predictors of long-term pain recurrence. The combination
of male sex and pain on the left side has not been reported as an important
predictor of long-term outcome. The cause of this relationship is unclear.
We found no connection between long-term outcome and type of compression
at the nerve root entry zone, a factor that previous studies4, 6, 17, 52
have related to outcome. Our study is different from those, however, in that
treatment was different for each patient, depending on the presence and type
of compression. As others have previously observed,48
trigeminal neuralgia exists without significant compression of the nerve root,
and in those cases we believe MVD to be inadequate treatment.
Posterior fossa exploration appears to be a safe treatment for trigeminal
neuralgia. The most important morbidities of posterior fossa exploration include
hearing loss (usually secondary to retraction injury to the cochlear nerve),
development of hydrocephalus and cerebrospinal fluid leakage as a result of
perioperative aseptic meningitis, cerebellar hemorrhagic stroke, and death.
In a series of 4400 consecutive posterior fossa explorations for MVD of cranial
nerves, McLaughlin et al21 reported complication
rates as high as 0.9% for cerebellar injury, 2% for hearing loss, and 2.5%
for clinically significant CSF leakage. The overall morbidity rates in our
series are comparable to those previously published, and, unlike previous
reports, this series involved no perioperative mortality. Although one may
argue that a patient's advanced age can lead to unacceptable morbidity, we
withheld posterior fossa exploration only for absolute anesthetic contraindications.
Therefore, our results reinforce the conclusion drawn by Ryu and colleagues30 that posterior fossa exploration can be successful
and safe in older patients.
For the past 10 years, stereotactic radiosurgery has become an alternative
treatment for trigeminal neuralgia. Several studies report complete pain relief
of up to 85% at 1 year53-56
and 56% at 5 years.53 Although maximum radiation
dose was variable among the studies (60-90 Gy), patients treated with 70 Gy
or higher had a statistically increased chance of complete pain relief.
Trigeminal dysfunction, primarily dysesthesias, is the most common complication
of the procedure, with an occurrence rate of 6% to 66%.45, 53-54,56
There is an observed significant association between higher radiation dose
and the development of trigeminal dysesthesias.56
Stereotactic irradiation appears to be a promising treatment for typical
trigeminal neuralgia, but it is not as effective in persistent complete pain
relief as posterior fossa exploration. Given the significantly lower morbidity,
it may be an appealing treatment in patients with recurrences following surgical
exploration or with multiple medical problems and high anesthetic risks.
Our analysis has several limitations. Despite the prospective manner
in which some of the follow-up data were obtained, it is a retrospective review.
The treatment was not uniform, as 3 types of procedures were used. Although
the number of patients represents the second largest published series of patients
undergoing posterior fossa exploration for treatment of trigeminal neuralgia,
the series is too small to permit a completely independent validation group
for the prediction model or to identify risk factors that are less prevalent.
The dichotomous presentation of the various predictors in the long-term outcome
model does not adequately represent clinical practice. Uniform trends were
identified in all the predictors along their range of values, but statistical
considerations and the small size of the patient sample size made it necessary
to include the most significant cutoff values in the model. We believe the
model is illustrative of a continuous risk for pain recurrence, and it should
be used with caution when applied to patients with characteristics close to
the cutoff values.
Despite these limitations, we believe this analysis and the derived
model are accurate. This is a large series of patients who underwent posterior
fossa exploration for 29 years. The same surgeon performed all procedures,
and the selection criteria for which surgery was performed remained unchanged
throughout the series. With regard to the model, the primary analysis was
supplemented with internal validation, which in all 3 iterations showed agreement
in the model development and validation subgroups.
CONCLUSIONS
We report the outcome of posterior fossa exploration for trigeminal
neuralgia and a validated model for risk stratification for eventual recurrence
of trigeminal pain. We expect the model to be a useful instrument in more
accurate decision making about treatment and in better counseling of patients
with trigeminal neuralgia.
AUTHOR INFORMATION
Accepted for publication March 13, 2002.
We thank Susan Eastwood, ELS(D), for critical review and editing of
the manuscript.
