Tag: Pain

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The utility of partial sensory rhizotomy and adjunct procedures in the surgical management of trigeminal neuralgia secondary to multiple sclerosis

J Neurosurg 144:1145–1153, 2026

This clinical study evaluates long-term outcomes of partial sensory rhizotomy (PSR) for trigeminal neuralgia (TN) secondary to multiple sclerosis (MS), comparing PSR alone, redo PSR, and PSR combined with microvascular decompression (MVD) or internal neurolysis (IN). Retrospective analysis of 37 procedures in 30 patients shows high immediate pain relief (89.2%), mean recurrence at 1.64 years, and variable durability across groups.

At final follow-up, combination therapy (PSR+MVD or PSR+IN) trended toward superior sustained pain freedom without increased complications, while first PSR commonly required additional interventions. The authors conclude PSR is an effective salvage option and suggest adjunctive MVD or IN may improve long-term outcomes, recommending prospective validation.

Objective Evaluate long-term outcomes of partial sensory rhizotomy (PSR) alone versus PSR combined with microvascular decompression (MVD) or internal neurolysis (IN) for trigeminal neuralgia secondary to multiple sclerosis.

Methods Retrospective review of PSR cases (2012–2023) grouped as first PSR, redo PSR, PSR+MVD, and PSR+IN; assessed pain outcomes, recurrence, and complications.

Cohort 30 patients underwent 37 procedures; 89.2% of procedures followed at least one prior ipsilateral TN procedure.

Immediate outcomes 89.2% achieved immediate postoperative pain relief (pain free with or without medication), with no significant differences between procedure groups.

Durability Pain recurred on average at 1.64 ± 1.71 years after the procedure, with no significant differences among groups.

Final follow-up pain freedom At mean 3.14 ± 2.58 years follow-up, 75% of PSR+MVD and 100% of PSR+IN cases were pain free; 52.3% of first PSR cases required additional procedures.

Complications Overall complication rate was 29.7% with no significant differences between groups; ipsilateral facial numbness was common (59.5%) and treated as an expected outcome rather than a complication.

Conclusion PSR functions effectively as a salvage option for MS-related TN, and adding MVD or IN may improve long-term pain relief without increasing complication rates.

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Long-term outcomes of microvascular decompression for trigeminal neuralgia in multiple sclerosis

J Neurosurg 144:1122–1133, 2026

This systematic review and meta-analysis evaluates microvascular decompression (MVD) outcomes for trigeminal neuralgia in patients with multiple sclerosis (TN-MS). The authors pooled 30 studies (265 unique TN-MS patients), finding neurovascular compression in 96.6% and a pooled long-term pain-free (BNI I) success rate of about 30%, with low heterogeneity and primarily transient sensory complications.

The report discusses limited, mostly retrospective evidence, methodological limitations, and potential dual mechanisms of TN in MS. Authors conclude MVD yields lower success than in classic TN but remains a reasonable option for selected TN-MS patients with demonstrable neurovascular compression; they call for prospective studies and refined patient selection.

Objective Evaluate long-term pain relief and complications of microvascular decompression (MVD) for trigeminal neuralgia in patients with multiple sclerosis (TN-MS), a group traditionally considered poor candidates for MVD.

Methods Systematic review/meta-analysis (PRISMA) of PubMed, Embase, Scopus, and Web of Science (search June 2024); primary endpoint was long-term pain-free status BNI I at final follow-up using random-effects meta-analysis of proportions.

Evidence base 30 studies were included, covering 429 TN-MS patients treated with MVD, representing 265 unique patients.

Neurovascular compression Compression was identified in 96.6% of reported TN-MS cases (via MRI and/or intraoperative findings).

Long-term efficacy Pooled long-term pain-free outcome (BNI I) after MVD was 30.2% (95% CI 24.2%–36.9%), with low heterogeneity across analyses.

Complications The most commonly reported complication after MVD was transient facial numbness (with other complications variably reported).

Interpretation MVD is less effective in TN-MS than in classic TN, but can still provide meaningful benefit, particularly when neurovascular compression is present.

Conclusion/implication MVD should not be categorically excluded for TN-MS; further prospective studies are needed to improve selection and outcomes.

