European Journal of Cardiovascular Medicine

Trigeminal neuralgia (TN), also known as Fothergill’s disease or “tic douloureux,” is a paroxysmal neuropathic pain disorder characterized by sudden, severe, electric shock-like pain in the distribution of one or more divisions of the trigeminal nerve. The pain is typically unilateral and can be triggered by activities such as chewing, speaking, or even light touch. TN is widely regarded as one of the most excruciating conditions known in clinical neurology, often leading to significant psychological distress, anxiety, and depression due to the unpredictability and severity of the episodes [1].

The trigeminal nerve (cranial nerve V) divides into three major branches: the ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves. The most commonly affected branches in TN are V2 and V3, either alone or in combination, with isolated involvement of V1 being relatively rare. TN most often presents in individuals over 50 years of age and shows a female preponderance, although cases have been documented in younger individuals, including rare paediatric presentations [2].

Most patients with TN have classic (primary) TN, attributed to a neurovascular conflict—most commonly a loop of the superior cerebellar artery (SCA)—compressing the trigeminal nerve at the root entry zone (REZ). Secondary (symptomatic) TN results from identifiable structural pathology such as cerebellopontine angle tumours, arteriovenous malformations, or multiple sclerosis plaques [3, 4].

Initial management is medical, with carbamazepine being the first-line drug. However, in patients who become refractory to pharmacological therapy or experience intolerable side effects, surgical intervention becomes necessary. Among various surgical options, microvascular decompression (MVD) has emerged as the most effective and durable surgical treatment, particularly for classic TN, with pain relief rates often exceeding 80% in long-term follow-up [5, 6].

MVD for TN requires meticulous microsurgical technique, involving the release of arachnoid adhesions and the mobilization of offending vessels away from the trigeminal nerve. While the SCA is the most frequent arterial culprit, surgical exploration may reveal more complex neurovascular configurations. In some cases, venous structures such as the petrosal vein or its tributaries may act as compressive agents—either in isolation or in combination with an arterial loop. In our series, two patients exhibited dual arterial and venous compression, necessitating tailored decompression of both components. The dorsal root entry zone of the trigeminal nerve is variable in length, and decompression must be thorough, extending to the distal cisternal segment when required [7].

In contrast, glossopharyngeal neuralgia (GPN) is a much rarer cranial nerve hyperactivity disorder, characterized by sharp, stabbing pain localized to the oropharynx, tonsillar fossa, base of the tongue, and sometimes radiating to the ear. Similar to TN, GPN is typically caused by vascular compression at the REZ of cranial nerve IX, often by the posterior inferior cerebellar artery (PICA) or vertebral artery. MVD remains the gold standard for medically refractory GPN. However, surgical management is more nuanced due to the anatomical proximity of cranial nerve X, and rhizotomy of cranial nerve X may be considered in select cases—albeit with significant risk of dysphagia and vocal cord palsy [8].

In this case series, we present our initial institutional experience managing both TN and GPN with MVD at a single neurosurgical centre. We provide detailed operative observations, discuss functional outcomes, and highlight anatomical variations including venous and combined arterial-venous neurovascular conflicts. Our series includes a unique case of GPN managed successfully without cranial nerve X rhizotomy, and one TN case involving reoperation for adhesions after a previously failed MVD.

Study Design and Setting

This is a retrospective single-centre observational case series conducted in the Department of Neurosurgery, King George Hospital, Andhra Medical College, Visakhapatnam, a tertiary care referral hospital in South India. The study included patients operated on between January 2023 and December 2023.

The aim was to evaluate the functional outcomes and intraoperative observations of microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN).

2. Patient Cohort and Data Collection

A total of 8 patients were included:

• 7 patients with classical trigeminal neuralgia
• 1 patient with glossopharyngeal neuralgia

All patients had medically refractory neuralgia and underwent MVD during the study period.

Clinical records, operative notes, imaging findings, and follow-up data were reviewed from the neurosurgical database and case files. A structured data collection sheet was used to extract the following:

• Demographics (age, sex)
• Side and distribution of pain
• Duration of symptoms
• MRI findings (including suspected neurovascular conflict)
• Intraoperative findings (offending vessel, surgical technique)
• Postoperative outcomes and complications
• Follow-up BNI pain scores

All procedures were performed by the same senior neurosurgeon, ensuring consistency in technique and reporting.

