Surgical Neurology 68 (2007) 505 – 512

www.surgicalneurology-online.com
Pain
Are the destructive neurosurgical techniques as effective
as microvascular decompression in the management
of trigeminal neuralgia?B
Mehdi Laghmari, MD4, Abdessamad El Ouahabi, MD, Yasser Arkha, MD,
Said Derraz, MD, Abdeslam El Khamlichi, MD
Department of Neurosurgery, Hôpital des spécialités O.N.O, C.H.U Rabat, Morocco
Received 12 March 2006; accepted 28 November 2006

Abstract Background: There are no randomized controlled trials comparing TC, PTGC, and MVD for
idiopathic TN at a single institution using quality criteria. The aim of the study was to assess the
long-term outcome (efficiency and morbidity) of treated patients with one of these techniques in the
same institution.
Methods: The authors present a retrospective study of 165 consecutive patients from 1983 to 2004.
The inclusion criteria were drug-resistant idiopathic TN and intolerance to medical treatment. Three
groups were set up according to the techniques used: group I (n = 73), treated by TC; group II
(n = 41), treated by PTGC; group III (n = 51), treated by MVD. The main judgment criterion was
pain relief. The second judgment criterion was morbidity. v 2 or Fisher exact test, Kaplan-Meier, and
log-rank were used for statistical analysis.
Results: The 3 groups were homogeneous according to age, duration of evolution, and pain
topography. Concerning sex, groups I and II were different (women, 58%; vs. 37%; P = .021). The
immediate efficiency for the 3 groups was, respectively, 96%, 94%, and 95% (NS). At 6 years
follow-up, 70%, 77%, and 72% of the patients, respectively, remained pain-free (NS). As determined
by the Kaplan-Meier survival curve, there was no difference between the 3 groups (log-rank,
P = .867). Hypoesthesia was more frequent for PTGC (89%).
Conclusions: In our study, we did not find MVD to be more effective than the other techniques.
However, it had the lowest long-term complication rate, which is a strong argument in choosing this
technique as the initial procedure for young and healthy patients. Percutaneous techniques, however,
are still recommended in specific circumstances.
D 2007 Published by Elsevier Inc.
Keywords: Balloon compression; Microvascular decompression; Radiofrequency thermocoagulation; Trigeminal neuralgia

1. Introduction
Abbreviations: CT, computed tomography; MRI, magnetic resonance Trigeminal neuralgia, or btic douloureux,Q is a syndrome
imaging; MVD, microvascular decompression; NS, nonsignificant; PTGC,
percutaneous balloon compression of the gasserian ganglion; TC, retro-
characterized by dreadful paroxysmal pain attacks. Via
gasserian percutaneous radiofrequency thermocoagulation; TN, trigeminal myelinated Ad-fibers, it is caused by non-nociceptive
neuralgia. stimuli such as yawning, chewing, light touch, and other
B
The authors submit this article for publication in Surgical Neurology. transmitted stimuli [10]. The diagnosis is usually made on
They confirm that this work is original. It has not been previously pub- the basis of the patient’s history and the absence of
lished in whole or in part nor has it been simultaneously submitted to any
other journal.
neurological deficits, with the exception of discrete hypal-
4 Corresponding author. gesia, thermohypesthesia, or mechanoceptive hypoesthesia
E-mail address: mehdi_laghmari@hotmail.com (M. Laghmari). in the trigger area [32]. The pathogenesis of TN and the
0090-3019/$ – see front matter D 2007 Published by Elsevier Inc.
doi:10.1016/j.surneu.2006.11.066
506 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512
Fig. 1. Surgical position and skin marks during TC procedure.
effect of the different surgical procedures are not completely
understood until now [19].
Surgical procedures are indicated when the TN is
unresponsive to medications or when the patient is intolerant
to medical treatment. A large spectrum of surgical techniques
has been used to treat patients with medically unresponsive
TN: MVD, radiofrequency rhizotomy (TC), trigeminal
glycerol injection, PTGC, and stereotactic radiosurgery.