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Historical evolution of microvascular decompression after Jannetta’s establishment: Anatomical maps and physiological compasses—a narrative review

Acta Neurochirurgica (2026) 168:74

This narrative review chronicles five decades of refinement in microvascular decompression (MVD) for trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia, tracing developments from Jannetta’s microsurgical breakthrough to contemporary practice. It emphasizes evolving microsurgical anatomy, tailored craniotomies, endoscopic/exoscopic visualization, and nuanced decompression techniques such as noncompressive transposition versus prosthetic interposition.

The article also highlights operative support advances—high-resolution MRI/MRA, virtual simulation, and intraoperative neuromonitoring (BAEP, LSR)—as physiological “compasses” that improve safety and outcome durability. Together, anatomical “maps” and physiological feedback frame current standards and ongoing challenges in achieving long-term, biologically harmonious decompression.

Microvascular Decompression (MVD) Evolution: MVD has developed from Jannetta’s original microsurgical demonstration of vascular compression into a safe, durable, and standardized surgical treatment for neurovascular compression syndromes, especially trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN).

Anatomical Foundations: Detailed microsurgical anatomy, including the “Rule of Three” for the cerebellopontine angle (CPA), enables tailored, minimally invasive approaches and underpins the understanding of neurovascular conflicts and surgical route selection.

Tailored Surgical Approaches: Three individualized approaches—lateral supracerebellar-infratentorial for TN, infrafloccular for HFS, and transcondylar fossa for GPN—minimize cerebellar retraction and optimize decompression, improving safety and efficacy.

Decompression Strategies: Techniques have shifted from prosthetic interposition (placing a material between vessel and nerve) to noncompressive transposition (mobilizing and securing the vessel away from the nerve), with evidence supporting better long-term outcomes for transposition.

Visualization and Simulation Advances: The integration of endoscopic/exoscopic systems, neuronavigation, and virtual simulation has enhanced visualization, surgical precision, and education, extending the original ethos of microscopic surgery.

Intraoperative Monitoring: Real-time monitoring using brainstem auditory evoked potentials (BAEPs) and lateral spread response (LSR) on facial EMG helps avoid complications and assess decompression adequacy, significantly reducing postoperative morbidity.

Role of Imaging: High-resolution MRI and MRA now routinely identify neurovascular compression preoperatively, though imaging findings are considered supportive rather than diagnostic due to limited specificity in low-grade conflicts.

Sustained First-Line Role: Despite advances in radiosurgery and pharmacotherapy, MVD remains the first-line surgical option for appropriately selected patients, due to its proven long-term efficacy and safety.

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Erector spinae plane block during standalone anterior lumbar surgery: impact on early ambulation, length of stay, and inpatient opioid use

J Neurosurg Spine 44:90–98, 2026

This clinical retrospective study assesses the impact of erector spinae plane block (ESPB) as an adjunct to multimodal analgesia in standalone anterior lumbar procedures (ALIF and lumbar TDR). Outcomes compared between ESPB and non-ESPB cohorts include in-hospital pain scores, opioid consumption (MME), time to ambulation, length of stay (LOS), and opioid-related complications.

Results show ESPB associated with lower day-of-surgery pain scores, earlier ambulation, and shorter LOS, with reduced in-hospital oral MME in univariate analysis; preoperative opioid use predicted higher perioperative opioid consumption and urinary retention despite ESPB. The authors emphasize ESPB as a component of enhanced recovery protocols and note limitations of retrospective design and sample size.

Erector Spinae Plane Block (ESPB): ESPB is a regional analgesic technique used as an adjunct in anterior-only lumbar surgeries, such as ALIF and total disc replacement, aiming to improve perioperative pain control and recovery outcomes.

Reduced Pain and Opioid Use: ESPB significantly lowers pain scores on the day of surgery and reduces in-hospital opioid use, especially oral morphine milligram equivalents (MMEs), compared to patients not receiving ESPB.

Shorter Hospital Stay: Patients receiving ESPB experience a significantly shorter hospital length of stay (LOS) and are more likely to be discharged earlier, including same-day discharge, than those without ESPB.

