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Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 871--872

Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era

Stephen R Lowe, Sunil J Patel 
 Department of Neurosurgery, Medical University of South Carolina, Charleston, USA

Correspondence Address:
Sunil J Patel
Department of Neurosurgery, Medical University of South Carolina, Charleston

How to cite this article:
Lowe SR, Patel SJ. Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era.Neurol India 2016;64:871-872

How to cite this URL:
Lowe SR, Patel SJ. Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era. Neurol India [serial online] 2016 [cited 2020 May 25 ];64:871-872
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Full Text

Patients with petrous apex/Meckel's cave meningioma will often present with trigeminal neuralgia that is intractable, thus requiring some form of treatment – either resection of the tumor and decompression of the nerve root, or radiosurgery.

The authors present a series of 17 patients with trigeminal neuralgia from meningiomas of the petrous apex, who underwent surgical resection and decompression of the trigeminal nerve root via an anterior subtemporal approach to the petrous apex (16 patients), or a retrosigmoid approach (1 patient). They report excellent postoperative relief of trigeminal nerve pain in 14 patients (82%) at a median follow up interval of 22 months, with one of these patients, who had a neurocutaneous disorder, experiencing recurrence of trigeminal pain. No patient had a permanent post-operative neurologic deficit, which the authors propose as an argument in favor of a minimally invasive surgical excision of the tumor.[1]

These results are consistent with published reports demonstrating excellent long-term relief of facial pain after decompressive resection of petrous apex tumors [Table 1].[1],[2],[3],[4],[5],[6] Barker and Jannetta reported 82% (19/23) of patients remaining pain-free on a long-term basis after resection of a posterior fossa neoplasm and suggested the tumor to be the causative lesion for the trigeminal pain in this cohort.[2] However, they reported a higher rate of postoperative cranial neuropathy and one post-operative death presumably from a co-morbid condition. Bir et al., also demonstrated the superiority of surgical resection in both immediate and long-term relief of pain.[3]{Table 1}

Alternatively, stereotactic radiosurgery is held to be safer in terms of peri-procedural morbidity and mortality, and is available as a treatment option for those patients who might otherwise be unable to tolerate a craniotomy or unwilling to accept the risk of the procedure. More recent reports have evaluated the role of radiosurgery in both control of trigeminal nerve pain and tumor control. Kano et al., reported almost identical relief of trigeminal pain with radiosurgery, with 83% of patients achieving post-interventional Barrow Neurological Institute (BNI) scores of I-IIIb.[4] However, the results were not as durable, with 30% of those experiencing initial relief developing recurrent pain. All patients showed tumor control at follow-up. Cho et al., reported that while radiosurgery was associated with high rates (95%) of tumor control, they had less satisfactory rates of trigeminal pain improvement (76%) and there was a recurrence of pain in 28% on final follow-up.[5] Kim et al., showed that targeting of both the tumor and the nerve root entry zone together are possible with radiosurgery and results in excellent (93%) relief of pain initially, albeit with only 63% reporting continued relief of pain at 5 years–again demonstrating that pain relief may not be as durable with radiosurgery.[6]

The evidence suggests that surgical resection of the tumor to decompress the trigeminal nerve root provides the most reliable and durable relief of trigeminal nerve pain in patients with trigeminal neuralgia secondary to a neoplastic lesion. However, the decision to offer surgery versus radiosurgery must be customized and tempered with the physical condition and age of the patient. Defining goals of treatment and discussing what defines “acceptable” risk of post-procedural morbidity and mortality with each individual patient must be at the forefront of how we determine the best modality with which to deliver care. For some patients, relief of pain with risks of general anesthesia and postoperative facial paresis or numbness, or third nerve palsy is not an acceptable outcome, and in these patients, radiosurgery represents a viable alternative. Additionally, while the authors describe their approach as being “minimally invasive,” the anterior subtemporal approach to the petrous apex cannot be considered “minimally invasive” for the patient, despite the very excellent and commendable postoperative results demonstrated in this series by the authors.

The goal of surgery in these patients is relief of facial pain. Barker and Jannetta noted a high co-incidence of concomitant vascular compression in patients with compressive posterior fossa lesions, which would make it reasonable to infer that targeting of the lesion alone via radiosurgery would be insufficient to effect relief of pain, and that craniotomy for both resection or debulking of tumor and microvascular decompression of the trigeminal nerve in the same setting may be the most reliable way to effect pain relief. Additionally, these authors also noted invasion of the perineurium by tumor in several cases requiring partial resection of the root. Accounting for this preoperatively can change the clinician's plan of care.[2]

Finally, it has to be noted that radiosurgery can always be an option after a craniotomy if there is inadequate relief of pain or recurrence of pain. However, opting to resect a tumor after radiation has been delivered is typically more challenging and (we would suspect) probably less safe and efficacious in reducing pain, though there is no published data to support or refute this claim.

We commend the authors on their contribution to the literature and their excellent surgical results.[1] We do agree that operative resection likely represents the 'gold standard' in terms of pain relief and durability of response. We would certainly caution against calling this “minimally invasive” and in referring all patients for this therapy based on these results alone. While young, healthy patients with small lesions are likely to show the most benefit with an acceptably low risk of perioperative morbidity and mortality with surgery, elderly patients or those with a high risk of perioperative morbidity do have viable alternative such as radiosurgery.

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1Ahmed AH, Alfiki A, Adel MF, M. Alsawy MFM, Al-Dash MF, Zein M, et al., Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era. Neurol India 2016;64:973-9.
2Barker FG, 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.
3Bir SC, Maiti TK, Bollam P, Nanda A. Management of recurrent trigeminal neuralgia associated with petroclival meningioma. J Neurol Surg B Skull Base 2016;77:47-53.
4Kano H, Awan NR, Flannery TJ, Iyer A, Flickinger JC, Lunsford LD, et al. Stereotactic radiosurgery for patients with trigeminal neuralgia associated with petroclival meningiomas. Stereotact Funct Neurosurg 2011;89:17-24.
5Cho KR, Lee MH, Im YS, Kong DS, Seol HJ, Nam DH, Lee JI. Gamma knife radiosurgery for trigeminal neuralgia secondary to benign lesions. Headache. 2016 Apr 4. doi: 10.1111/head.12801.
6Kim SK, Kim DG, Se YB, Kim JW, Kim YH, Chung HT, et al. Gamma Knife surgery for tumor-related trigeminal neuralgia: Targeting both the tumor and the trigeminal root exit zone in a single session. J Neurosurg 2016;1-7. PMID: 26799302.