Guidelines for Surgery of Trigeminal Neuralgia

If there is a significant neuro-vascular conflict seen on MRI and the patient is reasonably fit for brain surgery the MVD is the best surgical choice. This is because MVD has the best long term results. The complications, although rare, can be serious and must be taken into consideration.

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If there is no significant neuro-vascular conflict to be seen on MRI and the patient can accept numbness on the operated side a balloon compression will give almost as good long term results as MVD, while avoiding serious complications. Radiofrequency ablation and glycerol blockade are alternatives to balloon compression but have some drawbacks in comparison.

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If the patient wants to minimize all risks, stereotactic radiosurgery is the obvious choice. Short term and long term pain relief is however inferior compared to open surgery and percutaneous procedures.

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MVD is a doubtful procedure and will expose the patient to an unnecessary risk if no significant neuro-vascular conflict is seen on high definition MRI. Adequate, modern MRI protocols can "see" a neuro-vascular conflict better than any neurosurgeon. Internal neurolysis (neurocombing) has no advantages compared to percutaneous procedures neither with respect to pain relief nor complications. Rather the contrary.

If there is a significant neuro-vascular conflict but the patient is hesitating before an MVD she should be informed of the alternatives. The choice between a percutaneous procedure and stereotactic radiosurgery depends on how she evaluates the risk/effect profile.

There is a growing consensus that the balloon compression is the preferred percutaneous procedure due to its simplicity and very good long term results.