Faster Ambulation: ESPB is associated with a significantly shorter time to first ambulation after surgery, facilitating earlier rehabilitation.

Predictors of Opioid Use: Baseline (preoperative) opioid use is the strongest predictor of higher perioperative opioid requirements and is also linked to a higher incidence of postoperative urinary retention, regardless of ESPB administration.

Subgroup Benefits: Among ESPB patients, those with a shorter LOS (<2 days) had earlier ambulation, lower opioid use, and lower pain scores on postoperative day 1, indicating enhanced early recovery.

Multimodal Pain Management: ESPB should be considered as one component within a comprehensive multimodal pain management strategy (such as ERAS protocols), rather than as a standalone intervention.

Study Limitations: The findings are limited by the retrospective design, potential selection bias, lack of randomization, and incomplete data on preoperative opioid use, highlighting the need for larger, prospective studies

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Minimally invasive lumbar decompression versus open decompression for lumbar spinal stenosis: a propensity score–matched analysis

J Neurosurg Spine 44:55–61, 2026

This propensity score–matched retrospective study compares minimally invasive lumbar decompression (mild) with open decompression for lumbar spinal stenosis at a tertiary multisite center from 2005–2024. Primary outcomes included pain change (NRS), reoperation, and perioperative complications, with MCID defined as 30% NRS improvement.

Results show open decompression yielded greater pain improvement, higher MCID attainment, and lower overall reoperation rates, while mild had fewer durotomies but more neurological deficits. The authors recommend independent prospective studies to validate comparative efficacy and cost-effectiveness and note limitations including retrospective design and incomplete radiographic severity data.

Open decompression is more effective than the mild (minimally invasive lumbar decompression) procedure for achieving clinically significant pain improvement in patients with symptomatic lumbar spinal stenosis (43.1% vs 22.2% reached MCID; p < 0.001).

Reoperation rates are higher after the mild procedure compared to open decompression (46.2% vs 29.3%; p = 0.008), indicating less durable symptom relief with mild.

Pain outcomes favor open decompression, with patients reporting lower pain scores at last follow-up (mean NRS 2.3 vs 5.4; p < 0.001) and greater overall improvement from baseline.

Complication profiles are similar overall, but mild is associated with higher rates of postoperative neurological deficits (6.3% vs 0.6%; p = 0.003), while open decompression has a higher rate of durotomy (2.9% vs 0%; p = 0.024).

Procedure characteristics: The mild procedure is performed percutaneously through a small incision, typically by pain medicine physicians, and targets debulking the ligamentum flavum without muscle dissection.

Study limitations include retrospective design, incomplete matching for stenosis severity and baseline pain, and missing data on some outcomes, suggesting a need for prospective studies.

Existing literature on mild is often industry-sponsored and lacks direct comparison to open decompression; independent studies show mild may be less effective and more likely to require further surgery.

Clinical recommendation: Open decompression remains the gold standard for patients with symptomatic lumbar spinal stenosis who fail conservative management, while the mild procedure may offer less pain relief and higher reoperation risk.

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Outcome comparison between interposition and “contactless” transposition microvascular decompression approaches for trigeminal neuralgia

J Neurosurg 143:970–981, 2025

This study compared interposition and “contactless” transposition (Teflon and pericranial sling) microvascular decompression techniques for trigeminal neuralgia. Both were effective, but sling transposition showed improved midterm pain control and fewer complications. The only significant predictor of pain freedom was MRI evidence of clear nerve compression.

• Microvascular decompression (MVD) is a main surgical treatment for trigeminal neuralgia (TN), traditionally using Teflon interposition between nerve and artery.

• Recurrence of TN pain after MVD is often due to Teflon complications, prompting the development of “contactless” transposition techniques such as Teflon and pericranial sling transpositions.

• This retrospective study compared outcomes of interposition, Teflon transposition, and pericranial sling transposition in 305 TN patients.

• Sling transposition was mainly used for severe compression by the superior cerebellar artery and involved securing the artery to the tentorium with a pericranial graft.

• All techniques had similar short-term pain relief and complication rates, but sling transposition showed significantly higher pain-free rates at 2 years compared to other methods.

