Journal of Clinical Neuroscience 22 (2015) 818–822

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Clinical Study

Long term efficacy and patient satisfaction of microvascular

decompression and gamma knife radiosurgery for trigeminal neuralgia
Anil Nanda ⇑, Vijayakumar Javalkar, Shihao Zhang, Osama Ahmed
Department of Neurosurgery, Louisiana State Health Sciences Center, Post Office Box 33932, 1501 Kings Highway, Shreveport, LA 71130-3932, USA

a r t i c l e i n f o a b s t r a c t

Article history: The aim of our study was to evaluate the long term efficacy of microvascular decompression (MVD) and
Received 14 September 2014 gamma knife radiosurgery (GKRS) with respect to pain relief and patient satisfaction. Both these modal-
Accepted 29 November 2014 ities are accepted modalities of treatment for intractable trigeminal neuralgia. We excluded deceased
patients, those who had a prior intervention and those requiring an additional intervention following ini-
tial treatment. A total of 69 patients were included in the study. Of these, 49 patients underwent treat-
Keywords: ment by GKRS and 20 by MVD. Pain status was assessed using the Barrow Neurological Institute (BNI)
Long term outcomes
pain scale. The median follow up was 5.3 years. There was no significant difference between the two
Microvascular decompression
Patient satisfaction
groups with respect to initial pain relief (100% MVD, 84% GKRS; p = 0.055). There was no significant dif-
Radiosurgery ference in pain recurrence between the two groups (39% GKRS, 20% MVD; p = 0.133). At last follow up, 85%
Trigeminal neuralgia of patients who underwent MVD had total pain relief (BNI scale I) compared to only 45% of GKRS patients
(p = 0.002). There was no significant difference in the patient satisfaction with respect to undergoing the
same procedure again (90% MVD, 69% GKRS; p = 0.1) and recommending it to family members (95% MVD,
84% GKRS; p = 0.2). MVD offered total pain relief in a significantly higher number of patients than GKRS.
There was no significant difference in the patient satisfaction rate between the two groups.
Ó 2015 Elsevier Ltd. All rights reserved.

1. Introduction
In one of the epidemiological studies conducted in the USA, the
incidence rate of trigeminal neuralgia was 4.3 per 100,000 popula-
tion and the age adjusted rate for women was significantly higher
than that for men [1]. Medical management is the main stay of
therapy for idiopathic trigeminal neuralgia and surgery is indicated
when medical therapy fails. Various surgical treatment modalities
include microvascular decompression (MVD), balloon compres-
sion, radiofrequency thermocoagulation, glycerol rhizolysis, partial
sensory rhizotomy (posterior fossa), cryotherapy and neurectomy
or alcohol injections. Of all these surgical modalities, MVD is more
popular and it is the only non ablative technique. Gamma knife
radiosurgery (GKRS) is gaining popularity for treating idiopathic
trigeminal neuralgia not only due to its non-invasive nature but
also because patients can be discharged on the same day with
acceptable results.
We performed this study due to the lack of available literature
with respect to efficacy of both MVD and GKRS treatment modal-
ities and patient satisfaction. To our knowledge, there are only
⇑ Corresponding author. Tel.: +1 318 675 6404; fax: +1 318 675 6867.
E-mail address: ananda@lsuhsc.edu (A. Nanda).
two prospective studies [2,3] which have compared MVD and
GKRS. In one study the results did not reach statistical significance
[2]. In another study, [3] MVD was superior to GKRS in achieving
pain free status. We also identified only two patient satisfaction
surveys with regards to MVD or GKRS [3,4]. Out of these, only
one compares MVD and GKRS in terms of patient satisfaction [3].
Our study is the second such satisfaction survey.
MVD and GKRS are both accepted modalities of treatment for
intractable trigeminal neuralgia. The aim of our study was to eval-
uate the long term efficacy of both these modalities with respect to
pain relief and patient satisfaction. We attempted to evaluate the
pain relief patterns after treatment for trigeminal neuralgia follow-
ing GKRS and MVD.
