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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Microvascular decompression &#40;MVD&#41; in essential trigeminal neuralgia &#40;TN&#41; management was indicated by Dandy in 1934<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1&#44;2</span></a> and later pushed by Jannetta in 1967&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">3</span></a> It is a widely accepted surgical procedure when pharmacological treatment is ineffective&#46; The most accepted pathophysiological basis stems from the existence of neurovascular conflict &#40;NVC&#41;&#44; i&#46;e&#46; compression of the trigeminal nerve by the surrounding vascular structures&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> This conflict is identified in 80&#8211;90&#37; of patients who undergo the procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">5&#8211;9</span></a> Burchiel&#39;s aetiological classification&#8212;the most commonly used for trigeminal pain&#8212;does not consider the presence of NVC as a criterion when establishing TN subtypes&#46; Nevertheless&#44; the TN-1 and TN-2 subtypes&#44; known as &#8220;essential TN&#8221; are those in which the presence of NVC has been proposed as an aetiological mechanism &#40;see the foot of <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> for the complete classification&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">According to various published studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6&#44;10</span></a> 75&#8211;80&#37; of patients who undergo the procedure present an alleviation of their pain in the immediate postoperative period and 70&#37; of patients are pain free at 10 years&#8217; follow-up&#46; The global rate of complications for this procedure us 10&#8211;23&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">4&#44;6</span></a> Some 17&#8211;31&#37; of patients present pain recurrence&#44; most commonly in the first two years&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6&#44;11&#8211;14</span></a> The predictive factors for therapeutic success without recurrence are&#58; duration of symptoms less than 8 years&#44; TN-1 &#40;typical&#41; symptomatology&#44; constant cutaneous distribution and the presence of arterial vascular compression&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Imaging-based diagnostic techniques have gradually improved&#44; with MRI and angio-MRI&#44; predicting the presence of NVC with a sensitivity above 96&#37; and specificity of 90&#37; for TN-1 and 66&#37; for TN-2&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a> Various radiological studies have reported an absence of NVC in some 3&#8211;17&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">12</span></a> In most of these patients&#44; NVC was not found intraoperatively&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;12&#44;16&#8211;18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In 1934&#44; Dandy&#44; and later other authors&#44; indicated that NVC can occur without associated neuralgia and that the disease may be present in the absence of the above-mentioned intraoperative finding in some 5&#8211;21&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1&#44;11&#44;12&#44;14&#44;16&#8211;18</span></a> In 2009&#44; Miller et al&#46; evaluated the presence of NVC in a series of 257 patients and healthy subjects and determined that&#44; although NVC could be present in asymptomatic subjects&#44; it was often more intense and more proximal in those who developed symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a> This points to an absence of NVC in a certain percentage of TN patients&#44; and a pathophysiology substrate that has not been fully understood until now&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">7&#44;14&#44;17&#44;20&#44;21</span></a> A number of alternative theories on the possible aetiology of TN have arisen based on this evidence&#44; with NVC currently remaining the most widely accepted despite not applying to all patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1&#44;7&#44;21&#8211;23</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">objective</span> of this publication is to review those surgical options proposed in the literature that the surgeon might employ in the same surgical intervention when faced with the absence of NVC and to express our opinion on those options based on our own experience&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A bibliographic search of the PubMed&#44; Scielo and SpringerLink scientific databases was performed using the keywords&#58; rhizotomy of trigeminal nerve&#44; tractotomy&#44; neurolysis&#44; failed microvascular decompression and atypical trigeminal neuralgia&#46; Articles published in the last 10 years were reviewed&#44; and it was deemed relevant to mention some older articles cited in the reviewed articles due to their historical interest&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Articles were reviewed in English&#44; Spanish&#44; German and French&#44; as well as English abstracts of articles published in