Multiple Recurrences of Trigeminal Neuralgia Caused by Deformation of the Trigeminal Nerve

Microvascular decompression (MVD) is frequently used for the treatment of trigeminal neuralgia (TN). We present a case of TN with multiple recurrences despite different interventions. A 50-year-old patient presented with a five-year history of left TN. He initially had an MVD with Teflon padding that eliminated his pain for a year. When pain recurred, he went on to stereotactic radiosurgery, which did not help. He then had two percutaneous retrogasserian glycerol injections, the first one relieved pain for a year and the second only six months. After the second recurrence, we repeated the magnetic resonance imaging (MRI) of the brain, and it showed kinking of the nerve with the padding in place. We decided to re-explore the nerve based on the MRI findings. Intraoperatively, we observed the Teflon padding had become adherent to the petrous bone which caused deformation of the nerve. We did adhesiolysis with debulking of the padding, following which the nerve appeared more relaxed. Postoperatively, the patient had immediate resolution of his pain. At eight-month follow-up, the patient remained pain-free. Multiple factors can be involved in recurrence of TN after MVD. In this case, the size of the padding, continued distortion from the offending artery in addition to scarring from radiosurgery may have contributed to the deformation of the nerve and the recurrence of symptoms. A new MRI can be beneficial when the neuralgia symptoms recur in delayed fashion after successful MVD. Also, the use of a more compact padding material, like Gore-Tex, may cause less deformation of the nerve.