2. Methods
The study was approved by our Institutional Review Board.
Patients were briefed about the survey and after getting verbal
consent from the patient, a telephone interview with a standard-
ized questionnaire was conducted. Telephone interviews were
conducted to assess the pain status and complete the patient satis-
faction survey. Pain status was assessed using the Barrow
Neurological Institute (BNI) pain scale. Patient satisfaction with

http://dx.doi.org/10.1016/j.jocn.2014.11.028
0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
 A. Nanda et al. / Journal of Clinical Neuroscience 22 (2015) 818–822
respect to whether they would undergo the same procedure again
and/or recommend it to family members was assessed at the end
of telephone interview. The follow up was calculated from the date
of the initial procedure to the telephone interview.
In our study, a BNI score I (no trigeminal pain, no medication)
was considered as total pain relief. We divided the pain relief pat-
terns into the following categories: no pain relief, pain relief
improvement of one grade, pain relief improvement of two grades,
pain relief improvement of three grades, total pain relief, initial
pain relief–recurrence–total pain relief, initial pain relief–recur-
rence–partial improvement, initial pain relief–recurrence–no
improvement.
We excluded deceased patients, those who had a prior interven-
tion and those requiring an additional intervention following initial
treatment. Patients with more than one procedure were excluded in
order to reduce the bias which may arise due to the second
procedure and the status of total pain relief. A total of 230 patients
underwent treatment for idiopathic trigeminal neuralgia at our
institute. Of these 230 patients, 148 (64.3%) underwent a single
treatment, 73 (31.7%) underwent treatment twice and only nine
(3.9%) underwent treatment three times. Of the 148 single treat-
ment patients, only 121 were alive at the last follow up when the
interview was conducted and were included in the study. Of these
121 patients, successful telephone interview was obtained with only
69. A standardized questionnaire was used to assess the patient sat-
isfaction rate and status of pain at the time of interview. We also
reviewed the medical records to determine the initial pain status
following the procedure as well as pain recurrence.
3. Results
A total of 69 patients with successful telephone interviews were
included in the final analysis. Of these, 49 (71%) underwent GKS
and 20 (29%) underwent MVD. There was no significant difference
in the age between the two groups (MVD 61.3 years versus GKRS
63.39 years; independent sample t-test). The majority of the
patients were women (66.7%). There was no difference in the gen-
der distribution among the two groups. The median follow up peri-
od was 5.3 years.
3.1. Initial pain relief
Initial pain relief following the treatment was noted in 61
patients (88.4%). In the GKRS group, initial pain relief occurred in
83.7% of patients, and in 100% of MVD patients. Though all MVD
patients had initial pain relief, there was no statistically significant
difference when compared with GKRS patients (p = 0.055, chi-
squared test).
3.2. Recurrent pain
Recurrent pain was noted in 23 patients (33.3%). In the GKRS
group, recurrent pain was noted in 38.8%, and in 20% of MVD
patients. Though the proportion of patients with recurrent pain
was high in the GKRS group, there was no statistically significant
difference with the MVD patients (p = 0.133, chi-squared test).
3.3. Total pain relief
Total pain relief at the last follow up by telephone interview
was noted in 39 patients (56.5%). In the GKRS group, total pain
relief occurred in 44.9%, and in 85% of MVD patients. The propor-
tion of the patients with total pain relief was significantly higher
in the MVD group when compared with GKRS group (p = 0.002,
chi-squared test).
819
3.4. Pain relief patterns
No pain relief was noted in eight patients (16.3% GKRS, 0 MVD).
Pain relief improvement of one grade was noted in two patients
(4.1% GKRS, 0 MVD). Pain relief improvement of two grades was
noted in three patients (4.1% GKRS, 5% MVD). Total pain relief
(without initial recurrence) was noted in 33 patients (36.7%
GKRS, 75% MVD) (Fig. 1).
