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ORIGINAL ARTICLE
Abstract
In order to illustrate the inherent problems of managing bilateral trigeminal neuralgia a retrospective study of the 16 cases
of bilateral trigeminal neuralgia, out of just over 300 cases of trigeminal neuralgia, treated over a 14-year period, has been
performed. All the patients, presented with a typical history of trigeminal neuralgia and underwent surgical exploration. Pain
relief was initially achieved in all cases; however, only four remained cured, three have become pain free after additional
rhizotomy, a further one after peripheral cryotherapy and four with medical treatment. Four patients have had bilateral
operations for trigeminal neuralgia, but in two cases the pain was relieved on one side only. Bilateral trigeminal neuralgia
presents special problems of management with respect to underlying neuropathology (e.g. multiple sclerosis), the need for
the limitation of the use of ablative techniques in order to minimise the disability of bilateral sensory and motor dysfunction,
and the relatively poor response to microvascular decompression. These factors emphasize the multifactorial nature of the
cause of trigeminal neuralgia. Magnetic resonance tomographic angiography is now available and is important in determining
the range of therapeutic options for this group of patients.
Key words: bilateral, evoked potential, facial pain, microvascular decompression, trigeminal neuralgia.
Introduction
Idiopathic trigeminal neuralgia (TGN) is usually a
unilateral disease and bilateral cases are quite rare.^
Bilateral TGN (BTGN) has been reported to have an
incidence which varies between 0.3 and 6%.^"'
While the treatment of idiopathic TGN has become
relatively standarized, there remains a major
therapeutic dilemma in how to treat bilateral cases.
Ablative techniques carry the obligatory risk of
sensory and/or motor trigeminal deficits which, if
bilateral, may cause the patient to have serious
problems with speaking and eating, and therefore the
use of non-ablative methods must be considered.
To illustrate the magnitude of the problem, we
have retrospectively reviewed 16 cases of BTGN from
a total of 302 patients (5.2%) operated on for TGN
in our centre over the last 14 years.
Patients and methods
A total of 16 patients with BTGN presented to the
Walton Centre for Neurology and Neurosurgery in
Liverpool (UK) between 1983 and 1997, and have
been analysed. All presented as clinically typical of
TGN according to Rasmussen's classification.^
The ages ranged between 24 and 78 years (mean
Correspondence to. Professor J. Miles, Department of Neurological Sciences, Walton Centre for Neurology and Neurosurgery, Lower Lane,
Fazakerley, Liverpool L97 LJ, UK. Fax: 0151 529 5509. E-mail: MILES-J@WCNN.CO.UK
Received for publication 9 March 1999. Accepted 5 August 1999.
ISSN 0268-8697 print/ISSN 1360-046X online/00/010033-07 The Neurosurgical Foundation
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has a much lower risk of provoking anaesthesia doloSimultaneously bilateral MVD is a feasible and
reasonable option' if MRTA is positive bilaterally
and the pains of equal significance, such that removal
of one would not allow reduction in medication. This
would not only save the patients from two operations
with their attendant risks and complication, but also
save them from bearing the pain for an unnecessary
length of time.
More recently gamma knife radiosurgery has been
used, especially for patients in poor medical condition, with encouraging initial results. ^^ Some of the
problems of this technique are, however, that the
treatment will take several weeks to show some effect,
the follow-up available is still quite short and the
recurrence rate seems to be higher than with the
traditional treatment. Delayed radionecrosis may also
prove to be a risk, especially if the targeting involves
the pontine REZ region.
The problem of evolving pathology such as may be
expected in MS, also infiuences therapeutic decisions. We believe, as do Broggi et al.^^ that in cases
where the neurological condition is stable, perhaps,
for more than 2 years and particularly in the absence
of overt brain stem demyelination on MRI, neurovascular decompression should be considered. The
preoperative validation of vascular compression by
MRTA is again essential in these cases.
We believe that it is now possible to establish real
time intraoperative neurophysiological evidence of
improvement in nerve conduction in the trigeminal
nerve by MVD.*^ If this facility becomes routine it
might well play a major role in the surgical management of BTGN.
Conclusions
BTGN presents a definite therapeutic dilemma
compared with unilateral TGN. The pathophysiological mechanism responsible for the pain may be
more complex than that of unilateral cases.
The success rate of MVD for bilateral pain is far
less satisfactory than for the unilateral condition.
However, the quality of pain relief without
neurological deficit, still makes MVD a definite option
for treatment of this condition. Great consideration
must be given to the whole range of surgical options,
directed particularly, to minimizing denervating
morbidity.
In all cases where MVD will not work or will fail
with time (the median follow-up of our patients is
quite short), then a partial rhizotomy at the REZ
must be considered. However, if a percutaneous
procedure is to be used, then percutaneous microcompression seems to be, at the present time, the best
available option in terms of pain control and sensorymotor deficits.
Intraoperative trigeminal evoked potentials may
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