Efficacy and safety of microvascular decompression for trigeminal in patients with morbid obesity (A20211204)
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This study evaluated the efficacy and safety of microvascular decompression (MVD) for treating trigeminal neuralgia in patients with morbid obesity. The study found that while MVD surgery took longer and had higher risks in obese patients, it was still effective at reducing pain. Specifically, obese patients had longer surgery/anesthesia times, more pre-existing health issues, and higher complication rates during intubation. However, obese patients still experienced significant pain relief following surgery similar to non-obese patients, with over 65% reporting an excellent outcome. The study concluded that MVD should be considered for obese patients with TN when it is the only effective treatment option, and can be performed safely in specialized medical centers.
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Efficacy and safety of microvascular decompression for trigeminal in patients with morbid obesity (A20211204)
- 1. Efficacy and safety of microvascular decompression for trigeminal neuralgia in patients with morbid obesity Munguía-Rodríguez Aarón Giovanni, PhD; Segura-Zenón AF, MD; Segura-Lozano MA, MD, PhD. Neurología Segura Medical Center, Mexico.
- 2. Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder characterized by paroxysms of electric shock-like pain involving one or more divisions of the trigeminal nerve. Pain severity can hinder activities of daily living and impairs quality of life. Pharmacological therapy includes anticonvulsant medication that initially reduces TN pain intensity. However, the efficacy of medications generally decreases over time and can cause important side effects. info@neurologiasegura.net Introduction
- 3. Microvascular decompression (MVD) is the most effective treatment to achieve long-term pain relief for TN. MVD is offered to young and healthy patients, neurosurgeons tend to be reluctant to offer MVD to elderly and obese patients due to the comorbidities that could cause complications during general anesthesia and posterior fossa surgery. info@neurologiasegura.net Introduction
- 4. Introduction TN is not a life-threatening condition by itself. However, it can cause lifelong episodes of pain, becoming disabling. A quick and accurate diagnosis, as well as proper management can be beneficial for patients and lead to a better prognosis. No single studies of MVD have been done in patients with morbid obesity due to the small sample size, and to the refusal of some surgeons to operate on these patients. info@neurologiasegura.net
- 5. Objective To evaluate the safety and efficacy of MVD to treat TN in patients with morbid obesity. info@neurologiasegura.net
- 6. Materials and methods 1634 HDS patients 90 HFS 55 GPN 33 Combined HDS 272 Secondary TN 189 Atipical TN 1406 Classic TN 17 Underweight 241 Overweight 183 Class I obesity 72 Class II obesity 76 patients 50 Normal weight (BMI 18.5-24.9) 26 Class III obesity (BMI ≥ 40) 589 MVD surgeries 321 Non-operated 85 Other procedures than MVD February 2017 to October 2021 Demographics, characteristics of pain, comorbidities, pre-, peri-, intra-, and post-operative data, complication rates and outcomes Patients excluded info@neurologiasegura.net
- 7. Diagnosis of TN Clinical evaluation: unilateral, trigger points, paroxysmal and electric-shock pain. Routine MRI to confirm neurovascular conflict and rule out another entity. MVD should be offered to patients who were refractory to medication, who refused percutaneous procedures, or patients who received such treatments with unsatisfactory results. Specially, those whose quality of life is seriously compromised regardless of age and weight. info@neurologiasegura.net Materials and methods
- 8. Days before surgery Preoperative evaluation by the neurosurgeon, anesthesiologist and internist if necessary All patients are informed about the risks derived from the surgery and sign a consent letter Recommendations prior to surgery Control of comorbidities Healthy eating (fiber consumption) Drug suspension Improvement of lung capacity (spirometer 7-14 days before surgery) info@neurologiasegura.net Routine lab tests All patients: Blood count, blood chemistry, general urinalysis and coagulation tests Obese: Lipid, liver and thyroid profiles, chest X-ray and electrocardiogram Materials and methods Pre-operative management
- 9. 1.-Park bench positioning with placement of an endotracheal tube with metal core, central and urinary catheter and anti-embolism stockings. 2.-Skin incision in the retromastoid region of 5-7 cm, larger than normal weight due to adipose tissue. 3.-Dissection of planes until reaching the surface of the skull 5.-Infra-asterional craniectomy (20 mm diameter) 6.-Durotomy, CSF drainage and control of intracranial pressure1. 7.-Cerebellum surface retraction to access the cerebellopontine cistern 8.-Exploration, conflict identification and releasing of trigeminal nerve 9.-Polyurethane slings colocation 10.-Verification of surgical bed haemostasis 11.-Hermetic closure of the dura 12.- Optional bone recontruction of titanium miniplate colocation 13.-Closure of aponeurotic muscle plane, subcutaneous tissue, and the skin 14.-Controlled emergence Obese Normal weight info@neurologiasegura.net Surgical technique 1.-Oseguera-Zavala BS, Munguía-Rodríguez AG, Carranza-Rentería O, Flores-Solís MD, & Segura-Lozano MA. Prevalence of elevated intracranial pressure in patients with classical trigeminal neuralgia with overweight and obesity. Archivos De Neurociencias, 2020; 25(3), 6-13.