The study adhered to ethical standards of patient data confidentiality. Institutional approval was obtained for this case series. Since no experimental intervention was used and all procedures were routine standard-of-care surgeries, individual patient consent for inclusion in the study was waived.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Age ≥18 years
• Diagnosis of classic TN or GPN as per ICHD-3 criteria
• Failure of medical treatment (e.g., carbamazepine)
• MRI evidence suggestive of vascular contact at the root entry zone (REZ) of cranial nerve V or IX

Exclusion Criteria:

• Structural lesions (tumours, AVMs, multiple sclerosis)
• Previous radiosurgery or ablative procedures
• Inadequate records or loss to follow-up before 6 months

Surgical Technique

All 8 patients underwent retrosigmoid craniotomy for MVD under general anaesthesia in the lateral park-bench position. Standard steps included:

• Cerebellar retraction and dissection of the arachnoid of the cerebellopontine angle (CPA)
• Identification and mobilization of offending arteries or veins
• Placement of Teflon pledgets between the nerve and vessel (interposition technique)

Intraoperative variations included:

• Two TN cases with combined arterial (SCA) and venous (petrosal vein) conflict
• One TN patient had reoperative MVD, complicated by dense arachnoid adhesions
• The single GPN case showed arterial contact near the glossopharyngeal REZ, decompressed without requiring cranial nerve X rhizotomy

No intraoperative endoscope or navigation was used. All surgeries were performed by microsurgical technique under operating microscope magnification.

Postoperative Management and Outcome Assessment

Postoperative evaluation focused on pain relief, wound healing, CSF leaks, and cranial nerve deficits. All patients were followed up at 1 month, 3 months, and 6 months postoperatively.

Pain was assessed using the Barrow Neurological Institute (BNI) Pain Intensity Score, with:

• BNI I–II considered a successful outcome
• BNI III–V considered suboptimal or failed response

Complications such as CSF leak, wound issues, and cranial nerve dysfunction were noted. In one case, a CSF leak was identified and managed conservatively with bed rest and lumbar drainage.

Overview of Cohort Demographics and Clinical Profile

A total of eight patients who underwent microvascular decompression (MVD) for cranial neuralgia between January 2023 and December 2023 were included in this study. Of these, seven patients (87.5%) were diagnosed with classical trigeminal neuralgia (TN) and one patient (12.5%) with glossopharyngeal neuralgia (GPN). All patients had symptoms refractory to medical therapy and were considered surgical candidates based on clinical and radiological assessment.

The age range of the cohort was 52 to 68 years, with a mean age of 57.1 ± 5.3 years. The TN group included 4 males and 3 females, while the GPN case was female. Symptom duration ranged from 1.5 to 4 years, with a mean duration of 2.3 years in TN cases. The single GPN patient reported symptoms for approximately 3 years prior to surgery.

In patients with TN, the right side was affected in 4 cases and the left side in 3 cases. The distribution of pain involved the V2 and V3 branches most frequently. Specifically:

• 2 patients had pain limited to the maxillary division (V2)
• 2 patients had involvement of the mandibular division (V3)
• 2 patients had combined V2 and V3 involvement
• 1 patient had pain involving all three divisions (V1, V2, and V3)

The single GPN case presented with sharp, paroxysmal pain localised to the posterior oropharynx, tonsillar fossa, and base of tongue, with radiation to the ipsilateral ear—consistent with classical glossopharyngeal neuralgia. No sensory or motor deficits were found on clinical examination in any of the patients. Table 1 summarizes the key socio-demographic and clinical features of the cohort.

Table 1. Socio-demographic and Clinical Characteristics of Patients

Surgical Details and Intraoperative Findings

All eight patients underwent microvascular decompression (MVD) via a retrosigmoid craniotomy, performed by the senior author under operative microscope visualization. No endoscopic assistance or neuronavigation was employed in any case. The surgical procedure aimed to identify and mobilize any vascular structures in contact with the affected cranial nerve at its root entry zone (REZ) and interpose a Teflon felt pledget to achieve decompression.

In the trigeminal neuralgia (TN) group, the superior cerebellar artery (SCA) was identified as the most frequent offending vessel, encountered in four of seven cases (57.1%). In two cases (28.6%), a combination of SCA and a venous component—specifically the petrosal vein or its tributary—was observed causing compression at the nerve root. In these dual-conflict cases, both the arterial and venous elements were carefully dissected and decompressed using separate Teflon pledgets. No sacrifice of veins was required. One additional case showed isolated venous conflict, with a petrosal vein loop compressing the trigeminal nerve dorsally. This case was notable for successful decompression without arterial involvement.

