Mark E. Linskey, M.D.
Department of Neurological Surgery
University of California, Irvine Medical Center
101 The City Drive, Bldg. 56, Suite 400
Orange, CA 92868
714-456-6966
http://neurosurgery.uci.edu/facultybio/linskey/
Transcript: If a microvascular decompression fails, what’s next?
Trigeminal neuralgia patients who’ve had a microvascular decompression are often referred to our clinic for evaluation. The question becomes “What to do then?”
And in truth, the first thing we have to ask ourselves is “How do we feel about the microvascular decompression that was done?” If the microvascular decompression was not done by somebody who’s expert in the field and in particularly if the patient never had any pain relief at all then the number one thing we consider is reexploration. And that’s because the number one reason for complete immediate failure is a technically inadequate operation and that can usually be improved upon. If the operation’s been done by somebody very experienced, an expert in the field, and they’ve had complete pain relief but then recur late, five, seven, ten years later then this often implies that a tiny vein that was not a problem before has now dilated to a level that does cause a problem and there we again consider reexploration.
If the procedure was done by someone who is very expert and it’s an early failure then we consider a second line therapy. And all the second line therapies are palliative destructive procedures. They’re procedures where you try to damage the nerve on purpose in a controlled way. You’re no longer trying to treat the cause. You’re trying to treat the symptom and you’re trading the chance of relief of pain for a risk of numbness. Because of that we tend to prefer Gamma Knife Stereotactic Radiosurgery as our frontline palliative destructive procedure because it has the least chance of actually causing numbness within about an equivalent pain relief rate. The problem is that Gamma Knife takes six to eight weeks to work. So we have to access whether a patient can tolerate waiting. If they’re an extremist, they can’t drink, they can’t eat, they have to be admitted to the hospital for IV fluids, then that’s not the choice. The next choice would either be a glycerol or a Radiofrequency but that’s just because we do more of those. We don’t do balloon compressions. In another practice where a balloon compress was done more often, then that might be the choice.