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INVITED COMMENTARY
Year : 2009  |  Volume : 57  |  Issue : 2  |  Page : 138-139

Invited Commentary


Department of Neurology, University of Addis Ababa, Ethiopia and Department of Neurosurgery, University of Paris, France

Date of Acceptance16-Mar-2009

Correspondence Address:
Bernhard J Schaller
Department of Neurology, University of Addis Ababa, Ethiopia and Department of Neurosurgery, University of Paris
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.51280

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How to cite this article:
Arasho BD, Sandu N, Schaller BJ. Invited Commentary. Neurol India 2009;57:138-9

How to cite this URL:
Arasho BD, Sandu N, Schaller BJ. Invited Commentary. Neurol India [serial online] 2009 [cited 2020 Jul 4];57:138-9. Available from: http://www.neurologyindia.com/text.asp?2009/57/2/138/51280


As the authors write, trigeminal neuralgia (TN) is a severely painful condition that typically arises in otherwise healthy people in late middle age. [1] The underlying pathophysiologic mechanisms responsible for the paroxysmal pain of TN remains unknown, [2] despite extensive research directed towards the study of neurophysiology of the trigeminal system. Research has implicated central mechanisms in patients with TN; others have argued for a peripheral mechanism. Clinical observations supporting a peripheral mechanism include occurrence of TN as the manifestation of a mass lesion (tumor, dolichoectatic basilar/vertebral artery, or aneurysm) compressing the preganglionic trigeminal root in the posterior or middle cranial fossa. [3] However, Jannetta affirms that TN is a painful condition caused by an abnormality of the root entry zone of the trigeminal nerve, and that the abnormality may be associated with cross-compression by an artery loop that has imposed upon the nerve as a result of vascular elongation secondary to the aging process, or by a cross-compressing vein, or by both. [2],[4]

The treatment options for patients with TN include conservative and surgical ones. One of the surgical treatment options is micro-vascular decompression (MVD) - of which the authors' papers deal [1] with- for patients with typical TN and less than 65 years. The basis for this procedure is that there is persuasive evidence to show that TN is caused by demyelination of trigeminal sensory fibers within either the nerve root or, less commonly, the brainstem. In most cases, the trigeminal nerve root demyelination involves the proximal, CNS part of the root and results from compression by an overlying artery or vein. [4] Some large sequential case series from specialist centers report MVD rendering over two thirds of patient's pain free at 10 years and with one per cent experiencing facial numbness. [6],[7],[8] Complications are rare in good hands, but are reported as severe as brain stem and cerebellar infarction secondary to coagulation of a vein [9] or as a two per cent chance of permanent ipsilateral hearing loss. [10] A not very well known, but relatively common (in up to 18%), complication of MVD for TN is the intraoperative occurrence of the trigemino-cardiac reflex (TCR) first described by the senior author. [11] The TCR is a well-recognized phenomenon consisting of bradycardia, arterial hypotension, apnea, and gastric hypermotility during manipulation of one of the sensory branches of the trigeminal nerve.[12] TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20% to the baseline values before the stimulus and coinciding with the manipulation of the trigeminal nerve.[11] Schaller could for the first time demonstrate that a central stimulation of the trigeminal nerve during MVD leads to the TCR.[13] One may suggest that other complications of MVD - like the ipsilateral hearing loss - may be also influenced by the TCR[14] underlying its importance of prevention. After cessation of the manipulation, HR and MABP return (spontaneously) to levels before the stimulus.[13]

In conclusion, MVD is a very effective treatment for TN patients who are intolerant or refractory to the medical measures. There are some complications with the procedure which can rarely be fatal (like cerebellar and brain stem infarction). The TCR, observed in patients with skull base surgery and operations in the cerebello-pontine angle, is also a common complication with MVD and has to be known not only by anesthetist [1] but also by every surgeon performing MVD.

 
 » References Top

1.Kabatas S, Albayrak SB, Cansever T, Hepgul KT. Microvascular decompression as a surgical management for trigeminal neuralgia: A critical review of the literature. Neurol India 2009;57:134-8.  Back to cited text no. 1  [PUBMED]  Medknow Journal
2.Fields HL. Treatment of trigeminal neuralgia. N Engl J Med 1996;334:1125-6.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Barker FG 2nd, Jannetta PJ, Babu RP, Pomonis S, Bissonette DJ, Jho HD. Long-term outcome after operation for trigeminal neuralgia in patients with posterior fossa tumors. J Neurosurg 1996;84:818-25.  Back to cited text no. 3  [PUBMED]  
4.Jannetta PJ. Microvascular decompression of the trigeminal nerve for tic douloreux. In: Youmans - Neurological Surgery. Saunders Company, 4 th ed. vol.5, 1996. p. 3404-15.  Back to cited text no. 4    
5.Love S, Coakham HB. Trigeminal neuralgia: Pathology and pathogenesis. Brain 2001;124:2347-60.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Merrison AF, Fuller G. Treatment options for trigeminal neuralgia. BMJ 2003;327:1360-1.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Barker FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996;334:1077-83.  Back to cited text no. 7    
8.Olson S, Atkinson L, Weidmann M. Microvascular decompression for trigeminal neuralgia: Recurrences and complications. J Clin Neurosci 2005;12:787-9.  Back to cited text no. 8    
9.Singh D, Jagetia A, Sinha S. Brain stem infarction: A complication of microvascular decompression for trigeminal neuralgia. Neurol India 2006;54:325-6.  Back to cited text no. 9  [PUBMED]  Medknow Journal
10.Apfelbaum RI. Comparison of the long-term results of microvascular decompression and percutaneous trigeminal neurolysis for the treatment of trigeminal neuralgia. Int Congr Series 2002;1247:629-43.  Back to cited text no. 10    
11.Schaller B, Probst R, Strebel S, Gratzl O. Trigeminocardiac reflex during surgery in the cerebellopontine angle. J Neurosurg 1999;90:215-20.  Back to cited text no. 11  [PUBMED]  
12.Schaller B. Trigeminocardiac reflex: A clinical phenomenon or a new physiological entity? J Neurol 2004;251:658-65.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Schaller B. Trigemino-cardiac reflex during microvascular trigeminal decompression in cases of trigeminal neuralgia. J Neurosurg Anesthesiol 2005;17:45-8.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Schaller BJ. Trigeminocardiac reflex. J Neurosurg 2007;107:243.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]



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Sandu, N., Cornelius, J., Filis, A., Nöthen, C., Rasper, J., Kulinsky, V.I., Schaller, B.J.
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