- 10. Results info@neurologiasegura.net We present our general results by using an advanced software to evaluate the statiscal significance among the selected items comparing both groups as below taking a p<0.05
- 11. info@neurologiasegura.net Demographics Normal Obese p Value Number of patients 50 26 BMI 0.000 Range 20 to 24.9 40 to 56.3 Mean ± SD 23 ± 1.6 42.9 ± 5.2 Sex 0.763 Female 43 (86%) 23 (88.5%) Male 7 (14%) 3 (11.5%) Side affected 0.974 Left 29 (58%) 15 (57.7%) Right 21 (42%) 11 (42.3%) Age (yr) 0.614 Range 26-91 28-73 Mean ± SD 53.4 ± 17.4 50.8 ± 13.2 Duration of symptoms 0.200 Range 4 m to 25 y 3 m to 25 y Mean ± SD 7.2 ± 6.3 9.2 ± 6.8
- 12. info@neurologiasegura.net Pain characteristics Normal Obese p Value Branch affected 0.550 V1 1 (2%) - V2 8 (16%) 1 (3.8%) V3 6 (12%) 4 (15.4%) V1+V2 4 (8%) 1 (3.8%) V1+V3 - - V2+V3 20 (40%) 14 (53.8%) V1+V2+V3 11 (22%) 6 (23.1%) Type of pain 0.531 Electric shock 48 (96%) 23 (88.4%) Lazinating 7 (14%) 7 (26.9%) Burning 18 (36%) 10 (38.4%) Evoked pain 0.471 Cool 13 (26%) 8 (30.7%) Movement 27 (54%) 15 (57.7%) Presure 32 (64%) 19 (73%) Others 1 (2%) - Intensity (VAS) 0.171 ≤7 2 (4%) - 8 7 (14%) - 9 23 (32%) 7 (26.9%) 10 25 (50%) 19 (73.1%)
- 13. info@neurologiasegura.net Comorbidities Normal Obese p Value Number of preoperative comorbidities 0.025 Range 0 to 2 1 to 9 Mean ± SD 0.8 ±0.8 3.8 ±1.5 Grade of preoperative comorbidities 0.000 None 22 (44%) - Single 17 (34%) - Multiple 11 (22%) 26 (100%) Type of preoperative comorbidity Metabolic 10 (26.3%) 29 (40.2%) 0.025 Cardiovascular 10 (26.3%) 25 (34.7%) 0.005 Respiratory 9 (23.7%) 7 (9.7%) 0.011 Endocrines 5 (13.2%) 8 (11.1%) 0.115 Neurological (-TN) 2 (5.3%) 1 (1.4%) 1.000 Hematologic 2 (5.3%) 0 (0%) 0.282 Others 0 (0%) 2 (2.7%) 1.000
- 14. info@neurologiasegura.net Medications Normal Obese p Value Number of medications 0.770 Range 1 to 6 1 to 6 Mean ± SD 2.5±1.2 2.8±1.4 Range of medications 0.764 1 a 2 30 (60%) 12 (46.1%) 3 a 4 16 (32%) 10 (38.5%) ≥5 4 (8%) 4 (15.4%) Carbamazepine usage (%yes) 78% 84.6% 0.492 Carbamazepine dosage (mg) 0.000 Range 0 to 1200 0 to 3000 Mean ± SD 615.4 ± 298.7 1054.5 ± 620.8
- 15. info@neurologiasegura.net Intubation difficulty Normal Obese p Value ASA PS classification 0.000 ASA I 17 (34%) - ASA II 25 (50%) 2 (7.7%) ASA III 8 (16%) 20 (76.9%) ASA IV - 4 (15.4%) Intubation difficulty scale (IDS) 0.000 Easy 40 (80%) - Slight Difficulty 10 (20%) 7 (26.9%) Moderate to Mayor - 19 (73.1%) Impossible - -