Whereas MVD is an etiologic treatment and conservative
on the trigeminal nerve, all the other operations are destructive
to the fifth nerve. The type of surgery to be performed is
decided on a variety of factors including the patient’s age,
medical condition, prior surgery, and patient’s decision.
It is generally agreed that MVD provides the longest
duration of pain relief while preserving facial sensation
[3,17,37].
In experienced hands, MVD gives low morbidity and
low mortality rates. However, for many experts, MVD is not
recommended in the elderly or in patients with associated
comorbidities [2,11,16,26].
To our knowledge, surgical literature contains no
controlled randomized trial comparing these procedures. It
is therefore difficult to advise patients on when the best
treatment has to be opted for [39].
The aim of our study was to assess efficiency and mor-
bidity of the 3 operative techniques used in our department.
2. Material and methods
We retrospectively reviewed 165 consecutive patients
who underwent MVD, TC, or PTGC over the past 21 years.
Furthermore, a follow-up was obtained for all patients by
reviewing their chart records or by calling up the patients
whose charts were incomplete. All patients had idiopathic
TN, and all were resistant or intolerant to medical treatment.
Two patients had bilateral neuralgia, but only the more
severe side was treated in this study.
Response to surgery (pain relief), side effects, complica-
tions, probable drug intake, and patient satisfaction were
assessed for each procedure. The inclusion criteria were
drug-resistant idiopathic TN and TN intolerant to medical
treatment. Cases of atypical neuralgia and carcinomatous
pain were excluded from this investigation.
At the beginning of our experience, from 1983 to 1986,
TC was the only technique used, regardless of age, pain
topography, or medical status. However, after the acquisi-
tion of the 2 other procedures, we changed our strategy.
Retrogasserian percutaneous radiofrequency thermocoagu-
lation and PTGC were recommended for patients with
associated comorbidities, old patients (65 years and older)
and patients unwilling to accept risks related to a posterior
fossa craniotomy. For younger patients and those who were
not in the previously described groups, we suggested the
Janneta MVD technique [16]. In case of ophthalmic
neuralgia (V1), TC was not considered since the appearance
of the first cases of keratitis (2 of 15 cases).
Three groups were set up according to the technique
used. Group one included 73 patients treated by TC, which
acts as a selective injury of Ad and C fibers at 658C, with
selection of the painful trigeminal branch. Group 2 included
51 patients treated by MVD. The last group included
41 patients treated by PTGC as described by Mullan and
Lichtor [30].
2.1. Operative techniques
2.1.1. Retrogasserian percutaneous radiofrequency thermo-
coagulation
Retrogasserian percutaneous radiofrequency thermocoa-
gulation, as previously described by Sweet and Wepsic [34],
was performed under local anesthesia and anesthesia
standby. After the introduction of an 18- or 20-gauge needle
Fig. 2. Pear-shape appearance of balloon under fluoroscopic guidance
during PTGC.
 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512 507

Table 1 control. The shape and position of the balloon are checked
Patient population characteristics with respect to neighboring bone structures [9,23,30]. Then,
Parameter Type of treatment P the balloon is inflated for 5 minutes. Three elements indicate
TC MVD PTGC good positioning of the probe and efficacy of the inflation:
No. of patients 73 51 41 first is the feeling of the operator finger, which maintains a
Age (mean F SD) 53 aF 13 50 aF 12.5 55.5 F 11.5 .109a pressure during inflation; second is the pear-shape appear-
Sex (female/male) 58 37 48 .02 ance in the scope (Fig. 2); last is the bradycardia induced by
Duration of symptoms 60 F 42 47 F 34 44 F 41 .067 the trigeminocardiac reflex. After ganglion compression for
(mean F SD)
Lateralization 48% right 57% right 54% right .604
5 minutes, the contrast medium is aspirated, and the catheter
Division involved, n (%) is withdrawn. However, the procedure is not selective;
V1 2 (2.7) 5 (9.8) 4 (9.8) .197 hence, it is impossible to limit compression to a single
V2 17 (23.3) 9 (17.6) 8 (19.5) .732 division of the nerve [18,30].
