Medically Refractory Trigeminal Neuralgia: A Comparative Study of Outcomes of Microvascular Decompression versus Gamma Knife Radiosurgery and Percutaneous Radiofrequency Ablation.

Objective: The surgical options for medically refractory trigeminal neuralgia (TN) are diverse, with limited comparative evidence. This study evaluates and compares pain-free period and time to recurrence for patients who underwent microvascular decompression (MVD), gamma knife radiosurgery (GKRS), and radiofrequency ablation (RFA). Methods: A retrospective review of patients with medically refractory TN over a 10-year period from 2009 to 2018 at a tertiary neurosurgical center was performed. Patients with at least 1 year of follow-up after the treatment procedure were included. Clinical details, radiological records, intraoperative findings, and treatment details of radiosurgery and ablative procedures were recorded. Results: A total of 189 patients were included, the mean age being 52.54 (± 13.3) years, with a male:female ratio of 1.52:1. The mean duration of symptoms was 70.19 (± 57.6) months, with 86.3% of patients presenting with type 1 neuralgia. The median follow-up duration was 84, 100, and 67 months for MVD, GKRS, and RFA, respectively. The percentages of patients with favorable outcomes (Barrow Neurological Institute Pain Intensity Score [BNI I-IIIa]) were 87.8, 67.3, and 66.5%, respectively, for MVD, GKRS, and RFA. The median pain-free intervals were 65, 59, and 36 months, with recurrence rates of 24.2, 25, and 40.5% for MVD, GKRS, and RFA, respectively. Conclusion: This study reaffirms MVD as the best first-line treatment for medically refractory TN, with GKRS being a useful alternative in patients who are surgically unfit or unwilling, and an optimum second-line treatment for those with recurrences. RFA is useful as an adjunct in patients unfit for surgery, with a high initial efficacy albeit with high recurrence rates.