other languages&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 46 publications&#44; spanning a period from 1934 to the present day&#44; were reviewed&#46; Due to the low prevalence of the disease&#44; the majority are observational studies with small samples and therefore have a low level of scientific evidence&#46; Two of the reviewed studies are class <span class="elsevierStyleSmallCaps">ii</span>b&#44; several are class <span class="elsevierStyleSmallCaps">ii</span>c and the majority are class <span class="elsevierStyleSmallCaps">iii</span> according to the US Agency for Healthcare Research and Quality classification&#44; and therefore the level of recommendation they offer is limited&#46; The intraoperative techniques described in the literature are&#58; partial sensory rhizotomy&#44; exhaustive exploration of the <span class="elsevierStyleSmallCaps">v</span> cranial nerves and lower cranial nerves&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">2</span></a> arachnoid dissection&#44; trigeminal neurapraxia&#44; internal neurolysis &#40;&#8220;nerve combing&#8221;&#41; and pontine descending tractotomy&#46; We go on to establish general recommendations and discuss each of these techniques below&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results of the main clinical trials that make reference to these techniques&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Partial rhizotomy of the sensory root &#40;portio major&#41; of the <span class="elsevierStyleSmallCaps">v</span> cranial nerves &#40;PSR&#41;&#46; This may be the most traditional technique and the most studied of all those covered in this review&#46; It involves the partial surgical section of the sensory root of the trigeminal nerve from the caudal border to 2&#8211;5<span class="elsevierStyleHsp" style=""></span>mm from the root entry zone &#40;REZ&#41; in the encephalic trunk&#44; with the aim of halting the transmission of aberrant nociceptive signals present in the REZ&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A clinical response has been reported in 70&#8211;88&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">22&#44;24</span></a> In around 10&#8211;20&#37;of patients&#44; PSR does not lead to any improvement in the pain&#44; probably because the partial section performed was not sufficiently extensive&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">11</span></a> The hypothesis is a known secondary effect of PSR&#44; present in 67&#37; of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">25</span></a> and can be association with other complications such as keratitis and difficulties chewing and swallowing&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">26</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Arachnoid dissection&#46; A number of anatomical studies have demonstrated that the prepontine cistern can contain multiple arachnoid adherences&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">12&#44;17&#44;27&#44;28</span></a> In some cases&#44; the meticulous dissection and lysis of these adherences along the length of the nerve can effectively alleviate trigeminal pain&#46; Ishikawa et al&#46; presented a series of 9 cases without evidence of NVC in which all but one of the patients were pain free following arachnoid dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> Nevertheless&#44; after 15 months&#8217; follow-up&#44; the recurrence rate was 44&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> Other authors also highlight the importance of arachnoid dissection&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">17&#44;29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Trigeminal neurapraxia&#46; Seddon and Sunderland have described how compression and slight distraction of the trigeminal nerve can produce a certain lesion &#40;neurapraxia&#41; on the nerve<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">10&#44;15</span></a> and achieve improvement of symptoms&#44; based on the theory indicating that slight mechanical trauma can alleviate pain in TN&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">10&#44;30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Cheng et al&#46; performed this compression with bipolar forceps for 10<span class="elsevierStyleHsp" style=""></span>s along the length of the nerve&#44; avoiding torsion and excessive traction&#44; together with arachnoid dissection and isolation of the REZ with Teflon&#44; with good results&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">12</span></a> In this study&#44; 71&#37; of patients experienced complete and immediate alleviation of pain&#44; while 21&#37; experienced partial alleviation&#46; The procedure failed in the remaining 7&#37;&#46; At one month from the intervention&#44; 85&#37; of the patients no longer experienced pain&#46; The rate of complications was 35&#37; for facial hypoaesthesia and one patient who lost the ipsilateral corneal reflex&#46; After performing follow-up&#44; 38&#37; presented a recurrence of pain and only 46&#37; remained pain free at the end of follow-up &#40;46 months&#44; mean&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Internal neurolysis&#46; This was initially reported by Li et al&#46; in 1995&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">31</span></a> Also known as &#8220;nerve combing&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a> this procedure consists of dissection the sensory and motor roots of the <span class="elsevierStyleSmallCaps">v</span> cranial nerve into 5&#8211;10 fasciculi from the root entry zone &#40;REZ&#41; in the protuberance to Meckel&#39;s cave with a blunt Jacobson-type dissector or micro-needle&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> Technically&#44; fasciculation of both roots&#44; motor and sensory&#44; is recommended&#44; as it has been demonstrated that amyelinic nociceptive fibres pass along the motor nerve and there are connections between both portions&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">32</span></a> It is based on the theory of nerve damage and axonal destruction&#44; which probably decrease the excitability of abnormal trigeminal afferents&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">4&#44;31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Ma and Li presented a series of ten cases with some 70&#37; of patients being pain free in the immediate postoperative period&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a> Jie et al&#46; divided 60 patients with TN into two groups based on the intraoperative presence or absence of NVC&#44; and performed internal neurolysis on all of them&#46; They achieved complete alleviation of pain in 82&#46;1&#37; and partial alleviation in 7&#46;1&#37; of patients without signs of NVC&#44; compared with 62&#46;5&#37; and 25&#37; of patients with NVC&#46; The main complication of this technique is facial hypoaesthesia&#44; which was present in 16&#8211;80&#37; of patients&#46; According to Ma and Li&#44; up to 96&#37; of patients presented some degree of facial hypoaesthesia&#44; albeit with subsequent recovery&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a> Pain recurrence varied between studies from 4 to 10&#37; at two years&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">4&#44;29</span></a> and the results obtained were generally slightly better in patients with signs of NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Pontine descending tractotomy&#46; Tractotomy of the descending spinal tract of the trigeminal nerve was introduced in 1938 by Sj&#246;qvist&#44; and used for the treatment of glossopharyngeal neuralgia&#46; The technique would later be gradually refined by Crue et al&#46; Subsequently&#44; Kanpolat et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">33&#44;34</span></a> would apply the principles of stereotaxy to perform it&#46; Finally in 2015&#44; Ibrahim et al&#46; described the neuronavigation technique&#44; in which&#44; using a 7&#8211;9<span class="elsevierStyleHsp" style=""></span>mm angle dissector&#44; fibres are sectioned using a prepontine approach guided by neuroimaging in a plane parallel to the trigeminal nerve from which to approach the principal sensory nucleus of the trigeminal nerve and the transitional zone between the REZ and the rostral extent of the trigeminal tract&#44; above the caudal nucleus&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">According to the study&#44; candidates for trigeminal tractotomy were patients without NVC on the preoperative MRI&#46; Two groups were designated&#44; the first for MVD and tractotomy&#44; and the second receiving only tractotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">20</span></a> 86&#37; of the patients assigned to the tractotomy group experienced an immediate disappearance of their pain and 7&#37; experienced a partial reduction&#44; with a recurrence of 21&#37; at the end of follow-up&#46; Of these patients&#44; only 4&#37; presented facial hypoaesthesia&#44; compared to 12&#37; in the MVD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tractotomy group&#46; Moreover&#44; the good response in patients with type TN-4&#44; TN-5 and TN-6 atypical neuralgia is worth noting&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">On the aetiology of trigeminal pain</span><p id="par0095" class="elsevierStylePara elsevierViewall">In 1934&#44; Dandy proposed that the aetiology of TN was the presence of NVC&#59; nevertheless&#44; he also indicated that neurovascular contact occasionally occurs in healthy people and that TN could be present without NVC&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">1&#44;16</span></a> In fact&#44; up to 25&#37; of healthy people studied prevented NVC in imaging studies&#44; without the presence of TN&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">11&#44;35</span></a> Although the NVC theory is currently the most widely accepted&#44; it does not explain the disease in some 10&#8211;20&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">4</span></a> In 2009&#44; the observations of Miller et al&#46; indicated that those patients with more intense compression closer to the REZ often had more typical symptoms and were more responsive to