V3 16 (22) 8 (15.7) 7 (17) .648
V1 V2 11 (15) 8 (15.7) 6 (14.6) .990 2.2. Evaluation
V2 V3 20 (27.4) 12 (23.5) 8 (19.5) .579
V1 V2 V3 7 (9.6) 9 (17.6) 8 (19.5) .266 The main judgment criterion was successful (pain-free)
a
Statistical significance between TC and PTGC.
in short- and long-term period. Good result after surgical
treatment in TN was bno drug and no neuralgic pain.Q In
with a 2- or 5-mm exposed tip, test stimulation was good results, we also included patients who need low dose
performed. The position of the needle tip is modified of carbamazepine (400 mg daily at the most) in the
according to the stimulation effect. Then, 1 or 2 electro- postoperative course. Only results of the first intervention
coagulations were made to last 60 to 90 seconds at a were taken into account. The recourse to a second operation
temperature of 658C to 708C (Fig. 1). The lesion duration was regarded as being a failure. The second criterion of
and temperature depended on the pain distribution and the judgment was morbidity.
patient’s age [34]. The lesion generator RFG 3A (Radionics
Inc, Burlington, Mass) was used. 2.2.1. Imaging evaluation
Before 1993, patients were assessed by CT scan to
2.1.2. Microvascular decompression eliminate a tumor or vascular malformation. After 1993,
The surgical procedure was first described by Jannetta patients were assessed by axial and oblique sagittal images
et al [16]. It was performed via a retromastoid suboccipital of MRI with a 1.5 T scanner to show the offending vessels
craniectomy (3 cm in diameter) in a semiprone position and or other possible lesions such as petrosal meningioma,
through a vertical retroauricular incision. Under gentle schwannoma, or epidermoid cyst, and so on. In the present
retraction of the lateral cerebellum, an operating microscope series, TN symptomatic to other disease was excluded. No
and microinstruments were used. The petrosal vein was not patient had multiple sclerosis.
scarified unless it was necessary to get to the trigeminal
root. Then, the arachnoid investment of the trigeminal nerve 2.2.2. Statistic analysis
was opened, and the dorsal root entry zone was inspected Statistical analyses were performed using the SPSS
carefully. Each compressive vessel was microsurgically software system (version 11.0). t test, v 2, or Fisher exact
dissected and pushed away with a Teflon sponge. Some- test were used depending on different variables. t test was
times, no offending vessel was found, but a bony protrusion used in the comparison of mean duration and mean age,
from the petrous bone was compressive. If no offending whereas v 2 or Fisher tests were used in the comparison of
structure was found (9% of our cases), a partial rhizotomy sex, pain topography, and surgical outcomes. Kaplan-Meier
was performed. analyses of pain-free survival curves were constructed.

2.1.3. Balloon compression of the gasserian ganglion Table 2

We adopted the procedure first described by Mullan and Offending structures in 51 patients with TN treated by MVD
Lichtor in 1983 [23,30]. We inserted the 14-gauge catheter Offending structure No. of patients
in the jaw (the point of entry into the skin is 2.5 cm external Vascular 47
to the angle of the mouth) up to the ovale foramen. It is SCA 30
initially advanced parallel to the sagittal plane to avoid AICA 4
transfixion of the oral mucosa, the catheter then being PICA 2
Vein 11
redirected under fluoroscopic guidance until the foramen Bony prominence 2
ovale is entered. A no. 4 Fogarty catheter is introduced until Temporal bone spur 1
10 to 15 mm of the catheter lies beyond the needle tip. The Angulation of the entry of Meckel cavum 1
balloon is inflated with 0.75 to 1 mL of 300 mg I2/mL Arachnoiditis 2
Iohexol (Iopamiron 300 mg) until it begins to emerge SCA indicates superior cerebellar artery; AICA, anterior inferior cerebellar
proximate to the posterior fossa under lateral fluoroscopic artery; PICA, posterior inferior cerebellar artery.
