Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Letter
Case Report
Case Series
Commentary
Current Issue
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Systematic Review
Systematic Review Article
Technical Note
Techniques in Neurosurgery
View/Download PDF

Translate this page into:

Commentary
3 (
2
); 158-158

Commentary

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
Address for correspondence: Dr. Wei Cheong Ngeow, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia. E-mail: ngeowy@um.edu.my

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Trigeminal neuralgia is a devastatingly painful condition that severely reduces patients’ quality of life, and is most often managed by medical management using anti-convulsants, usually carbamazepine.[1] However, these cases can become refractory to medical treatment and need further neurosurgical intervention. In such a situation, one dilemma that often arises in under-developed and developing countries is an access to neurosurgical care and the mode of surgical interventions available. Neurosurgical treatments can be categorized as reversible or non-reversible. Some reversible neurosurgical interventions include the injection of local anesthetic agents,[2] alcohol[3] and botulinum toxin,[4] all of which can be done on an outpatient basis and even in rural practice by a trained medical practitioner or oral and maxillofacial surgeon. However, these procedures do not provide long lasting pain relief, and in the case of botulinum toxin injection, it can be very expensive. A recent issue of this journal highlighted an emerging role of transcutaneous electric nerve stimulation, which showed very promising results.[5] However, until more evidences are available, more invasive and irreversible neurosurgical treatment appears to be the best alternative for managing refractory trigeminal neuralgia.

Invasive neurosurgical treatment includes microvascular decompression (which is non-ablative) and various ablative procedures that are performed at various sites, namely peripherally, at the Gasserion ganglion or within the posterior cranial fossa. Peripheral neurectomy is a not a new neurosurgical procedure, having been practiced since late 19th century,[6] but documentations on its success and long term outcome is still lacking until today.[7] Therefore, with increased sophistication in neurosurgical procedures and the ability to scan and review the Merkel's cave and Gasserion ganglion using new and highly accurate imaging modalities, the currently accepted norm to surgically manage trigeminal neuralgia has shifted from peripheral intervention to a central one. However, evidence of the benefits of invasive surgical treatment, though generally accepted, rests on anecdotal reports and case series; no clinical trials have established the efficacy of any surgical procedure.[1] The lack of evidence leads us back to a very basic question: Is peripheral neurectomy still relevant in today's neurosurgical practice?

The answer, I believe, is a cautious yes! Anecdotal evidences have shown that some patient can be pain-free for a period up to 48 months when peripheral neurectomy is undertaken followed by the occlusion of the foramina for the nerve concerned.[89] To the best of my knowledge, Ali et al.[10] are the first to compare duration of pain-free period between cases of peripheral neurectomy with and without the occlusion of the foramina, and has clearly shown that the occlusion of the foramina provide an added advantage for peripheral neurectomy. Unfortunately, the patients were not randomized. In addition, the duration of follow-up is rather short at the moment (2 years). It would be good if Ali et al.[10] could provide updates in the future of the long term (5 and 10 years) outcome of this procedure. The statement by Normikka and Eldridge[7] best summarizes the indication for performing peripheral neurectomy: “…it may be useful in cases where other treatments have failed, and patient or doctor are reluctant to consider procedures aimed at the ganglion or root.”

References

  1. , , . Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Cochrane Database Syst Rev. 2011;9:CD007312.
    [Google Scholar]
  2. , , , , . Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008;62:248-54.
    [Google Scholar]
  3. , , . Brief report: The long-term outcome of mandibular nerve block with alcohol for the treatment of trigeminal neuralgia. Anesth Analg. 2010;111:550-3.
    [Google Scholar]
  4. , , . Injection of botulinum toxin type A (Botox) into trigger zone of trigeminal neuralgia as a means to control pain. Oral Surg Oral Med Oral pathol Oral Radiol Endod. 2010;109:e47-50.
    [Google Scholar]
  5. , , , . Role of transcutaneous electric nerve stimulation in the management of trigeminal neuralgia. J Neurosci Rural Pract. 2011;2:150-2.
    [Google Scholar]
  6. , . The operative treatment of facial neuralgia: A comparison of methods and results. Ann Surg. 1886;3:269-320.
    [Google Scholar]
  7. , , . Trigeminal neuralgia – pathophysiology, diagnosis and current treatment. Br J Anaesth. 2001;87:117-32.
    [Google Scholar]
  8. , . Peripheral neurectomy in the treatment of trigeminal neuralgia of second and third divisions. J Oral Surg. 1972;30:113-20.
    [Google Scholar]
  9. , . Surgical treatment of trigeminal neuralgia. J Oral Rehabil. 1999;26:613-7.
    [Google Scholar]
  10. , , , , , , . Peripheral neurectomies: A treatment option for trigeminal neuralgia in rural practice. J Neurosci Rural Pract. 2012;3:152-7.
    [Google Scholar]

    Fulltext Views
    426

    PDF downloads
    222
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections