Abstract

Background: The treatment landscape for trigeminal neuralgia (TN) involves various surgical interventions, among which microvascular decompression (MVD) stands out as highly effective. While MVD offers significant benefits, its success relies on precise surgical techniques and patient selection. In addition, the emergence of awake surgery techniques presents new opportunities to improve outcomes and minimize complications associated with MVD for TN.

Methods: A thorough review of the literature was conducted to explore the effectiveness and challenges of MVD for TN, as well as the impact of awake surgery on its outcomes. PubMed and Medline databases were searched from inception to March 2024 using specific keywords “Awake Neurosurgery,” “Microvascular Decompression,” AND “Trigeminal Neuralgia.” Studies reporting original research on human subjects or preclinical investigations were included in the study.

Results: This review highlighted that MVD emerges as a highly effective treatment for TN, offering long-term pain relief with relatively low rates of recurrence and complications. Awake surgery techniques, including awake craniotomy, have revolutionized the approach to MVD, providing benefits such as reduced postoperative monitoring, shorter hospital stays, and improved neurological outcomes. Furthermore, awake MVD procedures offer opportunities for precise mapping and preservation of critical brain functions, enhancing surgical precision and patient outcomes.

Conclusion: The integration of awake surgery techniques, particularly awake MVD, represents a significant advancement in the treatment of TN. Future research should focus on refining awake surgery techniques and exploring new approaches to optimize outcomes in MVD for TN.

Keywords: Awake craniotomy, Awake surgery, Microvascular decompression, Surgical precision, Trigeminal neuralgia

INTRODUCTION

Trigeminal neuralgia (TN), or tic douloureux, is a neurological disorder that causes sudden and intense pain in the trigeminal nerve distribution. The pain usually lasts a few seconds to a few minutes and is triggered by sensory stimuli or specific facial movements.[ 36 ] This condition is more common among women aged between 37 and 67 years and mainly affects the maxillary and mandibular branches of the trigeminal nerve.[ 11 ] TN is commonly addressed with medications, each with distinct side effects and effectiveness. Traditional first-line anticonvulsants such as carbamazepine and oxcarbazepine offer significant immediate pain relief.[ 48 ] However, their long-term efficacy may decline, necessitating higher doses or additional medications. These anticonvulsants can induce side effects such as dizziness, drowsiness, cognitive impairment, and liver toxicity.[ 10 ] Alternatives for long-term management include medications such as lamotrigine, gabapentin, botulinum toxin type A, pregabalin, baclofen, and phenytoin, either alone or in combination. Gabapentin and baclofen, which modulate calcium channels and act as a γ-aminobutyric acid agonist, respectively, show promise in alleviating TN symptoms. In addition, botulinum toxin type A, typically used for cosmetic purposes, presents as a potential TN treatment by inhibiting acetylcholine release from nerve terminals, thereby reducing pain signal transmission.[ 41 ] Over time, the frequency, duration, and intensity of pain attacks tend to increase, and may become resistant to medication. As a result, the condition can become chronic, significantly reducing the quality of life for those affected and leading to cognitive impairments such as anxiety and depression.[ 35 , 44 ]

Microvascular decompression (MVD) stands as the pinnacle of surgical intervention for classic TN, earning its reputation as the “gold standard” procedure. MVD involves meticulous exploration using microscopes or endoscopes to identify and alleviate compression on the trigeminal nerve caused by adjacent blood vessels or structures. A crucial aspect of MVD entails placing a cushioning material between the compressing vessel and the trigeminal nerve root to alleviate the pressure and subsequent pain.[ 36 ]

Studies conducted across multiple centers have consistently demonstrated the safety and efficacy of MVD in providing relief to TN patients. Pain relief rates following MVD have been reported to range impressively from 80% to 96%, highlighting its effectiveness in managing TN-associated facial pain.[ 23 , 47 ] Despite advancements in surgical techniques, TN remains a challenging condition to manage. While primary surgical interventions like MVD exhibit promising efficacy, long-term success rates may diminish. Approximately 75% of patients achieve pain freedom at the 2-year mark post-MVD, yet, this figure gradually declines to 44–64% by the 10^th year.[ 23 , 46 ] Furthermore, alternative surgical modalities such as stereotactic radiosurgery (SRS) may be considered, although with lower long-term success rates (38.8% vs. 52.8%) at 7 years follow-up compared to MVD, necessitating continued exploration for optimal management strategies.[ 5 ]