508 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512
3. Results
In the TC group, population consisted of 42 women and 31
men with ages ranging from 26 to 78 years (mean, 53 F 13).
The interval between onset and diagnosis was 60 months
(F42). The operation time was 30 to 80 minutes, and the
mean time was 40 minutes. The follow-up ranged from 12 to
200 months, and the mean was 95 months. Seven patients
were lost to follow-up.
In the MVD group, population consisted of 19 women
and 32 men, with ages ranging from 25 to 69 years (means,
50 F 12.5 years). Duration of symptoms before diagnosis
was 47 F 34 months. The operation time was 70 to 180
minutes (mean, 120 minutes). The follow-up ranged from
12 to 150 months (mean, 88 months). Only 4 patients were
lost to follow-up.
In the PTGC group, population consisted of 20 women
and 21 men, and mean age ranged from 34 to 70 years
(mean, 55.5 F 11.5 years). The duration of symptoms was
44 F 41 months. The operation time was 20 to 45 minutes
(mean, 30 minutes). The follow-up ranged from 10 to 96
months, and the mean was 72 months. Only 2 patients were
lost in the follow-up.
The 3 groups were homogeneous concerning age,
duration of symptoms, and pain topography. However, we
found a significant difference regarding sex between group I
and II, and the rate of ophthalmic neuralgia was different.
Indeed, since the appearance of the first cases of keratitis
induced by thermocoagulation of the first division of the
trigeminal nerve, this technique was not used anymore for
ophthalmic neuralgia. This is why we found a reduced rate
of ophthalmic neuralgia in group I (Table 1).
3.1. Operative findings
Among the 51 patients treated by MVD, a vascular
compression was responsible of TN in 47 patients (92%).
An arterial compression occurred in 36 patients. The most
common offending vessel was superior cerebellar artery (30
cases). Venous compression occurred in 11 cases. In 4 cases,
we did not find any vascular compression. But arachnoiditis
was obvious in 2 cases, and compressive temporal bone
spurs were found in 2 other cases (Table 2).
3.2. Short-term follow-up results
The follow-up materials were analyzed postoperatively
after 1 week (Table 3). Immediate postoperative pain relief
(without or with 400 mg of carbamazepine daily at the most)
was achieved in 96% (70/73), 94% (48/51), and 95% (39/41)
Table 3
Comparison of the efficacy at short term and long term in the 3 groups
TC, MVD, PTGC,
n = 73 (%) n = 51 (%) n = 41 (%)
Pain relief at 96 94 95
short term
Pain relief 70 77 72
after 6 years
Fig. 3. Actuarial Kaplan-Meier curve comparing efficacy with the
3 procedures.
for TC, MVD, and PTGC, respectively (v 2, P = .903, NS).
Considering only pain-free patients without any drug
intake, immediate postoperative pain relief was achieved,
respectively, in 90% (66/73), 92% (47/51), and 88% (36/41)
(v 2, P = .925). We had no casualties during our study.
3.3. Long-term follow-up results
After 6 years, the rate of pain relief declined to 70% (35/
50 cases), 77% (28/36), and 72% (23/32), respectively for
TC, MVD, and PTGC (v 2, P = .718, NS) (Table 3). If we
evaluate only pain-free patients with no drug intake, the
rates of pain relief were, respectively, 64% (32/50), 72%
(26/36), and 62% (20/32) (v 2, P = .510, NS). Only 7
patients in the TC group, 4 patients in the MVD group, and
2 patients in the PTGC group were lost in follow-up.
The data were also assessed by the Kaplan-Meyer
actuarial curve where the event was the set in of failure or
recurrence (Fig. 3). The log-rank did not display any
statistical difference between the 3 groups ( P = .867).