- 16. info@neurologiasegura.net Times Normal Obese p Value Hospital stay (hr) 0.080 Range 68 to 96 72 to 216 Mean ± SD 73.9 ± 7.6 81.6 ± 29.1 Operating room (min) 0.000 Range 125 to 276 104 to 331 Mean ± SD 172.6 ± 34 215.7 ± 51.4 Anesthetic time (min) 0.000 Range 106 to 200 122 to 324 Mean ± SD 148.7 ± 26.2 194.6 ± 49.3 Duration of surgery (min) 0.000 Range 65 to 158 72 to 284 Mean ± SD 112.4 ± 22 140.6 ± 44.9 Duration of microsurgery (min) 0.362 Range 25 to 93 37 to 107 Mean ± SD 58.1 ± 16.9 61.9 ± 16.3
- 17. info@neurologiasegura.net Intraoperative findings Normal Obese p Value Type of contact 0.780 Arterial 23 (46%) 11 (42.3%) Venous 12 (24%) 7 (26.9%) Mixed 14 (28%) 8 (30.8%) No contact 1 (2%) 0 Number of contacts 0.656 Simple 31 (62%) 14 (53.8%) Multiple 18 (36%) 12 (46.2%) No contact 1 (2%) 0 Responsible Vessel Arteries 0.932 SCA 30 (60%) 17 (65.4%) AICA 8 (16%) 4 (15.4%) VBD 3 (6%) 1 (3.8%) Veins 0.724 Pontine 9 (18%) 7 (26.9%) Ponto-trigeminal 7 (14%) 2 (7.7%) Unnamed 5 (10%) 4 (15.4%) Tributary to the SPVC 5 (10%) 3 (11.5%) SPVC 2 (4%) 3 (11.5%)
- 18. info@neurologiasegura.net Complications Normal Obese p Value Immediate complications Dizziness 20 (40%) 10 (38.5%) 0.254 Severe/persistent headache 21 (42%) 7 (26.9%) 0.157 Nausea 13 (26%) 9 (34.6%) 0.020 Paresthesia 11 (22%) 5 (19.2%) 0.732 Vomiting 9 (18%) 6 (23.1%) 0.075 Hypoesthesia 6 (12%) - 0.485 Vertigo 3 (6%) 1 (3.8%) 0.363 Hearing Loss 3 (6%) - 0.891 CSF leak* 1 (2%) 2 (7.7%) 0.363 Diplopia 2 (4%) - 0.891 Suppression crisis 1 (2%) 1 (3.8%) 0.271 Tinnitus 1 (2%) 1 (3.8%) 0.271 Facial paralysis* 1 (2%) 1 (3.8%) 0.271 Difficulty breathing - 1 (3.8%) 1.000 Dyspnea - 1 (3.8%) 1.000 Tachycardia - 1 (3.8%) 1.000 Deep venous thrombosis - 1 (3.8%) 1.000 Number of complications 0.589 Range 1 to 5 1 to 3 Mean ± SD 1.8±1.1 1.6±0.7 M A Y O R
- 19. info@neurologiasegura.net Outcomes Normal Obese p Value BNI Preop 0.178 BNI Score 1 - - BNI Score 2 - - BNI Score 3 2 (4%) - BNI Score 4 12 (24%) 11 (42.3%) BNI Score 5 36 (72%) 15 (57.7%) BNI Postop 1.000 BNI Score 1 32 (64%) 17 (65.4%) BNI Score 2 12 (24%) 6 (23.1%) BNI Score 3 4 (8%) 2 (7.7%) BNI Score 4 2 (4%) 1 (3.8%) BNI Score 5 - - Outcome 0.922 Excellent 31 (62%) 17 (65.4%) Good 13 (26%) 7 (26.9%) Persistence 4 (8%) 1 (3.8%) Recurrence 2 (4%) 1 (3.8%) Follow-up (months) 0.140 Range 1 to 43 1 to 57 Mean ± SD 23.5±13.9 28.7±15.5
- 20. info@neurologiasegura.net 10 30 50 70 90 110 130 Normal Weight Morbid Obese Relative Cost +15%
- 21. Conclusions MVD should be considered in morbid obese patients suffering from any type of TN when it is the only effective treatment to improve their quality of life in highly specialized medical centers with a very low rate of morbility. Safe and effective MVD surgery can be achieved with careful perioperative management. info@neurologiasegura.net
Editor's Notes
