Choice of open or percutaneous procedures in the surgical treatment of trigeminal neuralgia

The aim of this study was to define criteria for the selection of patients for percutaneous or open operations for the cure of drug-resistant trigeminal neuralgia (TN). Trigeminal percutaneous radiofrequency thermorhizotomy (TPRT) has an established place because of its safety in elderly patients, while microvascular decompression (MVD) has appeal in younger patients because of its non-destructive nature and because it attacks what is believed to be the primary etiology of tic douloureux. Nevertheless, MVD is a successful operation only when true neurovascular conflict (NVC) is ascertained, rather than a simple arterial loop and neurovascular contact. Probably, many immediate failures and early relapses are the consequence of the inadequate patient selection for MVD on the presumption that this operation is in any case the ideal cure. The inadequate selection can be explained by the difficult preoperative diagnosis of NVC in the past. Indeed, angiography and computed tomography showed the neurovascular contact but not the size of compression. Fortunately, today magnetic resonance imaging is a reliable instrument to ascertain NVC. So, the diatribe between the supporters of percutaneous techniques and MVD can be concluded with the following: (1) percutaneous techniques are indicated for patients without demonstrated NVC (including patients with TN in multiple sclerosis) and in those with NVC if MVD is contraindicated by ill-health or refused by the informed patient; and (2) MVD is indicated for patients with ascertained NVC who are in good health and who, informed of the surgical risk, favor this operation desiring no sensory deficit.