MVD&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">19</span></a> but little has been described regarding the postoperative evolution of patients with TN and without NVC&#46; There are several aspects of this theory which still need to be clarified&#44; such as the lack of correlation between constant compression and intermittent symptoms &#40;in some patients who have long pain free periods&#41;&#46; The relationship between the degree of compression and the intensity of facial pain also remains unclear&#44; as does the presence of unilateral pain in a patient with bilateral NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">21</span></a> Lee et al&#46; question the NVC theory&#44; extrapolating their series to the population and concluding that 99&#46;94&#37; of individuals with trigeminal NVC never develop TN&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Love et al&#46; detected central demyelinisation of the sensory root of the trigeminal nerve in patients with NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">36</span></a> Similar findings were made by Ma et al&#46;&#44; who revealed cholesterol crystals in the cytoplasm of trigeminal Schwann cells&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">29</span></a> Nevertheless&#44; the rapid recovery of nervous conductivity after MVD indicates that the demyelinisation is not the initial cause of the pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">21&#44;22</span></a> Rappaport et al&#46; proposed that primary anomalies reside in the trigeminal ganglion<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">37</span></a> while Pagni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">38</span></a> speculated that VNC caused an indirect effect on the trigeminal nucleus&#44; leading to epileptiform activity in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">34</span></a> Ishikawa et al&#46; propose a different theory based on trapping of the nerve through granulomatous adhesion and arachnoid enlargement&#44; which would limit root pulsatility&#44; altering its distensibility and promoting hyperactivity of the nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">17</span></a> In the most severe cases&#44; arachnoid enlargement could compromise the REZ&#44; causing pain&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">10</span></a> Cases of TN triggered by pontine infarctions have been described&#44; indicating a central aetiology&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">39</span></a> In 2002&#44; Devor et al&#46; proposed the &#8220;ignition hypothesis&#8221;&#44; according to which a trigeminal cytostructural alteration acts as a hyperexcitable discharge focus that generates painful paroxysms and is highly mechanosensitive to phenomena such as NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">40</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">However&#44; all of these theories are highly speculative and none has been scientifically proven&#46; This is due partially to the lack of animal models&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">On NVC</span><p id="par0110" class="elsevierStylePara elsevierViewall">MVD has been described as an effective surgical technique in 80&#8211;90&#37; of patients with TN&#46; The absence of neurovascular compression is one of the factors associated with failure of the surgery and pain recurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">16&#44;41</span></a> along with atypical neuralgia &#40;TN-2&#41;&#44; presence of venous NVC<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">23</span></a> and a duration of symptoms of more than 8 years&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">15</span></a> Lee et al&#46; concluded that recurrence presented similarly in patients with TN-1 and TN-2&#44; as well as in those with and without NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Based on new neurodiagnostic techniques&#44; several studies have determined that MRI has a high predictive value for the presence of NVC in TN-1 and TN-2&#44; achieving sensitivities above 96&#37;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a> and a specificity of 90&#37; in TN-1 and 66&#37; in TN-2&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">15&#44;16</span></a> Another study obtained high degrees of correlation between presurgical studies with MRI and intraoperative findings&#44; predicting the degree of compression with Kappa coefficients of 0&#46;746&#44; 0&#46;767 and 0&#46;86&#44; respectively&#44; for grades <span class="elsevierStyleSmallCaps">i</span> &#40;simple contact&#41;&#44; <span class="elsevierStyleSmallCaps">ii</span> &#40;distortion&#41; and <span class="elsevierStyleSmallCaps">iii</span> &#40;marked indentation&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">41</span></a> Even so&#44; with regard to radiology it has been reported that in 3&#8211;17&#37; of cases this NVC was not detected&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">12</span></a> Presurgical neuroimaging studies have gradually become more relevant&#44; not only in the detection