Twenty-three patients (33.3%) developed pain recurrence at
some point (38.8% GKRS, 20% MVD). The initial pain relief–recur-
rence–total pain relief pattern was noted in six patients (8.2%
GKRS, 10% MVD). The initial pain relief–recurrence–partial
improvement pattern was noted in 13 patients (22.4% GKRS, 10%
MVD). The initial pain relief–recurrence–no improvement pattern
was noted in four patients (8.2% GKRS, 0 MVD).
3.5. Patient satisfaction survey-Would you elect to undergo same
procedure again
Fifty-two (75.4%) patients were happy to undergo the same pro-
cedure again. With regards to GKRS, only 69.4% were happy to
undergo the same procedure and 90% of MVD patients. There
was no significant difference between GKRS and MVD patients in
terms of satisfaction with respect to undergoing the same proce-
dure again (p = 0.190, chi-squared test).
3.6. Patient satisfaction survey-Would you recommend to family and
friends
Sixty patients (87%) were happy to recommend the procedure
to family and friends. With regards to GKRS only 83.7% were happy
to recommend it, compared with 95% of MVD patients. There was
no significant difference between the two groups in patient satis-
faction with respect to recommending the procedures to family
and friends (p = 0.205, chi-squared test).
4. Discussion
Current options for patients who have inadequate or only a
transient relief with medications include MVD or several palliative
destructive procedures like rhizotomy directed at the trigeminal
nerve root or ganglion. Though MVD is currently the most fre-
quently reported procedure, not a single randomized controlled
trial was identified [5]. MVD like any other surgical procedure is
associated with complications like mortality, infection or those
related to general anesthesia, and the mortality rate is generally
<1%. Though MVD is generally offered to younger patients, a recent
systematic review and meta-analysis suggested that the majority
of elderly patients with trigeminal neuralgia can safely undergo
MVD [6]. The authors included eight studies in their meta-analysis
(1334 patients) and complications were not significantly higher in
elderly patients. Stereotactic radio surgery is one of the non surgi-
cal tools in the management of trigeminal neuralgia and radio-
surgery may be appropriate for a subset of patients who are not
good surgical candidates. In addition, radiosurgery could be con-
sidered as a good choice for patients with recurrent pain after fail-
ure of MVD or percutaneous surgery.
4.1. Long term results after MVD
Barker et al. [7] conducted a study with long term follow up and
found that 10 years after the surgical procedure 70% of patients
were totally pain free without any medication. The annual rate of
recurrence was less than 1%. Zakrzewska et al. [4] found that at 5
years the mean recurrence free rate following MVD was 84%.
820 A. Nanda et al. / Journal of Clinical Neuroscience 22 (2015) 818–822

Fig. 1. Pain relief patterns for patients who underwent microvascular decompression (MVD) and gamma knife radiosurgery (GKRS) for trigeminal neuralgia are shown for the
following categories: total pain relief without initial recurrence (A), pain relief improvement of one grade (B), pain relief improvement of two grades (C), initial pain relief–
recurrence–total pain relief (D), initial pain relief–recurrence–partial improvement (E), initial pain relief–recurrence–no improvement (F). n = 69.

Broggi et al. [8] found that the recurrence rate was 15.3% (follow up
1–7 years). In another study, at 5 years 38% of the MVD patients
had a recurrence of neuralgia [9]. Kondo [10] found a recurrence
rate of 8% with minimum follow up more than 5 years. In a recent
study by Sarsam et al. [11], complete pain relief was achieved in
71% at 10 years. In another study, 64% of patients who underwent
MVD remained completely pain free 20 years postoperatively [12].
In a series of 947 patients, of whom 362 had Kaplan Meier analysis,
Sindou et al. found that the probability of cure (no pain and no
medication) was 74% at 15 years follow up [13]. In another large
series, when patients were followed for more than 5 years, the long
term pain relief after MVD for those with typical trigeminal neural-
gia was excellent in 73% and good in an additional 7%, for an overall
significant pain relief in 80% of patients [14]. In the series by Kolluri
et al. [15] 78% were pain free at follow up of 5 years.