A unique technical challenge was encountered in one TN patient who had previously undergone MVD at another institution and presented with recurrent symptoms. During re-exploration, the nerve was found to be distorted and densely adherent to surrounding arachnoid, with fibrous bands obscuring the neurovascular plane. After meticulous dissection, a loop of SCA was identified and decompressed. No residual Teflon granuloma was found.

In the single glossopharyngeal neuralgia (GPN) case, neurovascular conflict was observed at the root entry zone of cranial nerve IX, presumed to be caused by a loop of the posterior inferior cerebellar artery (PICA). Adequate decompression was achieved with Teflon interposition. The adjacent cranial nerve X was clearly identified and preserved, and no rhizotomy or sectioning was performed.

There were no intraoperative complications such as excessive bleeding, cranial nerve trauma, or hemodynamic instability. In all cases, dural closure was achieved with a watertight suture technique and reinforcement with sealant.

Table 3. Distribution of Offending Vessels

These intraoperative findings reinforce the importance of thoroughly inspecting for both arterial and venous conflicts, especially in revision surgeries and atypical presentations. The successful decompression of a venous-only offender and identification of a dual conflict pattern underscore the need for meticulous microdissection beyond the initial arterial contact zone.

Postoperative Pain Outcomes

All patients were followed postoperatively at 1 month, 3 months, and 6 months, with pain outcomes assessed using the Barrow Neurological Institute (BNI) Pain Intensity Scale. A score of BNI I or II was defined as a favourable outcome, indicating either complete relief without medication or occasional mild pain not requiring pharmacological intervention.

 Longitudinal Pain Relief

At the time of hospital discharge, 4 out of 8 patients (50%) achieved BNI I, while the remaining 4 patients were classified as BNI II or III. By the 3-month follow-up, 6 patients (75%) had achieved BNI I, and this improvement was maintained at 6 months in all but one revision case, who remained at BNI II. The single GPN patient experienced complete resolution of pain (BNI I) with no recurrence or functional deficit during follow-up.

Statistical comparison using the Friedman test showed a significant reduction in BNI scores over time (p = 0.005), confirming sustained postoperative improvement. Pain severity dropped from a preoperative median of BNI V to a 6-month median of BNI I.

Table 4. Progression of Pain Relief (BNI Scores Over Time)

Outcomes by Pain Distribution (TN Only)

Among patients with trigeminal neuralgia, pain relief was stratified by trigeminal branch involvement. Patients with V3-only or combined V2–V3 involvement were most likely to achieve immediate BNI I scores. The one patient with pain in all three branches (V1, V2, and V3) also achieved complete relief. Only one TN patient—who had a venous-only conflict—had a BNI II outcome postoperatively. No patients in the TN cohort remained at BNI III or above at 6 months.

Table 5. Immediate Postoperative Pain Relief vs Pain Distribution (TN Cases Only)

 Complications and Safety

One patient with TN developed a cerebrospinal fluid (CSF) leak in the immediate postoperative period, managed successfully with conservative measures including lumbar drainage and bed rest. No other complications were observed. In particular:

• No facial numbness, hypoesthesia, or new sensory deficits
• No lower cranial nerve dysfunction in the GPN case (i.e., no dysphagia or vocal cord palsy)

There were no instances of wound infection, reoperation, or mortality.

Individual Case Highlights

Case 1: Combined Arterial and Venous Conflict (TN, Right Side)

A 54-year-old male presented with right-sided V2–V3 trigeminal neuralgia of 2.5 years’ duration, refractory to escalating doses of carbamazepine. MRI revealed a vascular loop suggestive of SCA compression. Intraoperatively, both the SCA and an overlying petrosal vein loop were found compressing the trigeminal nerve at the root entry zone. Careful dissection allowed dual decompression with Teflon interposition placed separately for each vessel, preserving the vein. The patient experienced immediate and sustained pain relief (BNI I) without neurological deficits.

Case 2: Reoperative MVD for Recurrent TN with Adhesions

A 60-year-old female, previously operated on for TN at an outside centre, presented with recurrence after 18 months. Intraoperatively, the nerve was densely adherent to the arachnoid and surrounding neurovascular structures, obscuring anatomy. Meticulous arachnolysis was performed, revealing an offending SCA loop, which was decompressed. No foreign material or granuloma was seen from the prior procedure. The patient improved postoperatively to BNI II, with no complications, though mild intermittent twinges persisted at 6 months.