• Clear vascular compression on MRI was the only significant predictor of pain freedom in multivariate analysis.

• Sling transposition uses autologous tissue, avoids foreign body reactions, and may provide more durable pain control, but is technically more complex.

• Further long-term studies are needed to confirm the durability of sling transposition for TN pain control.

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How to deal with the superior petrosal vein in microvascular decompression for trigeminal neuralgia?

Neurosurg Focus 59(3):E12, 2025

Sectioning the superior petrosal vein at its main trunk while maintaining venous crossflow is a safe and effective strategy during microvascular decompression for trigeminal neuralgia, improving surgical access without significantly increasing venous-related complications, according to a large retrospective study.

• Management of the superior petrosal vein (SPV) during microvascular decompression (MVD) for trigeminal neuralgia (TN) is controversial, with concerns about operative field access and potential complications.

• A retrospective study evaluated a technique of SPV division at its main trunk near the superior petrosal sinus, maintaining venous crossflow through contributories, in 171 out of 217 patients (79%).

• No statistically significant increase in venous-related complications was observed in the SPV division group compared to the preservation group.

• Only 3 possibly venous-related complications occurred in the SPV division group, all of which were mild and transient.

• Anatomical variations of the SPV require careful intraoperative assessment and preservation of collateral venous drainage for safety.

• Preoperative imaging and intraoperative techniques (e.g., indocyanine green angiography) are recommended to assess collateral flow before SPV division.

• The study concludes that SPV division at the main trunk with preservation of crossflow is a safe strategy that improves surgical exposure during MVD for TN.

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The efficacy of combining pulsed radiofrequency with low-temperature continuous radiofrequency for the treatment of primary trigeminal neuralgia

J Neurosurg 143:100–110, 2025

High-voltage pulsed radiofrequency (PRF) combined with low-temperature continuous radiofrequency (CRF) significantly improved 12-month response rates and pain scores in primary trigeminal neuralgia compared to PRF alone, with minimal complications. This combined approach offers a promising alternative for patients unresponsive to medication.

High-voltage pulsed radiofrequency (PRF) combined with low-temperature (60°C) continuous radiofrequency (CRF) was compared to high-voltage PRF alone for treating primary trigeminal neuralgia (TN) in a randomized controlled trial.

• 146 patients were randomized to either PRF+CRF or PRF alone, with 12-month response rate as the primary outcome.

• The PRF+CRF group had a significantly higher response rate at 12 months (83.6% vs 67.1%, p = 0.021) and better pain relief at all measured time points.

• Patient satisfaction scores were higher in the PRF+CRF group at 1, 6, and 12 months.

• Facial numbness and masseter muscle weakness were more frequent in the PRF+CRF group but were mild and resolved within months; no serious complications occurred.

• Both treatments were safe, with no cases of anesthesia dolorosa, corneal anesthesia, or keratitis.

• The study was limited by single-center design, open-label nature, and a smaller than expected difference in primary outcome, suggesting the need for larger studies.

• Conclusion: High-voltage PRF combined with low-temperature CRF offers better pain control and satisfaction than PRF alone, with minimal side effects, for patients with refractory TN.

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Stratifying trigeminal neuralgia and characterizing an abnormal property of brain functional organization: a resting-state fMRI and machine learning study

J Neurosurg 143:74–82, 2025

Resting-state fMRI and machine learning revealed distinct brain connectivity and activity differences between classical and idiopathic trigeminal neuralgia (TN) and controls. These findings identify potential neuroimaging biomarkers for TN subtypes, aiding diagnosis and understanding of TN pathophysiology.

Primary trigeminal neuralgia (TN) includes classical (CTN) and idiopathic (ITN) types, sharing clinical features but differing in neurovascular compression (NVC) presence.

• Resting-state fMRI and machine learning were used to analyze brain functional connectivity and spontaneous activity in 50 TN patients (28 CTN, 22 ITN) and 43 controls.

• TN patients showed increased connectivity between the medial prefrontal cortex (mPFC) and left planum temporale, and decreased connectivity between mPFC and left superior frontal gyrus.

• CTN patients had further reduced connectivity between the left insula and left occipital pole, and decreased activity in the right temporal pole compared to ITN.