The advent of awake surgery presents a notable advancement in the field of MVD. Awake MVD offers several advantages, including real-time patient feedback during the procedure, confirming the effectiveness of decompression, and minimizing risks associated with general anesthesia, particularly in vulnerable patient populations. During awake MVD, patients are typically under local anesthesia with sedation, allowing neurosurgeons to interact with them throughout the procedure. This facilitates immediate feedback on any changes in symptoms, ensuring precise and tailored intervention to address TN-associated pain effectively.[ 2 ] The objective of this review is to investigate awake MVD as a treatment for TN. Evaluating the efficacy of this intervention is essential for mitigating the effects of TN and improving patient outcomes. By thoroughly analyzing the available literature, the review aims to provide a detailed summary of the strengths and weaknesses of this approach and its potential implementation in clinical practice.

MATERIALS AND METHODS

A comprehensive review of the literature was carried out on PubMed and Medline databases, focusing on studies exploring the application of terms such as “Awake Neurosurgery,” “Awake craniotomy,” “Conscious sedation,” along with “Microvascular Decompression,” and “Trigeminal Neuralgia.” Only complete manuscripts reporting original studies involving human subjects or preclinical research and published until 2023, were considered for inclusion.

BRIEF HISTORY OF MVD

In 1934, Dr. Walter E. Dandy discovered that compression on the trigeminal nerve root was caused by a superior cerebellar artery (SCA) loop in 30.7% of cases and by a branch of the petrosal vein in 14% of cases.[ 11 , 12 , 27 ] However, he acknowledged that the surgical exposure of the day may not have provided an appropriate visualization of other compressive lesions that were not yet identified. In addition, Dandy did not distinguish between pulsatile and static compression nor take into account the possibility that mobilizing the responsible vessel away from the underlying nerve could play a part in tic douloureux.[ 12 , 27 ] Taarnhøj proposed an alternative procedure to decompress the trigeminal nerve root at the porus trigeminus.[ 45 ]

In 1959, Dr. W. James Gardner and his colleagues adopted this approach and conducted a study on the decompression of the sensory root of the trigeminal nerve. They accomplished this by selectively sectioning the posterior lateral part of the nerve. The study found that this approach resulted in significant improvement in pain relief for patients suffering from TN.[ 15 , 38 ] Although later refined and popularized by others, Gardner’s technique aimed to relieve pressure on the trigeminal nerve caused by vascular compression. For those with severe TN who are unresponsive to traditional therapies, this method marked a significant breakthrough.[ 38 ] Furthermore, Gardner expanded on Dandy’s findings by emphasizing how important it is to recognize and treat vascular compressions, like arterial loops, as the underlying causes of TN.[ 39 ] Gardner’s pioneering work remains foundational in the treatment of this condition especially those whose symptoms were uncontrollably refractory to treatment.[ 38 ] Building on the foundational contributions of Dr. W. James Gardner, Dr. Robert Rand, a distinguished neurosurgeon at the University of California Los Angeles, in collaboration with his resident, Dr. Peter Jannetta, has notably enhanced the neurosurgical approaches to treating complex nerve disorders.[ 25 , 27 , 37 ] Dr. Peter Jannetta discovered the trigeminal portio intermedia back in 1965 while conducting cranial nerve microdissections for dental students. He suggested that preserving these sensory fibers could prevent complete facial numbness. To treat TN, he and Rand came up with a subtemporal transtentorial method for selective rhizotomy.[ 24 ]

During his observations, Jannetta noticed the SCA pulsating and crushing the trigeminal nerve root, which he believed was the cause of the tic. He also proposed that treating vascular cross-compression could have therapeutic benefits. Jannetta explained his neurovascular compression (NVC) theory and suggested that decompressing the nerve in a non-traumatic way could potentially cure the disease without causing facial weakness.[ 27 ] In the first case, it was rare for the hemifacial spasm to be caused by a vein, but Jannetta’s insight and skill helped to identify and fix the problem safely. The patient recovered well, and the spasms stopped the next day.[ 24 ]

A few months later, Jannetta and Rand performed the first MVD for TN, which was successful and provided permanent pain relief to the patient.[ 38 ] Over the next few decades, Jannetta continued to refine his NVC concept and the MVD procedure, which is now performed worldwide.