Case 3: Venous-Only Conflict (TN, Left Side)

A 58-year-old female with isolated left V2 pain underwent MVD. No arterial compression was noted intraoperatively. Instead, a prominent tributary of the petrosal vein was seen impinging on the dorsal aspect of the trigeminal nerve. The vein was gently dissected off and decompressed using Teflon felt. The patient achieved BNI II outcome at 6 months, with significant reduction in attacks but rare breakthrough pain episodes. No venous infarction or cerebellar complications were encountered.

Case 4: Glossopharyngeal Neuralgia with Arterial Contact

A 55-year-old female presented with classical glossopharyngeal neuralgia, experiencing lancinating pain in the right posterior pharynx, tonsillar fossa, and base of the tongue, often triggered by swallowing. MRI was inconclusive, but intraoperative exploration revealed a vascular loop (presumed PICA) compressing the cranial nerve IX at its REZ. Decompression was performed using Teflon interposition. The adjacent cranial nerve X was preserved without rhizotomy. The patient remained pain-free (BNI I) with no voice changes or swallowing difficulty throughout the 6-month follow-up.

These representative cases illustrate the variability in neurovascular anatomy, and underscore the need for careful microsurgical technique to address both arterial and venous conflicts. They also demonstrate that GPN, although rare, can be managed successfully with nerve-sparing decompression when pathology is precisely identified.

Comparative Notes and Summary Analysis: Trigeminal vs. Glossopharyngeal Neuralgia

This case series included seven patients with trigeminal neuralgia (TN) and one patient with glossopharyngeal neuralgia (GPN), all of whom underwent microvascular decompression (MVD) via a retrosigmoid approach. Despite the difference in sample size, several meaningful comparisons can be made regarding presentation, intraoperative anatomy, surgical handling, and postoperative outcomes.

 Clinical Profile and Pain Patterns

• TN patients exhibited a more heterogeneous distribution of pain, with most involving the V2 and V3 branches, either singly or in combination. In contrast, the GPN case presented with well-localized pain in the posterior oropharynx and base of the tongue, with classic radiation to the ear—features that are typical but often underrecognized, leading to delayed referral.
• While TN is more prevalent and commonly encountered, GPN remains rare, making intraoperative familiarity less routine.
•  

 Intraoperative Observations

• Neurovascular conflict in TN was most commonly arterial (SCA), but venous involvement was identified in 3 out of 7 cases (1 venous-only, 2 dual-conflict). This highlights the need for meticulous inspection beyond the dominant artery.
• The GPN case demonstrated a presumed PICA loop compressing CN IX, and the operation required careful navigation around cranial nerve X, which was successfully preserved. The surgical corridor was narrower, and adjacent lower cranial nerves posed higher theoretical risk compared to TN.
• No CN X rhizotomy was needed in the GPN case, reinforcing the principle of nerve-sparing exploration.

 Technical Complexity

• Among TN cases, the revision surgery and dual-conflict decompressions presented the most complexity. Adhesions in the reoperative case required delicate arachnoid dissection and increased operative time.
• The GPN surgery, though straightforward in decompression, demanded heightened vigilance due to close anatomical relationships with critical brainstem structures and autonomic reflex arcs.

 Pain Outcomes

• At 6-month follow-up, all patients achieved BNI I or II, reflecting excellent pain control. Notably:
• 6 out of 7 TN patients (85.7%) achieved BNI I
• 1 TN patient (revision case) remained at BNI II
• The single GPN case also achieved BNI I, with complete symptom resolution and no vocal cord palsy, hoarseness, or dysphagia

 Complications

• One TN patient developed a CSF leak, resolved with conservative management. No other surgical or cranial nerve complications occurred.
• Importantly, no patient developed facial numbness, new sensory loss, or lower cranial nerve dysfunction.

Summary

• TN offered greater anatomical variability and surgical diversity, including dual vascular conflicts and revision scenarios.
• GPN, though less common, required precise anatomical dissection and functional nerve preservation, especially of CN X.
• MVD was safe and effective for both TN and GPN in this series, with high rates of pain relief and minimal complications.

Microvascular decompression (MVD) remains the gold-standard surgical approach for medically refractory trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN), both of which are disabling cranial neuralgias characterized by paroxysmal, lancinating pain along the distribution of the respective nerves. Although the literature is rich with studies focused on TN, there remains a relative paucity of comparative surgical series that evaluate both TN and GPN together from a neurosurgical lens. This series adds to that limited body of literature by not only reaffirming the safety and efficacy of MVD for both conditions, but also by highlighting key operative nuances and anatomical variations encountered in real-world surgical practice.