• TN patients exhibited heightened neural activity in frontal regions compared to controls.

• Machine learning (support vector machine) distinguished TN patients from controls with moderate accuracy (AUC 0.80).

• Findings suggest potential fMRI biomarkers for TN subtypes, aiding understanding of pathophysiology and improving diagnosis.

• Study limitations include small sample size and exclusion of bilateral/secondary TN, warranting further research.

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Effects of the length of preoperative conservative management on postoperative outcomes after primary microvascular decompression for trigeminal neuralgia

J Neurosurg 143:92–99, 2025

Prolonged preoperative conservative management with anticonvulsants in trigeminal neuralgia is associated with worse pain outcomes and higher pain recurrence after microvascular decompression. Early surgical intervention may improve postoperative results and reduce pain recurrence risk in these patients.

• Longer duration of preoperative conservative management (anticonvulsant use) before microvascular decompression (MVD) for trigeminal neuralgia (TN) is linked to worse postoperative pain outcomes and higher risk of pain recurrence.

• Median duration of conservative management before surgery was 1.74 years.

• Patients with longer conservative management had higher final BNI pain scores and greater rates of pain recurrence than those with shorter management.

• Longer conservative management predicted shorter pain-free survival after MVD.

• Younger age and longer conservative management duration were independent predictors of worse postoperative pain and recurrence.

• No significant difference in preoperative pain scores between groups; both had high pain levels pre-surgery.

• Findings suggest early surgical intervention may benefit TN patients who are candidates for MVD.

• Study was retrospective and single-institution, limiting generalizability; further research is needed.

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Deep learning–based segmentation of the trigeminal nerve and surrounding vasculature in trigeminal neuralgia

J Neurosurg 143:83–91, 2025

This study developed and validated deep learning U-Net models for automated 3D segmentation of the trigeminal nerve and surrounding vasculature in MRI of trigeminal neuralgia patients, enabling objective quantification of neurovascular conflict features and potentially improving preoperative evaluation and treatment planning.

• Deep learning (U-Net) models were used to segment the trigeminal nerve and surrounding vasculature in patients with trigeminal neuralgia using high-resolution CISS MRI.

• Six U-Net variants with different encoder backbones were tested; SE-ResNet50 performed best overall (Dice score = 0.775, IoU = 0.681).

• The models quantified anatomical features such as the surface area of neurovascular contact and distance to the contact point, showing no significant difference from manual segmentations.

• The best model achieved 100% sensitivity and specificity in detecting neurovascular conflict in the testing set.

• Automated 3D segmentation allows for objective, quantitative evaluation, improving on subjective and time-intensive manual methods.

• Limitations include inability to distinguish vessel type (artery vs. vein) and data from a single institution; future work should address these.

• The method may help standardize neurovascular conflict assessment and improve treatment selection for trigeminal neuralgia.

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Designing and clinical application of a 3D-printed personalized model of a radiofrequency needle guide with a maxillary fixator for puncture of the gasserian ganglion for trigeminal neuralgia treatment

J Neurosurg 142:1256–1262, 2025

The study presents a 3D-printed personalized model (3D PPM) for radiofrequency needle guidance in trigeminal neuralgia treatment, reducing radiation exposure and pain during procedures. It showed effectiveness in controlled needle insertion and minimized postoperative complications compared to traditional methods.

• A 3D-printed personalized model (3D PPM) of a radiofrequency needle guide with a maxillary fixator was designed for gasserian ganglion puncture in trigeminal neuralgia treatment.

• 3D PPM reduces radiation exposure and pain during needle insertion, and minimizes postoperative complications.

• The study found that the use of 3D PPM significantly decreased radiation time and dose area product compared to traditional methods.

• Pain severity during the procedure was less in patients using 3D PPM, with more reporting mild pain compared to those not using it.

• Cheek swelling was less frequent in the group using 3D PPM, though not statistically significant due to small sample size.

• The 3D PPM enhances the accuracy of needle insertion and reduces radiation exposure, making it beneficial for less experienced neurosurgeons.

• Limitations include the unsuitability for patients with metal dental implants or missing teeth due to fixation issues.