3.4. Results after repeated procedures
Some patients had to be operated several times because
of failure of the initial operation or recurrence of the
neuralgic pain. Twenty patients who were initially treated by
TC and who were not relieved were operated again (TC was
performed in 10 cases, MVD in 5 cases, and PTGC in 5
cases). Eight patients who initially underwent MVD
required another procedure (5 patients underwent TC, and
3 others underwent PTGC). Five patients who were initially
treated by PTGC without pain relief have been operated
again using the same technique.
Among all patients operated several times, good result
(without or with 400 mg of carbamazepine daily at most)
was achieved in 42% of the cases (14/33). Eleven patients
P displayed dysesthesia after the second procedure (7 after
TC, and 4 after PTGC).
.903 NS
3.5. Morbidity
.718 NS Ipsilateral numbness was an expected side effect and was
well tolerated. It occurred in 24% of the cases for TC, in
 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512 509

Table 4 comparing, in the same team, the 3 surgical techniques

Comparison of the complications in the 3 groups using the quality criteria and standards for outcome stated
TC, MVD, PTGC, P by Zakrzewska and Lopez [39].
n = 73 (%) n = 51 (%) n = 41 (%)
Complications related to cranial nerve V area 4.1. Efficacy
Ipsilateral hemifacial 22 12 43 .001
Our data regarding success with MVD are comparable to
numbness
Anesthesia dolorosa 2.8 0 0 .146 the published results in the literature (Table 5). Barker et al
Sum 24.8 12 43 .002 [3] published the most comprehensive study; they reported
Complications outside cranial nerve V that 70% of patients were pain-free after 10 years. These
Keratitis 2.8 0 0 .146 numbers are confirmed by Tronnier et al [37] and Burchiel
Meningitis 2.8 4 2.4 .901
et al [8], who also included patients with minor recurrences.
Cheek hematoma 1.4 0 2.4 .501
Cranial nerve palsy 1.4 2 2.4 .916 The data presented here for TC are comparable with
Hypoacousia 1.4 2 .685 those of other authors, especially in large series
Facial palsy 2.4 .226 [5,12,31,33,36]. Broggi et al [5] reported approximately
III Nerve palsy – 1000 patients treated with TC. Of these patients, 94.8%
Mortality 0 0 0 –
were pain-free immediately, and 18.1% experienced recur-
Sum 8.4 6 7.2 .885
Cumulative 33 21 50 .023 rence of pain during follow-up (mean, 9.3 years). Nugent
[31] followed up 800 patients, for an average length of 4.7
years, and reported 23% pain recurrence requiring a second
20% for MVD, and in 85% for PTGC ( P = .001). However, lesion. Good results in these retrospective studies were
after 6 years, these rates have decreased to 22%, 12%, and comparable with the results in the large prospective series of
43%, respectively ( P = .01). Other complications are Taha and Tew [35], who estimated the overall recurrence
detailed in Table 4. rate to 25% at 15 years follow-up.
There were 7 complications in group I: 2 keratitis, In our series, the results of PTGC were also comparable
2 anesthesia dolorosa, 2 meningitis, and 1 partial hearing with those published in the surgical literature. The imme-
loss. In group II, 8 complications occurred: 2 patients had diately reported successful rates were above 95% [13,24].
meningitis and 2 others had cranial nerve palsy, facial nerve The long-term recurrence rate reported after 5 years was
palsy resulting from vascular disorder occurred in 1 case, 20%, and the 10 years recurrence rate was 30% [13,24].
