A Comparison of Treatments for Trigeminal Neuralgia
Feb 2019 - Trigeminal Neuralgia Association Australia Original Article #

A comparison of microvascular decompression (MVD) surgery versus stereotactic radiosurgery (SRS) for trigeminal neuralgia

Benjamin Jonker | Neurosurgeon

Patients with trigeminal neuralgia will sometimes receive different advice depending on which doctor they see for their problem. It is always helpful for people to have an understanding of the pros and cons of different approaches.

The procedures in brief

Microvascular decompression (MVD) is our gold standard surgical procedure for trigeminal neuralgia involving an operation under a general anaesthetic through a cut behind the ear. It is highly successful, but obviously requires some time to recover from and there are a few serious but thankfully rare risks.

Another approach to trigeminal neuralgia, which has been particularly popular in the United States and Europe and to a lesser extent in Australia is stereotactic radiosurgery (also known as Gamma Knife if that particular brand of machine is used). This is a non-invasive procedure where multiple pinpoint beams of radiation are focussed onto the trigeminal nerve with the aim of stopping the excitability of the nerve that causes trigeminal neuralgia. It requires no anaesthetic or recovery time and doesn’t even require people to come off blood thinning medications.

How do we work out how to proceed?

One of the methods used in medical research when there are a large number of studies with information available is to do what is called a “systematic review and meta-analysis”. This entails finding all the relevant published papers that exist on the topic, and where possible numerically combining all the data using statistical methods to try and get the most comprehensive information on the topic.

Our systematic review of MVD versus SRS

In 2018 I published a systematic review and meta-analysis with my co-authors in British Journal of Neurosurgery. We sought to find all the relevant data that would allow us to compare surgical microvascular decompression (MVD) with radiosurgery (SRS).
We found 532 papers in the medical literature, and after removing duplicate publications and seeing whether the papers addressed our topic we were left with 39 studies. These included 1353 patients of which about half received MVD and the other half received SRS.

Whereas MVD had 91% of patients pain free after the procedure, the number was less for SRS with 66%. In other words MVD made 9/10 patients pain free, but SRS made 2/3 patients pain free.

Some patients will experience a recurrence over time but we also found that a number of years after treatment the proportion of pain free patients remained significantly higher with MVD compared to SRS.

Complications were more common in the MVD group than after SRS with CSF leak (brain fluid leak), loss of hearing on the side of surgery and wound infections being the most common.

We did, however find that SRS showed a greater association with facial numbness or abnormal sensation than did MVD. This was not unexpected, since the purpose of the radiation is to dampen down the firing of the trigeminal nerve.

What does this mean for me?

The take home message is that MVD remains the most effective procedure for trigeminal neuralgia, and for this reason it is the treatment of choice in most patients who need
a procedure for their TN, if they are otherwise healthy (or have manageable medical problems).

SRS (radiosurgery) is less effective, but the majority still obtain pain relief and it has a very low complication rate (aside from facial sensory changes). For this reason, patients with significant medical problems, or who can’t afford to be taking a number of weeks off to recover from their procedure may benefit from undergoing SRS.

I hope this has contained some helpful information. Please remember that this information is general and for an individual patient it is always advisable to discuss treatment options with an experienced practitioner!