In our series of eight patients (7 TN, 1 GPN), we observed a 100% rate of meaningful pain relief (BNI I–II) at 6-month follow-up, with no major neurological complications. This aligns with prior studies, such as those by Oesman et al. and Sindou et al., which reported long-term pain relief in over 80–90% of TN patients undergoing MVD [8,9]. The single GPN case in our cohort also achieved complete pain relief (BNI I) with preservation of cranial nerve X, consistent with previously published outcomes [10].

A particularly relevant comparison can be drawn to the single-centre case series by Park et al. (2022), which analyzed 196 TN patients treated via MVD and emphasized the high success rate when arterial conflicts, particularly those involving the superior cerebellar artery (SCA), were addressed using the interposition technique [11]. Similarly, in our TN cohort, SCA was the most common offender (57%), and Teflon interposition led to excellent relief in all cases.

However, our series provides additional depth by reporting:

• Three cases (42.8%) with venous involvement, including one isolated petrosal vein conflict and two dual arterial-venous compressions.
• A reoperative MVD in one TN patient with dense arachnoid adhesions.
• A GPN case managed without rhizotomy of cranial nerve X.

These findings align with the work of Rey-Dios and Cohen-Gadol (2013), who emphasized that GPN can often be surgically treated by careful decompression alone, without the need for adjunctive nerve sectioning, which carries a higher morbidity risk [12]. Our case further validates this approach, with complete symptom resolution and no dysphagia or vocal cord involvement.

The identification and decompression of venous conflicts in TN, though less commonly reported, are increasingly recognized as clinically significant. In a review by Greve et al. (2020), venous compression was found in up to 18% of TN cases and was associated with outcomes similar to arterial conflict when adequately decompressed [13]. Our case of isolated venous compression and two dual-vessel conflicts support this view and demonstrate that veins should not be overlooked during MVD, especially when MRI fails to show definitive arterial contact.

Another notable aspect of this series was the inclusion of a reoperative MVD case, which required meticulous dissection of dense arachnoid adhesions and re-identification of the offending vessel. Revision MVD has historically been associated with higher technical difficulty and lower success rates, especially when prior surgery failed to identify or completely decompress the neurovascular conflict [14]. In our case, although the patient achieved only a BNI II outcome, the relief was clinically meaningful and underscores the importance of re-exploration in selected patients.

From a technical standpoint, while the trigeminal nerve is relatively well-exposed in the CPA during retrosigmoid MVD, the glossopharyngeal nerve (CN IX) lies in close proximity to cranial nerves X and XI, near the jugular foramen. This anatomical cluster demands precise dissection and minimal traction to avoid postoperative morbidity. We echo the caution emphasized by Giorgi et al. and Kondo et al., who advocate a nerve-sparing decompression in GPN and reserve rhizotomy only for cases with non-revealing intraoperative anatomy or recurrence [15,16].

Despite being a single-case GPN experience, our surgical result validates this principle. By carefully identifying and decompressing the presumed PICA loop at the CN IX REZ, we avoided CN X manipulation, and the patient remained pain-free without any swallowing or voice issues—a feared complication in GPN surgeries.

Microvascular decompression (MVD) remains a safe and effective treatment modality for medically refractory trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN). In our single-center case series, we observed excellent surgical outcomes, with 100% of patients achieving significant pain relief (BNI I–II) at 6 months and no major neurological complications.

The series highlights several key surgical insights:

• Venous compression, either alone or in combination with arterial loops, is a clinically significant yet often underrecognized etiology of TN. Meticulous intraoperative inspection and gentle venous handling can yield outcomes equivalent to arterial decompression.
• Reoperative MVD, while technically more demanding due to scarring and adhesions, can still offer substantial benefit in carefully selected patients.
• In GPN, nerve-sparing decompression without cranial nerve X rhizotomy is achievable and should be the preferred approach when a clear vascular conflict is identified intraoperatively.

Though limited by a small sample size, particularly for GPN, our findings emphasize the importance of tailored microsurgical strategy, anatomical awareness, and patient-specific planning in achieving optimal outcomes in cranial neuralgia surgery.

Future prospective studies with larger cohorts and long-term follow-up are needed to further refine surgical decision-making, particularly regarding venous conflicts, reoperations, and GPN decompression protocols.

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