SUPERIOR LONG-TERM EFFICACY OF MVD COMPARED TO OTHER TREATMENTS

MVD is significantly more effective than other forms of treatment for TN in the long run. When performed by experienced surgeons, MVD not only swiftly alleviates pain but also exhibits relatively low rates of recurrence and complications. As the leading surgical option for treating TN, MVD is associated with better long-term success rates and reduced chances of recurrence despite offering only partial relief.[ 41 ] MVD is a unique and very successful therapeutic option for TN that provides long-term pain relief by reducing the compression of arteries and the thickened arachnoid on the trigeminal nerve. Singh et al. conducted a 5-year retrospective study involving 106 patients, demonstrating the efficacy of MVD. The findings suggest that in the hands of skilled practitioners, MVD remains a safe and economically viable choice for TN treatment, applicable to patients of all age groups.[ 43 ] Research studies have shown that MVD patients often report higher rates of satisfaction and significant improvements in quality of life compared to those undergoing peripheral nerve stimulation (PNS) or neuromodulation.[ 6 , 43 ] PNS typically involves the implantation of electrodes near the affected nerve, which are connected to an implanted pulse generator that delivers electrical impulses. These impulses can disrupt abnormal pain signals and provide relief to individuals suffering from TN.[ 6 ] Radiofrequency rhizotomy (RFN) presents a minimally invasive alternative, targeting specific pain-transmitting nerve fibers through radiofrequency radiation. Studies indicate notable enhancements in quality of life and patient-reported outcomes with RFN, with MVD patients expressing higher satisfaction rates.[ 26 , 29 ] SRS provides a noninvasive approach, delivering precise radiation beams to the trigeminal nerve root, thus alleviating pain without the necessity of surgery. Despite its appeal, MVD still exhibits significantly superior rates of complete pain relief and lower complications (17.6% vs. 19.3%) and recurrence rate (15.9% vs. 22.6%) in comparison to SRS.[ 5 , 42 , 46 ]

The method of managing MVD involves a surgical procedure designed to locate and relieve the pressure that the surrounding vascular structures are exerting on the trigeminal nerve. A tiny craniotomy allows the neurosurgeon to access the root entry zone (REZ) of the trigeminal nerve, where vascular compression frequently takes place. Using microsurgical techniques, the offending vessels are carefully dissected and padded with a Teflon felt or other suitable material to prevent further compression.[ 4 ]

The outcomes of MVD are remarkable, with many patients experiencing significant and sustained pain relief following the procedure. However, complications associated with MVD are also a point of concern and require careful consideration before opting for this treatment. The surgical procedure can be complex, requiring precision and expertise to navigate the delicate structures in the posterior fossa. Potential complications, although relatively low, include cerebrospinal fluid leakage, hearing loss, facial weakness, and infection. In addition, variability in outcomes poses a significant hurdle, with some patients experiencing suboptimal pain relief or recurrence of symptoms over time.[ 28 , 33 ]

HOW AWAKE SURGERY CHANGES THE LANDSCAPE OF MVD

The advent of awake surgery heralds numerous benefits, with the foremost being the optimization of tumor resection while preserving neurological function. Awake craniotomy offers a range of advantages, including a reduced necessity for postoperative monitoring in the Intensive Care Unit (ICU), leading to shorter or even eliminated ICU stays.[ 8 , 21 ] Patients undergoing awake craniotomy also exhibit fewer neurological deficits (7% vs. 23%) and experience shorter hospital stays (1.7 vs. 9 days) compared to those undergoing craniotomy under general anesthesia.[ 18 ] Furthermore, patients undergoing awake craniotomy under sedation circumvent the need for general anesthesia, thereby avoiding the inherent risks associated with intubation and mechanical ventilation.[ 18 ]

