Long-term results of microvascular decompression with video endoscopy in the treatment of patients with atypical trigeminal neuralgia

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Background: The incidence of atypical trigeminal neuralgia (aNTN) varies from 1 to 7 per 100,000 population per year. The main cause of its development is compression of the trigeminal nerve (TN) root by a vein and/or artery in the cerebellar cistern. To date, the final tactics of treatment for patients with aNTN has not been specified. The effectiveness of conservative methods of therapy does not exceed 50%.

The aim of this study was to evaluate the results of microvascular decompression using video endoscopy in the treatment of patients with atypical trigeminal neuralgia.

Methods: In the period from 2014 to 2021, 34 patients with aNTN were operated on, of which 18 (53%) patients had neuropathic pain (more than 4 points on the DN4 scale), and 15 (44%) patients had transformation of classical trigeminal neuralgia into atypical neuralgia. The conservative therapy (carbamazepine, gabapentin, pregabalin), administered to all the patients in the preoperative period, was not accompanied by a significant relief of pain syndrome. The maximum intensity of pain upon admission to the hospital was, according to the visual analog scale (VAS), 10 points, according to the BNI (Barrow Neurological Institute) Pain Intensity Scale — V (severe, persistent pain). All the patients underwent microvascular decompression of the trigeminal nerve root with the use of Teflon; in 12 (35%) patients, in addition to microscopy, video endoscopy was used. The average follow-up period after the surgery was 3.4±1.7 years (from 1 to 5 years).

Results: In all (100%) patients, the pain was completely eliminated (BNI I) after the surgery. A total five-year excellent and good outcome of the disease on the J. Miller and BNI scale (I -II) was noted in 80% (n=27) of patients with aNTN. The risk of pain recurrence after microvascular decompression was 14% (n=3) in the first three years, and 34% (n=4) after 5 years. The use of video endoscopy made it possible to identify the blood vessels compressing the root of the trigeminal nerve with a minimal displacement of the cerebellum and cranial nerves when visualizing the neurovascular conflict.

Conclusion: The microvascular decompression method with video endoscopy is effective in the treatment of patients with aNTN.

About the authors

Aleksey G. Vinokurov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: avinok@yandex.ru

MD, PhD

Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Aleksandr A. Kalinkin

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Author for correspondence.
Email: aleksandr_kalinkin27@mail.ru
ORCID iD: 0000-0002-1605-9088

MD, PhD

Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Andrey А. Bocharov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: nsi7@mail.ru
ORCID iD: 0000-0001-8970-3762

MD, PhD

Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Sergey M. Chupalenkov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: chupalenkovsm@gmail.com
ORCID iD: 0000-0001-5994-3124
Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Viktor N. Lesnyak

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: Iesnyak_kb83@mail.ru
ORCID iD: 0000-0002-2739-0649
SPIN-code: 5483-3113

MD, PhD

Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Gaukhar M. Yusubalieva

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency; Engelhardt Institute of Molecular Biology of the Russian Academy of Sciences

Email: gaukhar@gaukhar.org
ORCID iD: 0000-0003-3056-4889
SPIN-code: 1559-5866

MD, PhD

Russian Federation, 28, Orekhovy boulevard, Moscow, 115682; Moscow

Evgeniya S. Kazmina

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: Evg.k@bk.ru
ORCID iD: 0000-0002-3715-5140
Russian Federation, 28, Orekhovy boulevard, Moscow, 115682

Olga N. Kalinkina

Moscow State University of Medicine and Dentistry named after A.I. Evdokimov

Email: sunny1917@mail.ru
ORCID iD: 0000-0001-5538-904X

MD

Russian Federation, Moscow

Vsevolod V. Belousov

Federal center of brain research and neurotechnologies

Email: belousov@fccps.ru
ORCID iD: 0000-0001-6637-8098
SPIN-code: 6517-8373

Corresponding Member of the RAS, Doctor of Biological Sciences

Russian Federation, Moscow

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2. Fig. 1. Magnetic resonance imaging of the brain in the FIESTA mode in the axial (а, б) and frontal (в) planes in patients with trigeminal neuralgia, depending on the severity of the neurovascular conflict on the M. Sindou scale [12]: а — I degree; б — II degree; в — III degree. The red arrow indicates the blood vessel, the white arrow indicates the root of the trigeminal nerve.

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3. Fig. 2. Patient M. with trigeminal neuralgia due to the neurovascular conflict against the background of basilar artery dolichoectasia: а — preoperative images in the frontal plane, compression and dislocation of the trigeminal nerve (white arrow) by the basilar artery (red arrow) is determined; б — intraoperative images of the trepanation window measuring 3×4 cm; в — intraoperative images after dissections of the basilar artery (red arrow) from the root of the trigeminal nerve (white arrow); г — intraoperative images after installing a Teflon gasket (black arrow) between the basilar artery (red arrow) and the trigeminal nerve (white arrow).

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4. Fig. 3. Patient A. with trigeminal neuralgia against the background of the neurovascular conflict, which was detected by intraoperative video endoscopy: а, б — magnetic resonance imaging of the brain in the FIESTA mode in the axial (а) and frontal planes, which revealed the neurovascular conflict between the superior cerebellar artery (red arrow) and the root of the trigeminal nerve (white arrow); в — intraoperative images from a microscope, in which the neurovascular conflict was not detected (arrow); г — intraoperative images from the Minop Invent endoscope (viewing angle 30°), which revealed the superior cerebellar artery (red and black arrow) in the projection of the exit of the trigeminal nerve root from the pons (white arrow); д — after microvascular decompression, the superior cerebellar artery was visualized (arrow); е — a Teflon gasket (arrow) was installed between the nerve and the artery.

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5. Fig. 4. Intraoperative images of the stages of microvascular decompression of in patient A. with trigeminal neuralgia: а — a visualized neurovascular conflict, which is caused by the passage of an artery and vein (black arrow) through the sensitive (green arrow) and motor (white arrow) portions of the root; б — after dissection of the sensitive portion of the root (green arrow) and coagulation with vein crossing, complete decompression of the trigeminal nerve root (white arrow) was performed with preservation of the superior cerebellar artery (red arrow); в — intraoperative images after installing a Teflon gasket (white arrow).

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