• Despite limitations, the study shows promising results for 3D PPM in radiofrequency therapy of the gasserian ganglion, suggesting further research is needed.

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Gamma Knife radiosurgery for relapsing trigeminal neuralgia following microvascular decompression

J Neurosurg 142:1247–1255, 2025

Salvage Gamma Knife radiosurgery (GKRS) offers effective, noninvasive treatment for relapsing trigeminal neuralgia after microvascular decompression, with a favorable complications profile. Patients with facial numbness and better initial pain responses may experience more durable pain relief following salvage GKRS.

• Gamma Knife radiosurgery (GKRS) is explored as a treatment for relapsing trigeminal neuralgia (TN) following microvascular decompression (MVD).

• The study aimed to assess the response rate, complications, and predictors of pain relapse for salvage GKRS after MVD.

• 83.1% of patients experienced initial pain relief after salvage GKRS, with a median time to relapse of 1.75 years.

• Facial numbness post-GKRS decreased pain relapse risk, while a worse initial pain response increased it.

• Radiofrequency ablation (RFA) prior to MVD reduced the likelihood of an initial response to GKRS.

• Salvage GKRS is presented as an effective, noninvasive option for recurring TN after MVD, with a favorable complications profile compared to salvage MVD.

• The study acknowledges limitations, including potential selection bias and small sample size, and suggests further research with larger cohorts

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Morphological analysis of the trigeminal nerve in trigeminal neuralgia using the nerve’s centerline and multiple cross-sections of a 3D model

J Neurosurg 142:884–891, 2025

• Study Objective: Quantify morphological changes in trigeminal nerve causing trigeminal neuralgia (TN).

• Methods: Retrospective analysis of patients with TN undergoing microvascular decompression (MVD).

• Parameters Analyzed: Centerline length, curvature, torsion, cross-sectional area, flattening ratio, long-axis angle.

• Results: Affected side showed longer centerline, greater curvature, smaller area pre-surgery.

• Postoperative Changes: Affected side showed shorter centerline, larger cross-sectional area post-surgery.

• Concordance Rate: 91.4% between intraoperative findings and 3D model flexion locations.

• Accuracy of Segmentation: Manual segmentation showed 80%-90% concordance with surgical findings.

• Limitations: Retrospective, single institution, manual segmentation, not fully matching surgical findings.

• Further Analyses: Needed for patients without neurovascular compression (NVC) and with venous compression.

• Study Implications: Method helps analyze TN pathophysiology, aid diagnosis, predict treatment efficacy.

• Statistical Analysis: Mann-Whitney U-test, significance set at p < 0.05

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Outcome prediction following lumbar disc surgery: a longitudinal study of outcome trajectories, prognostic factors, and risk models

J Neurosurg Spine 42:33–42, 2025

This study aimed to 1) describe the 2-year postoperative trajectories of leg pain and overall clinical outcome after surgery for radiculopathy, 2) identify the preoperative prognostic factors that predict trajectories representing poor clinical outcomes, and 3) develop and internally validate multivariable prognostic models to assist with clinical decision-making.

METHODS This retrospective cohort study included patients enrolled in the Canadian Spine Outcomes and Research Network who were diagnosed with lumbar disc pathology and radiculopathy and had undergone lumbar discectomy at one of 18 spine centers. Potential outcome predictors included preoperative demographic, health-related, and clinical prognostic factors. Clinical outcomes were 1) 2-year univariable latent trajectories of leg pain intensity (numeric pain rating scale) and 2) overall outcomes comprising multivariable trajectories showing the combined postoperative courses of leg and back pain intensity (numeric pain rating scale) together with pain-related disability (Oswestry Disability Index). Each outcome model identified a subgroup of patients classified as experiencing a poor outcome based on minimal change in their clinical status after surgery. Multivariable risk model performance and internal validity were evaluated with discrimination and calibration statistics based on bootstrap shrinkage with 500 resamplings.