of NVC&#44; but also in presurgical planning on therapeutic alternatives such as pontine trigeminal tractotomy and nucleotomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">20&#44;33</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Lee et al&#46; observed that there was no vascular compromise in 29&#37; of patients with TN-1 and 18&#37; of patients with TN-2 in a series of 257 patients diagnosed with TN and treated with MVD&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a> Burchiel reports that in 15&#37; of cases vascular compression or contact cannot be seen during the surgical procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6&#44;13</span></a> The differences in the various series may be down to imprecise classification of NVC&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Pain recurrence</span><p id="par0125" class="elsevierStylePara elsevierViewall">As has been described above&#44; patients without NVC present a greater risk of recurrence&#46; Pain recurrence after MVD is present in 15&#8211;40&#37; of cases according to various authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">6&#44;10</span></a> The frequency appears to be lower following a successful MVD resolving patent NVC&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">16</span></a> but these statistics are not conclusive&#46; A number of other factors are associated with pain recurrence&#44; such as pain duration&#44; Burchiel subtype&#44; the procedure performed and the presence of venous NVC during the intraoperative exploration&#46; This last finding justifies up to 45&#37; of all cases of recurrence in some series&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recommendations</span><p id="par0130" class="elsevierStylePara elsevierViewall">Which intervention should be performed in the absence of NVC during an MVD&#63; The surgical decision in these cases is disputed and varies from doing nothing to complete section of the nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">12&#44;17</span></a> We consider exhaustive exploration of the trigeminal nerve<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">35</span></a> to be essential in order to ensure correct decompression&#46; It should not be limited to merely the proximal third&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">9&#44;18</span></a> At our centre&#44; we systematically perform microsurgical exploration of the ventral and ventrolateral surface of the encephalic trunk&#44; as far as the functional extent of the REZ&#44; according to certain authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">9&#44;18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In our opinion&#44; the various intraoperative assistance techniques&#44; such as videoangiofluoroscopy with indocyanine green and neuroendoscopy&#44; are especially valuable in those cases where visual identification of the NVC is challenging for the surgeon&#46; We rely on these methods when the patient&#39;s anatomical configuration and the angle of the approach do not allow us to explore the full extent of the nerve&#46; Nevertheless&#44; we do not believe that it is necessary to standardise its use for all cases of TN&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Secondly&#44; we habitually practice extensive arachnoid dissection&#44; releasing all adherences in the prepontine cistern using cold dissection&#44; demonstrating the mobility of the nerve using Jacobson dissectors&#46; We avoid the use of hook&#44; curved and angle dissectors due to the unnecessary risk of pulling and injuring the nerve&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Thirdly&#44; when faced with an absence of NVC&#44; we systematically review the lower cranial nerves&#44; angling the microscope and extending the arachnoid dissection to the caudal section&#46; According to a series published by Mayo clinic&#44; up to 10&#37; of patients present double essential neuralgia&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">43</span></a> Despite a thorough presurgical physical examination&#44; may trigeminal neuralgias&#44; especially those of the V3 branch&#44; share similar symptomatological characteristics with glossopharyngeal neuralgia&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">44</span></a> This figure explains the importance of the clinical examination of the patient and the identification of neuralgic pain in territories innervated by the glossopharyngeal nerve &#40;inner third of the external auditory canal&#44; posterior oropharynx and posterior tonsil pillar&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">9&#44;38&#44;42&#44;43</span></a> In our series&#44; we reviewed the lower cranial nerves when faced with an absence of trigeminal NVC&#44; finding NVC in the glossopharyngeal nerve in 4&#37; of cases &#40;data pending publication&#41;&#46; Selective anaesthetic block of the glossopharyngeal nerve for diagnostic purposes is one technique that can be used when it is unclear&#44; presurgically&#44; which nerve is affected&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">2&#44;45</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Fourthly&#44; we