- 2.-Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder characterized by paróxysms of electric shock-like pain involving one or more divisions of the trigeminal nerve. Pain severity can jinder activities of daily living and impairs quality of life. Pharmacological therapy includes antaiconvulsánt medication that initially reduces TN pain intensity. However, the efficacy of medications generally decreases over time and can cós impórtant side effects.
- 3.- Microvascular decompression (MVD) is the most effective treatment to achieve long-term pain relief for TN. MVD is offered to young and healthy patients, neurosurgeons tend to be reluctant to offer MVD to elderly and obese patients due to the comorbidities that could cause complications during general anesthesia and postyrior fossa surgery.
- 4.-Trigeminal Neuralgia is not a life-threatening condition by itself. However, it can cause lifelong episodes of pain, becoming disaybelin. A quick and accurate diagnosis, as well as proper mashment can be beneshial for patients and lead to a better prognosis. No single studies of Microvascular decompression have been done in patients with morbid obesity due to the small sample size, and to the refusal of some surgeons to operate on these patients.
- 5.- The aim of the study was to evaluate the safety and efficacy of microvascular decompression to treat trigeminal neuralgia in patients with morbid obesity.
- 6.- From February twenty-seventeen to October twenty-twenty-one, we attended one-thousand six-hundred thirty-four patients with jayperactive dysfunk-shional síndrómm We excluded patients with other neuropathies to only have patients with classic trigeminal neuralgia, of which the non-operated and those who received other types of procíídures were excluded. Five-hundred eighty-nine surgeries were performed, of which only patients with normal weight and class III obesity were included. Demographics, characteristics of pain, comorbidities, pre- intra-, peri- and post-operative information, complication rates, and outcome were collected for each patient. We selected morbid patients with the obyéctive that the results were more contrasting.
- 7.- The diagnosis of TN is beist on a clinical evaluation to identify iunilatheral feishial pain associated with trigger points and characteristic paróxsismall and electric nature of pain. All patients undergo routine MRI to confirm neurovascular conflict and rulaut another entity. The surgical treatment should be offered only to patients who were refractory to medication, who refused percutanyous procydures, or patients who received such treatments with unsatisfactory results. Specially, those whose quality of life is seriously compromised regardless of age and weight.