In addition, postoperative discomfort, such as pain, nausea, and vomiting, is diminished in awake craniotomy compared to procedures conducted under general anesthesia.[ 30 ] Awake craniotomy offers precise motor and speech mapping, particularly beneficial when dealing with lesions in eloquent areas of the brain controlling motor or language functions. Language and motor mapping during awake craniotomy facilitate the identification and preservation of these critical areas, preventing inadvertent damage during resection. This method also allows for the exploration of fine, highly specialized movements, which may not be effectively monitored through peripheral motor-evoked potentials or asleep mapping.[ 22 ]

Moreover, comparative studies between awake and asleep surgeries demonstrate a higher quantity of total resections achievable through awake craniotomy, contributing to an increased extent of resection (EOR).[ 13 ] Enhanced EOR has been correlated with improved seizure control post-treatment, suggesting a potential predictive value for postoperative outcomes. Notably, the minimum threshold of EOR associated with seizure control aligns with values established for overall outcomes, indicating the possibility of using these thresholds to forecast postoperative seizure control effectively.[ 32 ] Thus, awake craniotomy not only enhances surgical precision but also contributes to improved patient outcomes, particularly in terms of neurological function preservation.[ 34 ]

In an investigation, Gubian and Rosahl’s meta-analysis unveiled promising success rates for both MVD at 86.9% and radiosurgery at 71.1%.[ 19 ] These findings corroborate the well-established status of MVD as the primary treatment choice for TN, particularly among younger patients and those without concurrent health conditions. Historically, comorbidities have hindered the safety of MVD, excluding certain individuals from this effective treatment avenue and forcing them toward less optimal pain management methods.

The landscape of surgery undergoes a significant shift with the integration of awake procedures, as demonstrated by a recent study on TN. Abdulrauf et al. introduce a groundbreaking approach by demonstrating the feasibility of conducting awake MVD for TN. They suggest that within the framework of awake surgery, individuals who undergo MVD and experience persistent symptoms may benefit from additional insights gained during the awake phase.[ 2 ] By incorporating these insights into subsequent microsurgical interventions, there is potential for enhancing the success rate of the procedure. Encouragingly, all patients who experienced pain resolution intraoperatively remained free from pain postoperatively. However, one patient who did not achieve pain relief during surgery, despite multiple microsurgical attempts, continued to experience pain postoperatively.[ 2 ]

According to a study, it was observed that, except for Teflon granuloma, all other issues primarily arise due to the absence of intraoperative neurophysiological indicators that could promptly alert surgeons to suboptimal decompression during the surgery itself, thereby mitigating recurrences and the need for further interventions.[ 40 ] In response to these challenges, this study has endeavored to blend the benefits of awake anesthesia with minor refinements (such as utilizing a fat-Teflon sandwich instead of Teflon alone) to enhance the success rate of the gold standard technique, MVD. The preliminary experience with awake MVD underscores its safety, feasibility, and potential advantages for cranial nerve neuralgias. Notably, patients’ responses during awake MVD serve as valuable guides for subsequent management, facilitating tailored approaches, and determining the necessity and extent of selective partial rhizotomy/internal neurolysis as adjuncts to MVD, thereby ensuring comprehensive pain relief, particularly in individuals lacking NVC or deemed unsuitable for general anesthesia.[ 40 ] Furthermore, it is believed that this approach can enhance the detection rate of NVC, particularly in magnetic resonance imaging (MRI)-negative cases harboring concealed offending vessels.[ 40 ]

FUTURE DIRECTIONS AND CHALLENGES OF AWAKE MVD FOR TN

The developments and challenges in awake craniotomy techniques may also apply to awake surgery for MVD in treating TN.[ 17 ] As surgical and anesthetic practices progress, future directions may involve identifying the safest and most tolerated anesthetic approach for awake MVD.[ 17 ]

