Repeat Surgery for Recurrent or Refractory Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

Alan R Rheaume; Matthew Pietrosanu; Curtis Ostertag; Tejas Sankar

doi:10.1016/j.wneu.2024.02.097

Repeat Surgery for Recurrent or Refractory Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

World Neurosurg. 2024 May:185:370-380.e2. doi: 10.1016/j.wneu.2024.02.097. Epub 2024 Feb 24.

Authors

Alan R Rheaume¹, Matthew Pietrosanu², Curtis Ostertag³, Tejas Sankar⁴

Affiliations

¹ Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
² Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada.
³ Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
⁴ Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada. Electronic address: tsankar@ualberta.ca.

PMID: 38403014
DOI: 10.1016/j.wneu.2024.02.097

Abstract

Objective: Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited data exist to guide the selection of salvage surgical procedures. We aimed to compare pain relief outcomes after repeat microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS) to determine which modality was most efficacious for surgically refractory TN.

Methods: A PRISMA systematic review and meta-analysis was performed, including studies of adults with classical or idiopathic TN undergoing repeat surgery. Primary outcomes included complete (CPR) and adequate (APR) pain relief at last follow-up, analyzed in a multivariate mixed-effect meta-regression of proportions. Secondary outcomes were initial pain relief and facial numbness.

Results: Of 1299 records screened, 61 studies with 68 treatment arms (29 MVD, 14 PR, and 25 SRS) comprising 2165 patients were included. Combining MVD, PR, and SRS study data, 68.8% achieved initial CPR after a repeat TN procedure. On average, 49.6% of the combined sample of MVD, PR, and SRS had CPR at final follow-up, which was on average 2.99 years postoperatively. The proportion (with 95% CI) achieving CPR at final follow-up was 0.57 (0.51-0.62) for MVD, 0.60 (0.52-0.68) for PR, and 0.35 (0.30-0.41) for SRS, with a significantly lower proportion of pain relief with SRS. Estimates of initial CPR for MVD were 0.82 (0.78-0.85), 0.68 for PR (0.6-0.76), and 0.41 for SRS (0.35-0.48).

Conclusions: Across MVD, PR, and SRS, about half of TN patients maintain complete CPR at an average follow-up time of 3 years after repeat surgery. In treating refractory or recurrent TN, MVD and PR were superior to SRS in both initial pain relief and long-term pain relief at final follow-up. These findings can inform surgical decision-making in this challenging population.

Keywords: Microvascular decompression; Percutaneous rhizotomy; Recurrent; Repeat surgery; Stereotactic radiosurgery; Trigeminal neuralgia.

Publication types

Systematic Review
Meta-Analysis
Review

MeSH terms

Humans
Microvascular Decompression Surgery* / methods
Radiosurgery* / methods
Recurrence
Reoperation* / statistics & numerical data
Rhizotomy* / methods
Treatment Outcome
Trigeminal Neuralgia* / surgery