RESULTS The authors included data from 1142 patients (47.6% female). The trajectory models identified 3 subgroups based on the patients’ postoperative courses of pain or disability: 88.6% of patients in the leg pain model and 71.9% in the overall outcome model experienced a good-to-excellent outcome. The models classified 11.4% (leg pain outcome) and 28.2% (overall outcome) of patients as experiencing a poor clinical outcome, which was defined as minimal improvement in pain or disability after surgery. Eleven individual demographic, health, and clinical factors predicted patients’ poor leg pain and overall outcomes. The performance of the multivariable risk model for leg pain was inadequate, while the overall outcome model had acceptable discrimination, calibration, and internal validity for predicting a poor surgical outcome.

CONCLUSIONS Patients with lumbar radiculopathy experience heterogeneous postoperative trajectories of pain and disability after lumbar discectomy. Individual preoperative factors are associated with postoperative outcomes and can be combined within a multivariable risk model to predict overall patient outcome. These results may inform clinical practice but require external validation before confident clinical implementation.

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External assessment of preoperative scores for predicting outcome after microvascular decompression for trigeminal neuralgia

J Neurosurg 141:1056–1062, 2024

Recently, two scoring systems have been developed for predicting pain-free outcomes after microvascular decompression (MVD). Evaluation of these scores on large external datasets has been limited. In this study, the authors aimed to evaluate the performance of published MVD scoring systems in predicting pain-free outcome.

METHODS A total of 458 patients who underwent MVD for trigeminal neuralgia (TN) between 2007 and 2020 and had at least 6 months of follow-up were included in this study. Hardaway and Panczykowski scores were retrospectively computed for each patient and compared with postoperative pain recurrence and pain-free duration.

RESULTS The mean ± SD area under the receiver operating characteristic curve for predicting any pain recurrence after MVD was 0.567 ± 0.081 using the Hardaway score and 0.546 ± 0.085 using the Panczykowski score. On log-rank tests and Kaplan-Meier analysis, the patients with Hardaway scores of 0–2 had significantly shorter pain-free survival times after MVD than did those with a score of 3. Patients with a Panczykowski score of 1 had a significantly shorter pain-free duration after surgery compared with both patients with scores of 2–3 and patients with scores of 4–5. Patients with Panczykowski scores of 2–3 also had significantly shorter pain-free duration compared with patients with scores of 4–5.

CONCLUSIONS Both the Hardaway and Panczykowski scores may be useful for predicting postoperative pain-free duration in TN patients, and their utility may be greatest when scores are clustered. Continued refinement of both scoring systems will help to improve our ability to predict patient outcomes after MVD.

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Visualization of the nervus intermedius during microvascular decompression in hemifacial spasm: anatomical study

J Neurosurg 141:1049–1055, 2024

The surgical anatomy of the nervus intermedius (NI) is highly variable. The aim of this study was to describe the anatomy of the NI during endoscope-assisted microvascular decompression (MVD) in hemifacial spasm (HFS), and the involvement of the nerve in the vascular conflict.

METHODS The authors reviewed a prospectively maintained database for MVDs performed between 2002 and 2022 and extracted clinical data including patient demographics, symptoms, and offending vessel(s). Operative videos and photographs were analyzed retrospectively in an attempt to identify the NI.

RESULTS Endoscopic identification of the NI was possible in 139 of 435 MVDs. The anatomy is very variable. In 79 (56.8%) patients, a single-bundle pattern was detected, whereas a multiple-bundle pattern was identified in 60 (43.2%) patients. Overall the most common pattern was a single-bundle type A (49.7%). In 20.1%, a multiple-bundles type A was identified. In 4.3%, a single-bundle type B was detected. In 2.9% a single-bundle type C was found, and in just 0.7% a multiple-bundles type C was detected. A multiple-origin pattern (type D) was found in 31 patients (22.3%). The NI was frequently involved in the neurovascular conflict (approximately 85%). The type of NI or vascular compression pattern did not affect the results regarding the outcome or recurrence of HFS.

CONCLUSIONS The anatomy of the NI is for the first time evaluated endoscopically in MVD for HFS. The nerve had various anatomical patterns that were clearly identified. Further studies to evaluate the compression patterns in relation to NI neuralgia are warranted.