New treatments such as targeted ultrasound provide fresh approaches to managing TN and have shown encouraging early outcomes in preclinical research. Targeted ultrasound relieves pain without requiring invasive surgery using precisely focused ultrasound waves to ablate the target tissue.[ 3 ] Despite their promise, more clinical studies are required to confirm their efficacy and safety in TN patients. A multidisciplinary strategy combining medication, interventional techniques, and surgical interventions is necessary to optimize patient outcomes and enhance the quality of life due to the subtleties and complexity of TN management. Moreover, adopting newer strategies to minimize sedatives and opioids could enhance patient comfort and safety during awake MVD procedures. Research could explore optimal airway devices and intravenous infusions tailored to individual patient responses using titration algorithms for improved outcomes.[ 16 ] The implementation of closed-loop control systems involves using real-time feedback to adjust mechanical ventilation parameters such as tidal volume and respiratory rate. This system tailors adjustments based on patient-specific variables and desired clinical targets. This advanced technology can enhance anesthesia management during awake MVD by ensuring precise control of variables critical for patient safety and comfort. A closed-loop control system predicts the respiratory mechanics of a patient and adjusts the ventilation settings accordingly using mathematical models.[ 16 ] Such devices allow anesthesiologists to maintain ideal end-tidal carbon dioxide levels during awake MVD treatments, reducing the danger of hyper- or hypocapnia and ensuring proper brain perfusion. Closed-loop control systems also provide the possibility of customized ventilation plans based on the physiological response and surgical needs of each patient. These systems ensure accurate control of variables like end-tidal carbon dioxide levels by continuously monitoring and adjusting ventilation parameters in real-time, reducing the difficulties associated with manual ventilation management, such as variability in patient response and the need for frequent adjustments during surgery.[ 31 ] These developments are intended to benefit awake MVD treatments for TN by optimizing surgical circumstances, improving patient safety, and improving results.[ 17 ]

Moreover, given the continuous progress in surgical methods and technology, it is clear that further investigation and refinement of endoscope-assisted procedures may be necessary in the future directions of MVD for TN. This means that there is a need to investigate further and refine the use of endoscopes alongside traditional operating microscopes in MVD procedures.[ 1 ] One major benefit of the combined method is that it integrates endoscopic and microscopic techniques to improve navigation and visualization in the surgical field. It blends the greater illumination and panoramic view of endoscopes with the accuracy of conventional operating microscopes. With this method, surgeons may better identify complex structures, thoroughly understand the surgical anatomy, and carry out precise procedures that yield better results. This is particularly important because such compression may not be fully appreciated with microscopic visualization alone.[ 9 ] By focusing on refining and expanding the application of endoscope-assisted techniques in awake MVD surgery for TN, the aim is to improve surgical precision and ultimately enhance patient outcomes.[ 7 ]

Challenges persist in MVD for TN as not all patients experience successful outcomes, with varied rates of pain relief and symptom recurrence. Factors influencing recurrence include pain location, gender, and vascular compression. However, other factors such as age, onset side, disease duration, and recurrence show partial relevance and lack statistical significance.[ 49 ] Addressing this requires larger studies and a comprehensive exploration of pathology and electrophysiology. Preoperative imaging techniques such as MRI and magnetic resonance angiography are vital for assessing neurovascular relationships, yet their accuracy may vary. Before surgery, a 3.0-Tesla MRI system was utilized alongside advanced three-dimensional MRI techniques, including magnetic resonance angiography and fast spoiled gradient recalled MRI, to evaluate the anatomical connection between neuronal and vascular structures at the trigeminal REZ (TREZ). The study revealed that in 27 out of 29 patients, or 93%, surgical findings and MRI results were consistent. Moreover, every patient who underwent MVD experienced complete pain relief. This underscores the utility of high-resolution MRI in identifying neurovascular contact at the TREZ.[ 14 , 20 ] Managing TN presents challenges due to arachnoid adhesions and abnormal anatomical relationships. Grasping these complexities is paramount for optimizing outcomes in MVD for TN.

CONCLUSION

The integration of awake surgery techniques, particularly awake MVD, represents a significant advancement in the treatment of TN. By optimizing surgical precision and patient safety, awake surgery techniques have the potential to enhance the success rates of MVD and improve patient outcomes. Despite these advancements, challenges remain in the field of MVD for TN. Variability in patient responses and the need for further refinement of surgical methods pose ongoing challenges. In addition, the identification of optimal anesthetic approaches for awake MVD and the integration of newer technologies, such as targeted ultrasound, require further investigation.

Future research should focus on refining awake surgery techniques and exploring new approaches to optimize outcomes in MVD for TN. Multidisciplinary collaboration and continued advancements in surgical methods and technology are essential for addressing the complexities of TN management and improving patient care.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent was not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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