4.2. Long term results after GKRS
In a long term study by Dhople et al. [16] 81% of patients report-
ed initial pain relief and actuarial rates of freedom from treatment
failure at 1, 3, 5, and 7 years were 60, 41, 34, and 22%, respectively.
In the study by Kimball et al. [17] at 10 years 50% of the patients
had good pain control when GKRS was used as repeat procedure
for trigeminal neuralgia. In another study by Riesenburger et al.
[18] a good treatment outcome from initial GKRS was achieved
in 58.5% patients for whom the mean follow up period was 48
months (range: 36–66). In another study by Little et al. [19] when
GKRS was used as the primary treatment, 45% of the patients were
pain free at 7 years. Gellner et al. [20] studied the role of repeat
GKRS with a mean follow up of 5.4 years after repeat radiosurgery.
Pain relief was noted in 72.7% of the patients. In the series by Park
et al. [21] with a minimum follow up of 3 years 94.1% of the
patients had a good treatment outcome at the last follow up. In
the study by Han et al. [22] the actuarial recurrence free survival
rates were 84.8%, 76.1%, 69.6%, 63.0% and 45.8% at 1, 2, 3, 4 and
5 years after radiosurgery. In the study by Regis et al. [23], at 5
years 58% of the patients remained pain free and 83% had no tri-
geminal nerve disturbance. In another study by Urgosik et al.
[24] initial successful results were achieved in 96% of patients with
complete pain relief in 80.4%. Relief was achieved after a median
latency of 3 months (range: 1 day–13 months). GKRS failed in 4%
of patients. Pain recurred in 25% of patients after a median latent
 A. Nanda et al. / Journal of Clinical Neuroscience 22 (2015) 818–822
interval of 36 months (range: 6–94). The initial success rate after a
second GKRS was 89%, and 58% of patients were pain free.
4.3. Comparison of MVD and GKRS
There are very few studies in the literature in which authors
have compared the results of MVD with GKRS [2,25]. Pollock [25]
retrospectively reviewed experiences with 77 patients of which
49 underwent MVD and 28 GKRS. With a mean follow up of 2.15
years, respective actuarial rates of pain relief at 1 and 3 years post
treatment were 75% and 72% for MVD, and 59% and 59% for GKRS
(p = 0.01). Brisman [2] performed a prospective cohort study of
MVD and GKRS in a series of 85 patients. With a short clinical fol-
low up he reported 12 and 18 month pain relief rates of 68 and 68%
for MVD, respectively, and 58% and 24% for GKRS. These results did
not reach a statistical significance (p = 0.089). In another study by
Linskey et al. [3] the largest prospective cohort comparative analy-
sis with the longest clinical follow up, MVD was significantly supe-
rior to GKRS in achieving and maintaining a pain free status in
those with trigeminal neuralgia. This is consistent with our study
where the proportion of patients with total pain relief was sig-
nificantly higher in the MVD group compared with the GKRS group.
Though the proportion of patients with recurrent pain in our study
was high in GKRS patients, when compared with the MVD group,
this did not reach a statistical significance.
4.4. Patient satisfaction survey
Zakrzewska et al. [4] first published a patient satisfaction sur-
vey after MVD or partial sensory rhizotomy. In their study, the
response rate for MVD was 90% and overall satisfaction rate was
89%, and 72% in the posterior rhizotomy group. Satisfaction with
outcome was higher in those undergoing this as a primary proce-
dure. In the MVD group 4% of the patients were unsatisfied where-
as in the partial sensory rhizotomy group 20% were unsatisfied.
This difference was statistically significant (p < 0.01).
In another patient satisfaction survey, 3.9–8.5 years after initial
treatment 100% of the responding patients in the MVD cohort
answered that they would elect to undergo the same procedure
again or would recommend the procedure to family or friends. In
the GKRS cohort, however, only 75% of responding patients indicat-
ed that they would elect to undergo the same procedure again or
would recommend the procedure. The main reason for dissatisfac-
tion was loss of pain control leading to a negative impact on qual-
ity of life.
