Peripheral Neurectomy for Management of Trigeminal Neuralgia Refractory to Multiple Surgical Procedures

Trigeminal Neuralgia (TN) is defined as a recurrent, unilateral, brief, electric shock-like pain and is associated with a significant deterioration in quality of life due to the debilitating nature of the pain. The first line treatment is medical therapy, and surgical treatment is reserved for patients with inadequate pain control or undesirable side effects. Surgical options for treatment may include microvascular decompression (MVD), stereotactic radiosurgery, percutaneous radiofrequency rhizotomy, and percutaneous balloon compression of trigeminal ganglion. MVD is considered the procedure of choice due to its high efficacy and safety profile; however, it carries a recurrence rate of 1%-5% annually and 15%-35% long term. Although re-operative MVD has been reported for recurrent cases, it carries a high risk of complications due to arachnoid adhesions and distorted anatomy. Peripheral neurectomy is a simple, expeditious, low-risk procedure that is well tolerated by patients and can be done even under local anesthesia. We report a case of a 69-year-old man who presented with a debilitating TN in the V1 and V2 territory refractory to MVD, stereotactic radiosurgery, and percutaneous balloon compression of the trigeminal ganglion, who had been treated with neurectomy of the left supraorbital, supratrochlear, and infraorbital nerves, with an excellent outcome at 6 months follow-up. Peripheral neurectomy is an effective alternative for patients with refractory TN who failed multiple surgical interventions. Previous publications have reported an elevated long-term recurrence rate after this procedure, perhaps due to peripheral nerve regeneration or neuroma formation. It is not yet studied whether using nerve conduits may lead to a decrease in recurrence.