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The Safety and Efficacy of Dorsal Root Entry Zone Lesioning for Pain Management in Patients With Brachial Plexus Avulsion

Neurosurgery 95:259–274, 2024

Persistent neuropathic pain after brachial plexus avulsion (BPA) is common and generally nonresponsive to medical management. Dorsal root entry zone (DREZ) lesioning is the last resort for pain management in patients with BPA. This study aims to investigate and compare the outcomes and complications of DREZ procedures.

METHODS: A systematic literature search was conducted to identify all related studies. Comparisons were based on the number of patients with preoperative pain vs postoperative pain, with the effect size calculated using the risk ratio. Mean visual analog scale (VAS) scores were extracted and analyzed between interventions. A meta-regression analysis was performed to identify risk factors for final outcomes. The rates of complications were also assessed and analyzed between interventions.

RESULTS: A total of 30 studies with 917 patients (90.0% male and 10.0% female, mean age: 42.9 ± 16.6) were included in this systematic review. Of the 917 patients who underwent surgery, 655 (71.4%) patients had significant pain reduction at the last follow-up (P < .05). The weighted mean preoperative VAS score was 8.3 ± 1.3, compared with postoperative VAS scores (1.9 ± 2.2); a significant improvement was observed (P < .05). The subgroup analysis showed that microsurgical DREZotomy (MDT) is associated with better outcomes in terms of VAS score improvements compared with radiofrequency (RF)-assisted DREZ lesioning (P < .05). Meta-analysis showed that the relative risk of motor deficits was significantly lower in the MDT group, compared with the RF-assisted group (P < .05). Meta-regression showed that older age is correlated with an elevated risk of postoperative motor deficits compared with the incidence of sensory loss.

CONCLUSION: DREZ lesioning is effective for intractable pain alleviation after BPA. Compared with RF-assisted DREZ lesioning, MDT is associated with better VAS score improvements and a lower rate of postoperative motor weakness.

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Intra‑operative hypertension as a predictor of surgical outcomes in microvascular decompression surgery for trigeminal neuralgia

Acta Neurochirurgica (2024) 166:297

The trigeminocardiac reflex (TCR) has traditionally been characterized by a sudden decrease in heart rate, asystole, or hypotension during the manipulation of the trigeminal nerve (MTN) or its branches. While this classical TCR is well-documented, there is limited literature on alternative forms of TCR, such as the development of intraoperative hypertension (HTN) or tachycardia, and the underlying pathogenesis. Furthermore, a gap exists in understanding the correlation between intraoperative blood pressure readings and postoperative outcomes, particularly regarding pain relief in patients with trigeminal neuralgia (TN). Our study aims to examine intraoperative blood pressure trends during microvascular decompression (MVD) for TN and assess their impact on postoperative outcomes.

Methods We selected 90 patients who underwent MVD for TN treatment. Blood pressure and heart rate were recorded both preoperatively and during the procedure, specifically during the MTN period, using an arterial line. The Barrow Neurological Institute (BNI) Pain Scale was calculated for all patients both pre- and post-operatively to evaluate pain relief after surgery.

Results The mean age of the patients was 61.0 ± 12.35 years, with 64.4% being females. Classical TCR (hypotension) was observed in only 2.2% of patients, whereas 80% of patients developed hypertension (≥ 140/90) during MTN. The mean preoperative systolic blood pressure was 128 ± 22.25, and the mean intraoperative systolic blood pressure during MTN was 153.1 ± 20.2. An analysis of covariance, utilizing either preoperative BNI or duration of symptoms as covariate variables, revealed a statistically significant association between intraoperative HTN and postoperative BNI. A linear regression model demonstrated that intraoperative HTN following MTN significantly predicted a lower postoperative BNI score (p = 0.006).

Conclusions Intraoperative HTN during MTN, an observed yet underexplored phenomenon, demonstrated a correlation with improved postoperative outcomes. Furthermore, it is recommended to conduct additional investigations into potential neurovascular conflicts in patients not manifesting intraoperative HTN following MTN. A comprehensive understanding of TCR, encompassing its various forms, is vital for optimizing surgical management. This study underscores the imperative for further research to unravel the mechanisms linking intraoperative HTN to surgical outcomes in TN patients.

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Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery

J Neurosurg Spine 40:465–474, 2024

Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS).

METHODS This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months.

RESULTS A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits.

CONCLUSIONS Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

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