also consider controlled neurapraxia to be a safe technique&#46; In those cases when no NVC is detected&#44; we perform a blunt compression along the cisternal portion of the trigeminal nerve with bipolar clamps&#44; avoiding pulling or twisting the nerve&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Finally&#44; internal neurolysis appears to offer good results in the short term&#44; but due to the rate of postsurgical hypoaesthesia and the theoretic aggressiveness of the technique&#44; we only contemplate using it for failed MVDs and reinterventions&#44; not as a first line treatment&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Our attitude towards intraoperative use of other techniques is conservative&#44; as these are also in need of clarification&#46; There are few studies following up PSR&#44; but pain recurrence is 42&#37; at one year&#44; with a further 2&#37; for each subsequent years<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">24&#44;25&#44;28</span></a> and facial hypoaesthesia is a very common complication&#46; In fact&#44; a study conducted by Zakrzewska et al&#46; in 2005 reported a high degree of dissatisfaction on the part of patients treated with PSR &#40;20&#8211;22&#37;&#41; compared to those treated with MVD&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">23&#44;45&#44;46</span></a> We support the conclusion of this study&#44; according to which&#44; due to the high rate of complications and the rate of pain recurrence at 4 years&#44; there is no current evidence to use PSR in comparison with MVD&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">35</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">On the other hand&#44; pontine tractotomy&#44; guided by neuronavigation with diffusion tensor imaging and fibre-tracking &#40;DTI-FT&#41;&#44; produces interesting results&#44; particularly in the management of atypical neuralgia and postherpetic facial pain&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">46</span></a> We believe that precision can be difficult to achieve in this procedure&#44; due to the brain-shifting inherent in the retrosigmoid approach&#46; It is likely that obtaining intraoperative MRI images or an endoscopic approach could help to increase precision in this procedure&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In our review of the literature&#44; no single procedure from those described above offers a sufficiently favourable frequency of success and adverse effects for us to recommended it above other options&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0175" class="elsevierStylePara elsevierViewall">In those patients in whom clear NVC is not detected intraoperatively&#44; we recommend exhaustive exploration of the nerve &#40;using neuroendoscopy and videoangiofluoroscopy with indocyanine green where necessary&#41;&#46; In the absence of NVC&#44; these patients may benefit from thorough arachnoid dissection&#44; exploration of the lower cranial nerves and controlled neurapraxia&#46; &#8220;Nerve combing&#8221; should be reserved for recurrences after failed MVDs and we advise against the use of PSR due to its high rate of hypoaesthesia and relatively high rate of recurrence&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Alternatives based on new technologies such as pontine tractotomy and nucleotomy should also be investigates&#44; as we believe they are tools that will bring us a greater understanding of the pathophysiology of TN&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Introducci&#243;n"
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            1 => array:2 [
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              "titulo" => "Resultados"
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          "titulo" => "Discussion"
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              "identificador" => "sec0025"
              "titulo" => "On the aetiology of trigeminal pain"
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            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "On NVC"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Pain recurrence"
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            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Recommendations"
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          "identificador" => "sec0045"
          "titulo" => "Conclusions"
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    "fechaRecibido" => "2017-07-20"
    "fechaAceptado" => "2018-02-03"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Failed microvascular decompression"
            1 => "Trigeminal neuralgia"
            2 => "Neurovascular conflict"
            3 => "Partial sensory rhizotomy"
            4 => "Internal neurolysis"
          ]
        ]
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Microdescompresi&#243;n vascular fallida"
            1 => "Neuralgia trigeminal"
            2 => "Conflicto neurovascular"
            3 => "Rizotom&#237;a parcial sensitiva"
