Raygor Kunal P, Lee Anthony T, Nichols Noah, Wang Doris D, Ward Mariann M, Barbaro Nicholas M, Chang Edward F
1Department of Neurological Surgery, University of California, San Francisco, California; and.
2Department of Neurological Surgery, University of Texas at Austin, Texas.
Neurosurg Focus. 2020 Oct;49(4):E23. doi: 10.3171/2020.7.FOCUS20446.
Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly.
A prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up.
One hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I-IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control.
In this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient's unique condition and wishes.
三叉神经痛（TN）的常见外科治疗方法包括微血管减压术（MVD）和立体定向放射外科治疗（SRS）。已有关于老年患者采用MVD治疗的描述，但尚未与耐受性良好且无创的SRS进行前瞻性比较。作者旨在直接比较老年特发性TN首次手术治疗的长期疼痛控制情况和不良事件发生率。
回顾一个前瞻性收集的数据库，纳入1997年至2017年在单一机构接受治疗的TN患者。对术前人口统计学资料、手术过程和术后结果进行标准化收集。数据分析仅限于65岁以上首次接受特发性TN治疗且至少随访1年的患者。
在研究期间，193例符合研究纳入标准的患者接受了TN手术（54例MVD，24例MVD+感觉根切断术，115例SRS）。在MVD手术中，若动脉未压迫三叉神经，则进行部分感觉根切断术（MVD+感觉根切断术）。SRS队列中的患者比MVD和MVD+感觉根切断术队列中的患者年龄更大（平均±标准差，分别为79.2±7.8岁、72.9±5.7岁和70.9±4.8岁；p<0.0001），且Charlson合并症指数更高（分别为3.8±1.1、3.0±0.9和2.9±1.0；p<0.0001）。术后即刻或短期无痛率（巴罗神经学研究所[BNI]疼痛强度评分I），MVD为98.1% , MVD+感觉根切断术为95.8%，SRS为78.3%（p=0.0008）。在最后一次随访时，72.2%的MVD患者预后良好（BNI评分I-IIIa），而MVD+感觉根切断术和SRS患者的这一比例分别为54.2%和49.6%（p=0.02）。总共有0例（0%）SRS患者、5例（9.3%）MVD患者和1例（4.2%）MVD+感觉根切断术患者发生任何不良事件。多因素Cox比例风险分析表明，手术类型（p=0.001）和术后感觉变化（p=0.003）与疼痛控制在统计学上显著相关。
在本研究队列中，首次接受MVD手术的患者疼痛缓解持续时间在统计学上显著长于首次接受MVD+感觉根切断术或SRS手术的患者。SRS术后不良事件较少，尽管MVD相关并发症发生率与年轻患者的已发表发生率相当。总体而言，结果表明，尽管年龄较大，但MVD和SRS对老年患者都是有效的选择。治疗选择可根据患者的独特病情和意愿进行调整。