Author contributions: Study concept and design (Drs Theodosopoulos, Marco, and Wilson); acquisition of
data (Drs Theodosopoulos, Marco, and Wilson and Ms Applebury); analysis and interpretation of data (Drs Theodosopoulos,
Marco, and Lamborn); drafting of the manuscript (Drs Theodosopoulos, Marco, Lamborn, and Wilson and Ms Applebury);
critical revision of the manuscript for important intellectual content (Drs Theodosopoulos, Marco, and Wilson); statistical expertise (Drs Theodosopoulos and Lamborn); obtained funding (Drs Theodosopoulos and Wilson); administrative, technical,
and material support (Drs Theodosopoulos, Marco, and Wilson
and Ms Applebury); study supervision (Drs Theodosopoulos
and Wilson).
Corresponding author and reprints: Philip V. Theodosopoulos, MD,
Department of Neurological Surgery, The University of California, San Francisco,
505 Parnassus St, Room M787, Campus Box 0112, San Francisco, CA 94143-0112
(e-mail: theodop{at}neurosurg.ucsf.edu).
From the Department of Neurological Surgery, The University of California,
San Francisco, School of Medicine.
REFERENCES
| |
1. Tenser RB. Trigeminal neuralgia: mechanisms of treatment. Neurology. 1998;51:17-19.
FREE FULL TEXT
2. Sweet WH. The treatment of trigeminal neuralgia (tic douloureux). N Engl J Med. 1986;315:174-177.
ISI
| PUBMED
3. Kitt CA, Gruber K, Davis M, Woolf CJ, Levine JD. Trigeminal neuralgia: opportunities for research and treatment. Pain. 2000;85:3-7.
FULL TEXT
|
ISI
| PUBMED
4. Barker II FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal
neuralgia. N Engl J Med. 1996;334:1077-1083.
FREE FULL TEXT
5. Bederson JB, Wilson CB. Evaluation of microvascular decompression and partial sensory rhizotomy
in 252 cases of trigeminal neuralgia. J Neurosurg. 1989;71:359-367.
ISI
| PUBMED
6. Burchiel KJ, Clarke H, Haglund M, Loeser JD. Long-term efficacy of microvascular decompression in trigeminal neuralgia. J Neurosurg. 1988;69:35-38.
ISI
| PUBMED
7. Broggi G, Franzini A, Lasio G, Giorgi C, Servello D. Long-term results of percutaneous retrogasserian thermorhizotomy for
"essential" trigeminal neuralgia: considerations in 1000 consecutive patients. Neurosurgery. 1990;26:783-787.
FULL TEXT
|
ISI
| PUBMED
8. Choi CH, Fisher III WS. Microvascular decompression as a therapy for trigeminal neuralgia. Microsurgery. 1994;15:527-533.
FULL TEXT
|
ISI
| PUBMED
9. Correa CF, Teixeira MJ. Balloon compression of the gasserian ganglion for the treatment of
trigeminal neuralgia. Stereotact Funct Neurosurg. 1998;71:83-89.
FULL TEXT
|
ISI
| PUBMED
10. Goya T, Wakisaka S, Kinoshita K. Microvascular decompression for trigeminal neuralgia with special reference
to delayed recurrence. Neurol Med Chir (Tokyo). 1990;30:462-467.
FULL TEXT
11. Ischia S, Luzzani A, Polati E. Retrogasserian glycerol injection: a retrospective study of 112 patients. Clin J Pain. 1990;6:291-296.
ISI
| PUBMED
12. Apfelbaum RI. Surgery for tic douloureux. Clin Neurosurg. 1983;31:351-368.
PUBMED
13. Ischia S, Luzzani A, Polati E, Ischia A. Percutaneous controlled thermocoagulation in the treatment of trigeminal
neuralgia. Clin J Pain. 1990;6:96-104.
ISI
| PUBMED
14. Jannetta PJ. Microsurgical management of trigeminal neuralgia. Arch Neurol. 1985;42:800.
FREE FULL TEXT
15. Jannetta PJ. Outcome after microvascular decompression for typical trigeminal neuralgia,
hemifacial spasm, tinnitus, disabling positional vertigo, and glossopharyngeal
neuralgia (honored guest lecture). Clin Neurosurg. 1997;44:331-383.
PUBMED
16. Jho HD, Lunsford LD. Percutaneous retrogasserian glycerol rhizotomy: current technique and
results. Neurosurg Clin N Am. 1997;8:63-74.
ISI
| PUBMED
17. Klun B. Microvascular decompression and partial sensory rhizotomy in the treatment
of trigeminal neuralgia: personal experience with 220 patients. Neurosurgery. 1992;30:49-52.
ISI
| PUBMED
18. Kondo A. Follow-up results of microvascular decompression in trigeminal neuralgia
and hemifacial spasm. Neurosurgery. 1997;40:46-52.
FULL TEXT
|
ISI
| PUBMED
19. Lee KH, Chang JW, Park YG, Chung SS. Microvascular decompression and percutaneous rhizotomy in trigeminal
neuralgia. Stereotact Funct Neurosurg. 1997;68(pt 1):196-199.
20. Lovely TJ, Jannetta PJ. Microvascular decompression for trigeminal neuralgia: surgical technique
and long-term results. Neurosurg Clin N Am. 1997;8:11-29.
ISI
| PUBMED
21. McLaughlin MR, Jannetta PJ, Clyde BL, Subach BR, Comey CH, Resnick DK. Microvascular decompression of cranial nerves: lessons learned after
4400 operations. J Neurosurg. 1999;90:1-8.
22. Meglio M, Cioni B, Moles A, Visocchi M. Microvascular decompression versus percutaneous procedures for typical
trigeminal neuralgia: personal experience. Stereotact Funct Neurosurg. 1990;54-55:76-79.
23. Mendoza N, Illingworth RD. Trigeminal neuralgia treated by microvascular decompression: a long-term
follow-up study. Br J Neurosurg. 1995;9:13-19.
FULL TEXT
|
ISI
| PUBMED
24. North RB, Kidd DH, Piantadosi S, Carson BS. Percutaneous retrogasserian glycerol rhizotomy: predictors of success
and failure in treatment of trigeminal neuralgia. J Neurosurg. 1990;72:851-856.
FULL TEXT
|
ISI
| PUBMED
25. Puca A, Meglio M, Cioni B, Visocchi M, Vari R. Microvascular decompression for trigeminal neuralgia: prognostic factors. Acta Neurochir Suppl (Wien). 1993;58:165-167.
PUBMED
26. Rand RW. Leksell gamma knife treatment of tic douloureux. Neurosurg Clin N Am. 1997;8:75-78.
ISI
| PUBMED
27. Rath SA, Klein HJ, Richter HP. Findings and long-term results of subsequent operations after failed
microvascular decompression for trigeminal neuralgia. Neurosurgery. 1996;39:933-940.
ISI
| PUBMED
28. Regis J, Bartolomei F, Metellus P, et al. Radiosurgery for trigeminal neuralgia and epilepsy. Neurosurg Clin N Am. 1999;10:359-377.
ISI
| PUBMED
29. Rose FC. Trigeminal neuralgia. Arch Neurol. 1999;56:1163-1164.
FREE FULL TEXT
30. Ryu H, Yamamoto S, Sugiyama K, Yokota N, Tanaka T. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo). 1999;39:226-230.
FULL TEXT
31. Scrivani SJ, Keith DA, Mathews ES, Kaban LB. Percutaneous stereotactic differential radiofrequency thermal rhizotomy
for the treatment of trigeminal neuralgia. J Oral Maxillofac Surg. 1999;57:104-112.
FULL TEXT
|
ISI
| PUBMED
32. Sindou M, Mertens P. Microsurgical vascular decompression (MVD) in trigeminal and glosso-vago-pharyngeal
neuralgias: a twenty-year experience. Acta Neurochir Suppl (Wien). 1993;58:168-170.
PUBMED
33. Spendel MC, Deinsberger R, Lanner G. Operative treatment of trigeminal neuralgia. Stereotact Funct Neurosurg. 1997;68(pt 1):187-189.
34. Sun T, Saito S, Nakai O, Ando T. Long-term results of microvascular decompression for trigeminal neuralgia
with reference to probability of recurrence. Acta Neurochir (Wien). 1994;126:144-148.
FULL TEXT
35. Taarnhøj P. Decompression of the posterior trigeminal root in trigeminal neuralgia:
a 30-year follow-up review. J Neurosurg. 1982;57:14-17.
ISI
| PUBMED
36. Taha JM, Tew JM Jr, Buncher CR. A prospective 15-year follow up of 154 consecutive patients with trigeminal
neuralgia treated by percutaneous stereotactic radiofrequency thermal rhizotomy. J Neurosurg. 1995;83:989-993.
ISI
| PUBMED
37. Taha JM, Tew JM Jr. Comparison of surgical treatments for trigeminal neuralgia: reevaluation
of radiofrequency rhizotomy. Neurosurgery. 1996;38:865-871.