and a partial hearing loss occurred in 1 case. There was no
cerebrospinal fluid leakage. In group III, only 3 complica- 4.2. Morbidity
tions occurred: 1 patient had meningitis, 1 had facial In surgical literature, rates of anesthesia dolorosa after
hematoma, and the last had third cranial nerve palsy. TC ranged from 0.7% to 9.6% [5,8,15,20,29]. The
With the exclusion of ipsilateral facial numbness which, occurrence rate of this complication in our series was found
was mild and well tolerated, the arithmetical sum of all other to be 2.8%. The 2 patients who experienced this complica-
complications did not display any significant difference tion were treated at the beginning of the study. They were
between the 3 groups (Table 4). not compliant during the procedure. Operators had to
perform several successive thermocoagulations, generating
4. Discussion deafferentation pain. After this complication, patients who
were candidates for a destructive percutaneous surgery,
Trigeminal neuralgia is a very troublesome disease that
causes significant life disruption. The concept of a neuro- Table 5
Outcome in the selected series about surgical treatment of TN
vascular conflict is a cause widely accepted and extended to
other cranial rhizopathies [27]. However, the pathophysiol- Series Technique No. of Follow-up Rate of complete
patients period (mo) pain relief (%)
ogy is still not completely understood [19]. Numerous
surgical procedures are currently available for drug refrac- Barker et al [3] MVD 1185 120 70
Tronnier et al [37] MVD 225 240 64
tory TN. Klun et al [21] MVD 178 62.4 84
In the management of TN, one should be certain of the Chen et al [9] MVD 114 24 75.4
accuracy of the diagnosis [1,8,9,11]. It is mandatory to Our series MVD 51 72 77
perform MRI studies to eliminate possible mass lesions in Broggi et al [5] TC 1000 120 81.9
the cerebellopontine angle, demyelinating plaque associated Nugent et al [31] TC 800 56.4 77
Kampolat TC 1216 60 56
with multiple sclerosis, and vascular malformation [10,14]. et al [20]
Once diagnosis of essential TN refractory to medical Our series TC 73 72 70
treatment is made, it is difficult to assert which therapeutic Lobato et al [24] PTGC 144 35 91.3
option is appropriate. In the surgical literature, we found Brown et al [6] PTGC 50 36 69
only the study of Meglio et al [28] wherein the 3 techniques Chen et al [9] PTGC 127 24 85.5
Our series PTGC 41 72 72
were compared in the same team. Our study is the first one
510 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512
Fig. 4. Algorithm summarizing surgical options for TN.
because of advanced age or bad general status, and who
were not fully compliant were treated by PTGC. Thus, this
complication did not reoccur.
In our study, numbness was high in the PTGC group.
It is probably because of the method. Compression time
(5 minutes) in our series was longer than generally
reported (1 to 3 minutes) [9,22]. Mild to moderate
ipsilateral hemifacial numbness was intentionally expected
because it was correlated with a high rate of pain relief.
This possible adverse effect was explained beforehand.
Thus, its occurrence in the postoperative course did not
affect their satisfaction when the pain was relieved.
The complication rate of MVD in our series was
comparable to that reported in the recent literature.
Microvascular decompression had the lowest long-term
complication rate. Only 12% of the patients had hemifacial
numbness, and 2% had hypoacousia.
4.3. Comparative studies
4.3.1. Microvascular decompression versus retrogasserian
percutaneous radiofrequency thermocoagulation
Surgical literature contains several reports comparing the
results of TC with those of MVD [1,8,11,28,37,38]. In the
series of Apfelbaum et al [1], both techniques (MVD and
TC) were considered highly effective, but TC was associ-
ated with more severe complications. In particular, the high
rates of corneal anesthesia (7 of 48 patients) and anesthesia
dolorosa (6 of 48 patients) were much higher than the rates
reported by other authors [5,8,15,20,29]. However, in 9
cases of the TC group reported by Apfelbaum, the first
branch was involved [1]. This is a group of patients in which
TC should not be currently recommended [37].
In the series of Burchiel et al [8], 90% of the patients
treated by MVD were pain-free at 1 year. After TC, 65% of
the patients were pain-free at 1 year, and 35% were pain-free
after 5 years follow-up. These authors advise MVD because
the pain relief effect does not depend on the production of a
sensory defect.