            4 => "Neur&#243;lisis interna"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia&#46; Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients&#46; However&#44; despite advances in diagnostic techniques&#44; neurovascular conflict is sometimes not detected during surgery&#46; The aim of this paper is to systematically review all the options available to best manage this scenario&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described&#46; The success rates of these techniques&#44; pain recurrence rates and rates of complications are also reported&#46; Finally&#44; we provide suggestions based on our experience&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There is no gold standard&#44; but several techniques could be successfully used in the absence of neurovascular conflict&#46; The use of destructive techniques&#44; such as PSR&#44; should be held as treatments of last resort&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La presencia de conflicto neurovascular es la hip&#243;tesis aceptada en el desarrollo de la neuralgia trigeminal y la microdescompresi&#243;n vascular&#44; la t&#233;cnica quir&#250;rgica m&#225;s empleada en su tratamiento&#46; Sin embargo&#44; pese a los avances diagn&#243;sticos&#44; en ocasiones dicho conflicto es indetectable intraoperatoriamente&#46; El objetivo de este trabajo es revisar sistem&#225;ticamente las opciones de manejo ante dicha situaci&#243;n&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existen diversas t&#233;cnicas descritas que se pueden emplear ante la ausencia de conflicto neurovascular durante una microdescompresi&#243;n vascular&#46; Describimos dichas t&#233;cnicas&#44; sus tasas de &#233;xito&#44; la recurrencia del dolor y de complicaciones&#44; y damos nuestras recomendaciones sobre la materia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">No existe un consenso terap&#233;utico&#44; pero se dispone de diversas opciones quir&#250;rgicas ante la ausencia de conflicto neurovascular&#46; Creemos que las t&#233;cnicas destructivas como la RPS deben relegarse a &#250;ltima l&#237;nea terap&#233;utica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Leidinger A&#44; Mu&#241;oz-Hernandez F&#44; Molet-Teixid&#243; J&#46; Ausencia de conflicto neurovascular durante la microdescompresi&#243;n vascular en el manejo de la neuralgia trigeminal esencial&#58; &#191;qu&#233; hacer&#63; Revisi&#243;n sistem&#225;tica de la literatura&#46; Neurocirugia&#46; 2018&#59;29&#58;131&#8211;137&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">TN&#58; Burchiel classification &#40;TN-1&#58; typical&#59; TN-2&#58; atypical&#59; TN-3&#58; trigeminal neuropathic pain&#59; TN-4&#58; iatrogenic trigeminal dysafferentation&#59; TN-5&#58; MS-associated trigeminal neuralgia&#59; TN-6&#58; postherpetic neuralgia&#59; TN-7&#58; atypical facial pain&#41;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">BNI&#58; Barlow Neurological Institute Pain Index&#59; CSF&#58; cerebrospinal fluid&#59; CR&#58; corneal reflex&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Burchiel classification&#46; Taken from Miller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">27</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total alleviation of pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Partial alleviation of pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Hypoaesthesia and complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klun et al&#46;&#44; 1992&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial sensory rhizotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#8211;94&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Facial hypoaesthesia 1 pt<br>Permanent corneal damage 1 pt<br>Hearing loss 1 pt&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Revuelta-Gutierrez&#44; 2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurapraxia<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Arachnoid dissection<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>REZ isolation with Teflon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#37;<br>2 pt&#46; &#40;at 4 months&#41;<br>2 pt&#46; &#40;at 8 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;6&#37; transitory H&#46;<br>28&#46;6&#37; permanent H&#46;<br>4&#46;8&#37; transitory loss of CR &#40;12<span class="elsevierStyleHsp" style=""></span>m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean 17&#46;7<span class="elsevierStyleHsp" style=""></span>m<br>Range 4&#8211;65<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arachnoid enlargement 23&#46;8&#37;<br>Dissociation of fibres 4&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ishikawa&#44; 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arachnoid debridement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immediate improvement<br>2&#46;2&#37; &#40;BNI 1&#41;<br>Delayed improvement<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> 66&#46;6&#37; &#40;BNI 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arachnoid enlargement 100&#37;&#46; Dissociation of fibres 15&#8211;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ma et