In our patient satisfaction survey, a higher proportion of
patients were happy to undergo the procedure again in the MVD
group (90%) compared to the GKRS group (69%). A similar trend
was noted when the patients were evaluated for whether they
would recommend the procedure to family or friends. There was
no statistically significant difference for these observations in our
study.
4.5. Future directions
A recent Cochrane Review concluded that there is very low
quality evidence for the efficacy of most neurosurgical procedures
for trigeminal neuralgia due to the poor quality of the trials, and
that there is little evidence to help comparative decision making
about the best surgical procedure [5]. Though the long term results
with MVD are better, high quality evidence is lacking to support
this [5]. The recent Cochrane Review suggested that there is an
urgent need for high quality evidence in order to improve out-
comes for patients with trigeminal neuralgia [5]. There is also bias
in the selection of patients for either MVD or GKRS. In a study by
Dhople et al. [16], the median age of GKRS patients was 64 years
821
and those undergoing MVD were a full decade younger. Proper
age-matched comparison studies between the MVD and GKRS
may reveal if there is a true difference in efficacy. Future prospec-
tive studies may also aid in identifying predictors or outcome vari-
ables which will help clinicians to decide on the optimal treatment
modality. Though such predictors have been studied in some
recent series [26,27], they are lacking high quality evidence.
5. Conclusions
From our study, MVD offered total pain relief in significantly
higher number of patients than GKRS. There was no significant dif-
ference in the rates of patient satisfaction between the two groups
although there was a trend for greater satisfaction after MVD. Our
observations regarding long term efficacy of MVD are similar to
those published in the literature, but there is a lack of high quality
evidence to support the clinical practice. Properly matched
prospective studies or randomized controlled trials are needed to
help clinicians in selecting the appropriate mode of treatment
and improving the patient outcomes.
Conflicts of Interest/Disclosures
The authors declare that they have no financial or other con-
flicts of interest in relation to this research and its publication.
References
[1] Katusic S, Beard CM, Bergstralh E, et al. Incidence and clinical features of
trigeminal neuralgia, Rochester, Minnesota, 1945–1984. Ann Neurol
1990;27:89–95.
[2] Brisman R. Microvascular decompression vs. gamma knife radiosurgery for
typical trigeminal neuralgia: preliminary findings. Stereotact Funct Neurosurg
2007;85:94–8.
[3] Linskey ME, Ratanatharathorn V, Penagaricano J. A prospective cohort study of
microvascular decompression and Gamma Knife surgery in patients with
trigeminal neuralgia. J Neurosurg 2008;109:160–72.
[4] Zakrzewska JM, Lopez BC, Kim SE, et al. Patient reports of satisfaction after
microvascular decompression and partial sensory rhizotomy for trigeminal
neuralgia. Neurosurgery 2005;56:1304–11 [discussion 1311–2].
[5] Zakrzewska JM, Akram H. Neurosurgical interventions for the treatment of
classical trigeminal neuralgia. Cochrane Database Syst Rev 2011;9:CD007312.
[6] Sekula Jr RF, Frederickson AM, Jannetta PJ, et al. Microvascular decompression
for elderly patients with trigeminal neuralgia: a prospective study and
systematic review with meta-analysis. J Neurosurg 2011;114:172–9.
[7] Barker 2nd FG, Jannetta PJ, Bissonette DJ, et al. The long-term outcome of
microvascular decompression for trigeminal neuralgia. N Engl J Med
1996;334:1077–83.
[8] Broggi G, Ferroli P, Franzini A, et al. Microvascular decompression for
trigeminal neuralgia: comments on a series of 250 cases, including 10
patients with multiple sclerosis. J Neurol Neurosurg Psychiatry
2000;68:59–64.
[9] Zakrzewska JM, Thomas DG. Patient’s assessment of outcome after three
surgical procedures for the management of trigeminal neuralgia. Acta
Neurochir (Wien) 1993;122:225–30.
[10] Kondo A. Follow-up results of microvascular decompression in trigeminal
neuralgia and hemifacial spasm. Neurosurgery 1997;40:46–51 [discussion 51–
2].