Van Loveren et al [38] compared 700 percutaneous
procedures with 50 MVD. After a 6-year follow-up for TC,
79% of the patients remained pain-free after a single
procedure. After 3 years, 84% of the patients who
underwent MVD were pain-free with a 12% recurrence
rate. The major complications were hearing problems
(10%), dysesthesia (16%), and diplopia in 1 case. The
authors clearly stated that TC was the best treatment for TN,
but this report might be biased because 700 TC procedures
were compared with only 50 MVD [38].
From 1977 to 1997, Tronnier et al [37] performed 316
TC and 378 MVD. Overall, there was a 50% rate of
recurrence of pain after 2 years for TC. On the other hand,
64% of the patients who underwent MVD remained
completely pain-free 20 years postoperatively. The authors
state that MVD is a more effective and long-lasting
procedure for healthy patients [37].
4.3.2. Microvascular decompression versus balloon com-
pression of the gasserian ganglion
In the literature, there are various results for PTGC
concerning the initial success rate (range, 64%-100%) and
long-term outcome [4,7,13,24,30]. Chen and Lee [9] found
in 120 patients treated by PTGC an immediate relief of their
neuralgia in 94.5% of the cases. During the follow-up
period, the recurrence rate was 9.2% (11/120). The 120
patients who were successfully treated initially developed
mild to moderate, and occasionally marked, ipsilateral
hemifacial numbness. The complication rate of the PTGC
was 3.9%. During the follow-up period, the recurrence rate
was 18.5% (20/108). Microvascular decompression had the
highest pain recurrence rate at the first 2 years of follow-up,
as well as the highest rates of major complications and
perioperative morbidity. Meanwhile, PTGC had the highest
rates of facial numbness and minor complications [9].
4.3.3. Retrogasserian percutaneous radiofrequency
thermocoagulation versus balloon compression
of the gasserian ganglion
Lopez et al [25] performed a systematic review of
destructive neurosurgical techniques for the treatment of
TN. They systematically identified all of the studies
reporting outcomes and complications of destructive tech-
niques for treatment of TN and assessed them with
predefined quality criteria [25,39]. Among 175 studies
identified, 9 could be used to assess rates of complete pain
relief, and 22 could be used to assess complications. They
concluded that TC offers the highest rates of complete pain
relief, although further data on PTGC were required [25].
4.3.4. Microvascular decompression versus retrogasserian
percutaneous radiofrequency thermocoagulation versus
balloon compression of the gasserian ganglion
In the literature, we found only 1 study comparing in the
same team the 3 techniques [28]. In this preliminary report,
Meglio et al [28] compared 3 techniques: MVD (n = 20),
TC (n = 33), and PTGC (n = 74). At 24 months, they
found that the rates of pain-free patients were 75%
 M. Laghmari et al. / Surgical Neurology 68 (2007) 505 – 512
for MVD, 57.6% for TC, and 57.2% for PTGC. These
authors stated that MVD was the best treatment in otherwise
healthy patients.
Contrarily to Meglio et al, we failed to demonstrate that
MVD was more effective than other techniques. In our
study, the 3 populations determined by the type of procedure
were homogenous concerning age, pain topography, and
duration of symptoms. This situation allowed us to compare
safety and efficacy of the 3 techniques with minimum bias.
Our results point out that the 3 procedures were highly
effective at short-term as well as at long-term follow-up.
However, we found that MVD had the lowest complication
rates at long-term follow up. It is suitable for young healthy
patients as the first choice.
We recommend this therapeutic algorithm in the man-
agement of TN unresponsive to medications (Fig. 4). The
TC and PTGC are still indicated for unhealthy people or for
patients who do not want to experience a craniotomy. Apart
from facial numbness, which was expected and often well
tolerated, PTGC was technically rather simple and also
totally painless for the patient. It is still recommended for
elderly patients with high comorbidity, noncompliant
patients, and in cases where the ophthalmic branch (V1)
is involved.
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