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Vol. 31. Issue 2.
Pages 53-63 (March - April 2020)
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Vol. 31. Issue 2.
Pages 53-63 (March - April 2020)
Clinical Research
DOI: 10.1016/j.neucie.2019.07.004
Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why
Masaje de la raíz trigeminal en el tratamiento quirúrgico de la neuralgia de trigémino sin contacto neurovascular arterial: cuándo, cómo y porqué
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Enrique Urculo
Corresponding author
, Alejandro Elua, Mariano Arrazola, Patricia Torres, Sergio Torres, Jose Undabeitia
Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
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Table 1. Clinical characteristics of 10 patients who underwent trigeminal root massage.
Table 2. Operative findings, results and follow-up.
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Abstract
Background

During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call “trigeminal root massage” (TRM).

Methods

52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant.

Results

All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa.

Conclusions

The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don’t find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as “nerve combing”. Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.

Keywords:
Trigeminal neuralgia
Microvascular decompression
Trigeminal root.massage
Venous compression
Petrosal venous system
Pain
Abbreviations:
MVD
TN
TR
TRM
REZ
Resumen
Introducción y objetivos

Durante la exploración microquirúrgica de la raíz trigeminal en el ángulo pontocerebeloso en pacientes con neuralgia del trigémino (NT) primaria sin una evidente compresión arterial, el cirujano se encuentra en una situación comprometida, ya que no existe una estrategia quirúrgica establecida. El objetivo de este estudio es la de describir en esos casos una maniobra quirúrgica que llamamos «masaje de la raíz trigeminal» (MRT).

Métodos

Se revisan un total de 52 pacientes consecutivos con NT primaria a quienes se ha realizado una exploración de la raíz trigeminal por vía suboccipital retrosigmoidea. Entre ellos hemos encontrado 10 pacientes sin una evidente compresión arterial durante la exploración microquirúrgica. En 8 de los 10 casos ha existido un contacto venoso de la raíz trigeminal a lo largo de su trayectoria cisternal, procediendo a la coagulación y sección de la/s vena/s. En los 10 casos se ha procedido, finalmente, a un suave masaje de la raíz trigeminal sin interposición de ningún material.

Resultados

Los 10 pacientes experimentaron una inmediata desaparición de la neuralgia y el curso postoperatorio fue favorable excepto por un caso de complicación severa con edema cerebeloso, meningitis e hidrocefalia. La recidiva fue del 40%. Seis pacientes obtuvieron una desaparición completa de la neuralgia, sin medicación específica, en un seguimiento medio de 5 años. No ha habido mortalidad ni anestesia dolorosa postoperatoria.

Conclusiones

La maniobra quirúrgica descrita es una alternativa útil y sencilla en casos donde, durante la exploración microquirúrgica de la raíz trigeminal, no encontramos una clara compresión arterial, con resultados similares a otras posibilidades como la rizotomía parcial o más laboriosas como la llamada nerve combing. En cualquier caso, un 40% de recidiva dolorosa a los 5 años significa que, aunque es una buena alternativa, no es una técnica definitiva en la curación de todos los enfermos con NT sin conflicto arterial.

Palabras clave:
Neuralgia del trigémino
Descompresión microvascular
Masaje de la raíz trigeminal
Compresión venosa
Sistema venoso petroso
Dolor

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