- 8.- Obese and morbidly obese patients require more medical care and monitoring before undergoing surgery. Praior to surgery, comorbidities will be controlled, it is recommended to eat healthily, mainly foods with fayber, medications such as eintycoaguiulants should be suspended and especially it is recommended to perform exercises with a spirómeder 7 to 14 days before surgery to improve lung capacity. The routine lab tests for all patients include blood count, blood chemistry, general yurin-nalysis and coagulation tests. For obese patients, stádies of lípit, liver a tairoid profiles, chest X-ray and electrocardiogram are added. Possible candidates for surgery are previously evaluated by the neurosurgeon, anesthesiologist and internist, if any abnormality is detected that interferes with the operation or endayngers the life of the patient, the patient is referred to the corresponding specialist and undergoes treatment until it is controlled and surgery is resquéshchl. If control is not achieved, the patient is no longer a candidate for surgery. All patients are informed about the risks derived from the surgery and sign a consent letter
- 9.- The steps of the surgical technique are listed here, which is very similar between normal and obese patients. -The main difference is the difficulty to position and intubate the obese patient, they require the placement of an endotracheal tube with metal core, central and urinary catheter and anti-embolism stockings. -The procedure also needs a skin incision of 5-7 centimeters that is larger than normal weight due to ádiposs tissue. -At this moment, the surgery is carried out in the same way, always monitoring the stability of the patient. -Another important point to consider is the prevalence of high intracranial pressure in obese patients as we reported before.
- 5.- The aim of the study was to evaluate the safety and efficacy of microvascular decompression to treat trigeminal neuralgia in patients with morbid obesity.
- 10.- The results: We included Fifty patients with normal weight and Twenty-six grade three obesity, with an average Body Mass Index of twenty-three and forty-three, respéctibly. Female patients were more abundant in both groups, the right side was slightly more affected, the average age in both groups was similar, around Fifty-three and Fifty-one years. The duration of symptoms before surgery was 7 and 9 years with no significant difference between the two groups.
- 11.- The characteristics of pain were similar in both groups, being the combination of branches V2 and V3 is the most affected, the type of pain was mainly electrical, most patients mention that pressure and movement were the main triggers of pain and patients present severe intensity of pain at the time of surgery. These results indicate that obesity does not influence the characteristics of pain.
- 12.- In the case of preoperative comorbidities, all obese patients had a higher number of comorbidities than normal-weight patients. And they also presented with multiple comorbidities. Metabolic and cardiovascular comorbidities such as daiabiris and jaypertenshion were the most common in obese patients. Normal weight patients have a higher number of respiratory comorbidities mainly by tóbacco dypendens.
- 13.- It might be thought that obese patients consume more medications, however we faund that the number of medications ingested was similar in both groups. Most of the patients used carbamá-ze-pín. What we must highlight is that the dose of carbamá-ze-pín. used was significantly higher for obese patients, possibly requiring higher doses due to their greater volume of distribution.
- 14.- Before anesthesia, we found that obese patients had higher degrees of EISA Physical Status Classification and higher Intubation difficulty scale (IDS). So Anesthetic management of obese patients requires more attention and care.
- 15.- Regarding the times, the jóspiral esteiin and the duration of microsurgery did not show significant differences between groups while the stay in the operating room, the anesthetic time and the duration of surgery were longer in the obese. More time means the use of more medical supplies.
- 16.- Regarding intraoperative fayndings, there are no significant differences between the two groups of patients. The contact is mainly arterial and single by the supyrior cerebellar artery, when it is a venous contact, the pón-tín veins are the most frequent. These findings suggest that there are no obesity-related anatomical changes in the neurovascular conflict.
- 17.- Postoperative complications are very dayvers, however their frequencies are very similar between the groups. It was only shown that obese patients have more nóshea than those of normal weight. Obesity does not seem to increase the risk of suffering more postoperative complications; however, the medical center must be prepared for any unexpected event.
- 18.- Microvascular decompression reduces pain in both groups in a similar way, so obesity does not appear to affect the efficacy of surgery. In the most current follow-up, forty-eight presented excellent results, twenty had good results, 5 had persystens and only 3 had recurrence. So far, our results suggest that obesity is not related to persystens or recúrrence, however more studies are still required.
- 19.- The extra handling and supplies to guarantee the safety of the obese patient generates an additional cost to the surgery of approximately 15%.
- 20.- MVD should be considered in obese patients when it is the only effective treatment to improve their quality of life. Safe and effective MVD surgery can be achieved with careful perioperative management.