FULL TEXT
|
ISI
| PUBMED
38. Taha JM, Tew JM Jr. Treatment of trigeminal neuralgia by percutaneous radiofrequency rhizotomy. Neurosurg Clin N Am. 1997;8:31-39.
ISI
| PUBMED
39. Urgosik D, Vymazal J, Vladyka V, Liscak R. Gamma knife treatment of trigeminal neuralgia: clinical and electrophysiological
study. Stereotact Funct Neurosurg. 1998;70(suppl 1):200-209.
40. Wilkinson HA. Trigeminal nerve peripheral branch phenol/glycerol injections for tic
douloureux. J Neurosurg. 1999;90:828-832.
ISI
| PUBMED
41. Yoon KB, Wiles JR, Miles JB, Nurmikko TJ. Long-term outcome of percutaneous thermocoagulation for trigeminal
neuralgia. Anaesthesia. 1999;54:803-808.
FULL TEXT
|
ISI
| PUBMED
42. Young RF, Vermeulen S, Posewitz A. Gamma knife radiosurgery for the treatment of trigeminal neuralgia. Stereotact Funct Neurosurg. 1998;70(suppl 1):192-199.
43. Zakrzewska JM, Jassim S, Bulman JS. A prospective, longitudinal study on patients with trigeminal neuralgia
who underwent radiofrequency thermocoagulation of the gasserian ganglion. Pain. 1999;79:51-58.
FULL TEXT
|
ISI
| PUBMED
44. Kondziolka D, Flickinger JC, Lunsford LD, Habeck M. Trigeminal neuralgia radiosurgery: the University of Pittsburgh experience. Stereotact Funct Neurosurg. 1996;66(suppl 1):343-348.
45. Kondziolka D, Lunsford LD, Flickinger JC, et al. Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional
study using the gamma unit. J Neurosurg. 1996;84:940-945.
ISI
| PUBMED
46. Kondziolka D, Lunsford LD, Habeck M, Flickinger JC. Gamma knife radiosurgery for trigeminal neuralgia. Neurosurg Clin N Am. 1997;8:79-85.
ISI
| PUBMED
47. Kondziolka D, Perez B, Flickinger JC, Habeck M, Lunsford LD. Gamma knife radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol. 1998;55:1524-1529.
FREE FULL TEXT
48. Piatt JH Jr, Wilkins RH. Treatment of tic douloureux and hemifacial spasm by posterior fossa
exploration: therapeutic implications of various neurovascular relationships. Neurosurgery. 1984;14:462-471.
ISI
| PUBMED
49. Barker II FG, Jannetta PJ, Bissonette DJ, Jho HD. Trigeminal numbness and tic relief after microvascular decompression
for typical trigeminal neuralgia. Neurosurgery. 1997;40:39-45.
FULL TEXT
|
ISI
| PUBMED
50. Jannetta PJ. Trigeminal neuralgia [letter]. Neurosurgery. 1986;18:677.
FULL TEXT
51. Zorman G, Wilson CB. Outcome following microsurgical vascular decompression or partial sensory
rhizotomy in 125 cases of trigeminal neuralgia. Neurology. 1984;34:1362-1365.
FREE FULL TEXT
52. Szapiro J Jr, Sindou M, Szapiro J. Prognostic factors in microvascular decompression for trigeminal neuralgia. Neurosurgery. 1985;17:920-929.
ISI
| PUBMED
53. Maesawa S, Salame C, Flickinger JC, Pirris S, Kondziolka D, Lunsford LD. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal
neuralgia. J Neurosurg. 2001;94:14-20.
ISI
| PUBMED
54. Brisman R. Gamma knife radiosurgery for primary management for trigeminal neuralgia. J Neurosurg. 2000;93(suppl 3):159-161.
55. Nicol B, Regine WF, Courtney C, Meigooni A, Sanders M, Young B. Gamma knife radiosurgery using 90 Gy for trigeminal neuralgia. J Neurosurg. 2000;93(suppl 3):152-154.
56. Pollock BE, Phuong LK, Foote RL, Stafford SL, Gorman DA. High-dose trigeminal neuralgia radiosurgery associated with increased
risk of trigeminal nerve dysfunction. Neurosurgery. 2001;49:58-62.
FULL TEXT
|
ISI
| PUBMED
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Affected Side and Risk of Pain Recurrence After Surgery for Trigeminal Neuralgia
Cucchiara and Messe
Arch Neurol 2003;60:1169-1170.
FULL TEXT
|
