Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada.
World Neurosurg. 2024 May;185:370-380.e2. doi: 10.1016/j.wneu.2024.02.097. Epub 2024 Feb 24.
Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited data exist to guide the selection of salvage surgical procedures. We aimed to compare pain relief outcomes after repeat microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS) to determine which modality was most efficacious for surgically refractory TN.
A PRISMA systematic review and meta-analysis was performed, including studies of adults with classical or idiopathic TN undergoing repeat surgery. Primary outcomes included complete (CPR) and adequate (APR) pain relief at last follow-up, analyzed in a multivariate mixed-effect meta-regression of proportions. Secondary outcomes were initial pain relief and facial numbness.
Of 1299 records screened, 61 studies with 68 treatment arms (29 MVD, 14 PR, and 25 SRS) comprising 2165 patients were included. Combining MVD, PR, and SRS study data, 68.8% achieved initial CPR after a repeat TN procedure. On average, 49.6% of the combined sample of MVD, PR, and SRS had CPR at final follow-up, which was on average 2.99 years postoperatively. The proportion (with 95% CI) achieving CPR at final follow-up was 0.57 (0.51-0.62) for MVD, 0.60 (0.52-0.68) for PR, and 0.35 (0.30-0.41) for SRS, with a significantly lower proportion of pain relief with SRS. Estimates of initial CPR for MVD were 0.82 (0.78-0.85), 0.68 for PR (0.6-0.76), and 0.41 for SRS (0.35-0.48).
Across MVD, PR, and SRS, about half of TN patients maintain complete CPR at an average follow-up time of 3 years after repeat surgery. In treating refractory or recurrent TN, MVD and PR were superior to SRS in both initial pain relief and long-term pain relief at final follow-up. These findings can inform surgical decision-making in this challenging population.
手术可以有效治疗三叉神经痛（TN），但术后疼痛复发或无反应较为常见。重复手术经常被提供，但指导选择挽救性手术程序的数据有限。我们旨在比较重复微血管减压（MVD）、经皮神经根切断术（PR）或立体定向放射外科（SRS）后的疼痛缓解结果，以确定哪种方式对手术难治性 TN 最有效。
进行了 PRISMA 系统评价和荟萃分析，纳入了接受重复手术的成人经典或特发性 TN 的研究。主要结局包括末次随访时完全缓解（CPR）和充分缓解（APR）的疼痛缓解，在多元混合效应比例荟萃回归中进行分析。次要结局为初始疼痛缓解和面部麻木。
在筛选的 1299 份记录中，纳入了 61 项研究，共 68 个治疗臂（29 项 MVD、14 项 PR 和 25 项 SRS），共 2165 例患者。综合 MVD、PR 和 SRS 的研究数据，68.8%的患者在重复 TN 手术后出现初始 CPR。平均而言，综合 MVD、PR 和 SRS 样本中，49.6%的患者在末次随访时具有 CPR，平均术后 2.99 年。在 MVD、PR 和 SRS 的最终随访中，达到 CPR 的比例（95%CI）分别为 0.57（0.51-0.62）、0.60（0.52-0.68）和 0.35（0.30-0.41），SRS 的缓解比例明显较低。MVD 的初始 CPR 估计值为 0.82（0.78-0.85）、PR 为 0.68（0.6-0.76）、SRS 为 0.41（0.35-0.48）。
在 MVD、PR 和 SRS 中，约一半的 TN 患者在重复手术后平均 3 年的随访中保持完全 CPR。在治疗难治性或复发性 TN 时，MVD 和 PR 在初始疼痛缓解和最终随访时的长期疼痛缓解方面均优于 SRS。这些发现可以为这一具有挑战性的人群的手术决策提供信息。