[11] Sarsam Z, Garcia-Finana M, Nurmikko TJ, et al. The long-term outcome of
microvascular decompression for trigeminal neuralgia. Br J Neurosurg
2010;24:18–25.
[12] Tronnier VM, Rasche D, Hamer J, et al. Treatment of idiopathic trigeminal
neuralgia: comparison of long-term outcome after radiofrequency rhizotomy
and microvascular decompression. Neurosurgery 2001;48:1261–7 [discussion
1267–8].
[13] Sindou M, Leston J, Decullier E, et al. Microvascular decompression for primary
trigeminal neuralgia: long-term effectiveness and prognostic factors in a series
of 362 consecutive patients with clear-cut neurovascular conflicts who
underwent pure decompression. J Neurosurg 2007;107:1144–53.
[14] Tyler-Kabara EC, Kassam AB, Horowitz MH, et al. Predictors of outcome in
surgically managed patients with typical and atypical trigeminal neuralgia:
comparison of results following microvascular decompression. J Neurosurg
2002;96:527–31.
[15] Kolluri S, Heros RC. Microvascular decompression for trigeminal neuralgia. A
five-year follow-up study. Surg Neurol 1984;22:235–40.
822 A. Nanda et al. / Journal of Clinical Neuroscience 22 (2015) 818–822
[16] Dhople AA, Adams JR, Maggio WW, et al. Long-term outcomes of Gamma Knife
radiosurgery for classic trigeminal neuralgia: implications of treatment and
critical review of the literature. Clinical article. J Neurosurg 2009;111:351–8.
[17] Kimball BY, Sorenson JM, Cunningham D. Repeat Gamma Knife surgery for
trigeminal neuralgia: long-term results. J Neurosurg 2010;113:178–83.
[18] Riesenburger RI, Hwang SW, Schirmer CM, et al. Outcomes following single-
treatment Gamma Knife surgery for trigeminal neuralgia with a minimum 3-
year follow-up. J Neurosurg 2010;112:766–71.
[19] Little AS, Shetter AG, Shetter ME, et al. Long-term pain response and quality of
life in patients with typical trigeminal neuralgia treated with gamma knife
stereotactic radiosurgery. Neurosurgery 2008;63:915–23 [discussion 923–4].
[20] Gellner V, Kurschel S, Kreil W, et al. Recurrent trigeminal neuralgia: long term
outcome of repeat gamma knife radiosurgery. J Neurol Neurosurg Psychiatry
2008;79:1405–7.
[21] Park SH, Hwang SK. Outcomes of gamma knife radiosurgery for trigeminal
neuralgia after a minimum 3-year follow-up. J Clin Neurosci 2011;18:645–8.
[22] Han JH, Kim DG, Chung HT, et al. Long-term outcome of gamma knife
radiosurgery for treatment of typical trigeminal neuralgia. Int J Radiat Oncol
Biol Phys 2009;75:822–7.
[23] Regis J, Arkha Y, Yomo S, et al. Radiosurgery in trigeminal neuralgia: long-term
results and influence of operative nuances. Neurochirurgie 2009;55:213–22.
[24] Urgosik D, Liscak R, Novotny Jr J, et al. Treatment of essential trigeminal
neuralgia with gamma knife surgery. J Neurosurg 2005;102:29–33.
[25] Pollock BE. Comparison of posterior fossa exploration and stereotactic
radiosurgery in patients with previously nonsurgically treated idiopathic
trigeminal neuralgia. Neurosurg Focus 2005;18:E6.
[26] Kano H, Kondziolka D, Yang HC, et al. Outcome predictors after gamma knife
radiosurgery for recurrent trigeminal neuralgia. Neurosurgery
2010;67:1637–44 [discussion 1644–5].
[27] Shaya M, Jawahar A, Caldito G, et al. Gamma knife radiosurgery for trigeminal
neuralgia: a study of predictors of success, efficacy, safety, and outcome at
LSUHSC. Surg Neurol 2004;61:529–34 [discussion 534–5].