Nerve Combing for Idiopathic Trigeminal Neuralgia Without Neurovascular Compression.

Area of Science:

• Neurosurgery
• Neurology
• Pain Management

Background:

• Trigeminal neuralgia (TN) classification includes classical, secondary, and idiopathic forms.
• Pathophysiology and surgical management of idiopathic TN are debated, particularly without clear neurovascular compression.
• Idiopathic TN presents as medically refractory paroxysmal facial pain.

Purpose of the Study:

• To investigate the role of axial torsion and arachnoid adhesions in idiopathic TN.
• To evaluate the efficacy of nerve combing with posterior fossa exploration for idiopathic TN.

Main Methods:

• Reported two cases of idiopathic TN treated with posterior fossa exploration and nerve combing.
• Preoperative MRI showed vascular contact without compression; intraoperative findings included arachnoid adhesions and nerve root torsion.
• Meticulous arachnoid dissection and nerve combing were performed, with electrophysiological monitoring in one case.

Main Results:

• Both patients experienced complete postoperative pain relief.
• Transient sensory disturbances were noted postoperatively.
• Intraoperative monitoring suggested reduced neural hyperexcitability after intervention.

Conclusions:

• Axial torsion of the trigeminal nerve root, potentially caused by arachnoid adhesions, may contribute to idiopathic TN pathophysiology.
• Carbamazepine trial can aid clinical diagnosis of TN-like pain, even without MRI evidence of compression.
• Nerve combing combined with arachnoid dissection offers an effective surgical option for select idiopathic TN patients.