al&#46;&#44; 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Internal neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#37; &#40;BNI 1&#8211;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#37;<br>&#40;in 3 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#37; transitory H&#46;<br>CR and motor intact&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Min&#46; 3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jie et al&#46;&#44; 2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Internal neurolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#46;1&#37; &#40;BNI 1&#41;<br>7&#46;1&#37; &#40;BNI 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;9&#37; permanent H&#46;<br>3&#46;6&#37; ophthalmoplegia<br>3&#46;6&#37; CSF fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean 52<span class="elsevierStyleHsp" style=""></span>s<br>Range 48&#8211;96<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cheng&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurapraxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;4&#37;<br>&#40;BNI 1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;4&#37;<br>&#40;BNI 2&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;3&#37; permanent H&#46;<br>21&#46;4&#37; transitory H&#46;<br>3&#46;6&#37; loss of CR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean 46<span class="elsevierStyleHsp" style=""></span>s<br>Range 8&#8211;60<span class="elsevierStyleHsp" style=""></span>s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#46;4&#37; pain free without medication at follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ibrahim&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pontine trigeminal tractotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#37; hypoaesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44<span class="elsevierStyleHsp" style=""></span>m mean<br>1&#8211;143<span class="elsevierStyleHsp" style=""></span>m range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good response in the TN-4&#44; TN-5 and TN-6 subgroups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Systemic review of techniques recommended in patients without neurovascular conflict during an MDV&#46; Outcomes and complications&#46;</p>"
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    "bibliografia" => array:2 [
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Vol. 29. Issue 3.
Pages 131-137 (May - June 2018)
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Vol. 29. Issue 3.
Pages 131-137 (May - June 2018)
Review article
Absence of neurovascular conflict during microvascular decompression while treating essential trigeminal neuralgia. How to proceed? Systematic review of literature
Ausencia de conflicto neurovascular durante la microdescompresión vascular en el manejo de la neuralgia trigeminal esencial: ¿qué hacer? Revisión sistemática de la literatura
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Andreas Leidinger
Corresponding author
andreas_leidinger@hotmail.com

Corresponding author.
, Fernando Muñoz-Hernandez, Joan Molet-Teixidó
Servicio de Neurocirugía, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Table 1. Systemic review of techniques recommended in patients without neurovascular conflict during an MDV. Outcomes and complications.
Abstract
Introduction

Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario.

Results

Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described. The success rates of these techniques, pain recurrence rates and rates of complications are also reported. Finally, we provide suggestions based on our experience.

Conclusions

There is no gold standard, but several techniques could be successfully used in the absence of neurovascular conflict. The use of destructive techniques, such as PSR, should be held as treatments of last resort.

Keywords:
Failed microvascular decompression
Trigeminal neuralgia
Neurovascular conflict
Partial sensory rhizotomy
Internal neurolysis
Resumen
Introducción

La presencia de conflicto neurovascular es la hipótesis aceptada en el desarrollo de la neuralgia trigeminal y la microdescompresión vascular, la técnica quirúrgica más empleada en su tratamiento. Sin embargo, pese a los avances diagnósticos, en ocasiones dicho conflicto es indetectable intraoperatoriamente. El objetivo de este trabajo es revisar sistemáticamente las opciones de manejo ante dicha situación.

Resultados

Existen diversas técnicas descritas que se pueden emplear ante la ausencia de conflicto neurovascular durante una microdescompresión vascular. Describimos dichas técnicas, sus tasas de éxito, la recurrencia del dolor y de complicaciones, y damos nuestras recomendaciones sobre la materia.

Conclusiones

No existe un consenso terapéutico, pero se dispone de diversas opciones quirúrgicas ante la ausencia de conflicto neurovascular. Creemos que las técnicas destructivas como la RPS deben relegarse a última línea terapéutica.

Palabras clave:
Microdescompresión vascular fallida
Neuralgia trigeminal
Conflicto neurovascular
Rizotomía parcial sensitiva
Neurólisis interna

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