Partial sensory trigeminal rhizotomy at the pons for trigeminal neuralgia

Microvascular decompression is preferred among open procedures for the treatment of trigeminal neuralgia. However, in some cases the decompression cannot be performed, either because no significant vascular compression of the trigeminal nerve is found at surgery or because a patient's vascular anatomy makes it unsafe. Partial sensory rhizotomy is a commonly used alternative in these instances. The outcome after partial sensory rhizotomy was reviewed retrospectively in 83 patients with an average follow-up period of 72 months. Sixty-four (77%) of these patients had no evidence of vascular contact at operation. The remaining 19 patients (23%) had vascular structures in proximity to the trigeminal nerve but still underwent partial sensory rhizotomy in place of or in addition to microvascular decompression either because the offending vessel could not be moved adequately (11 cases) or because the vascular contact was considered insignificant (eight cases). Outcome was classified as: excellent if there was no trigeminal neuralgia postoperatively; good if pain persisted or recurred but was less severe than preoperatively; and poor if persistent or recurrent pain was equal to or greater than the preoperative pain in severity and was refractory to medication, or was severe enough to require additional surgery. The outcome was excellent in 40 patients (48%), good in 18 (22%), and poor in 25 (30%); follow-up durations were similar for the three outcome categories. The failure rate was 17% for the 1st year and averaged 2.6% each year thereafter. Two variables were predictive of a poor outcome: prior surgery and lack of preoperative involvement of the third trigeminal division. Major complications occurred in 4% of cases and minor complications in 11%. The authors conclude that partial sensory rhizotomy is a safe and effective alternative to microvascular decompression when neurovascular compression is not identified at operation or when microvascular decompression cannot be performed for technical reasons.