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The Value of Cryosurgery in the 

Management of Trigeminal Neuralgia:  

a Systematic Review

     

M. Lindström 

N. Thuring 

 

 

 

 

Handledare: S.Isaksson, M.Rohlin    Masteruppsats (30hp)        Malmö högskola  Tandläkarprogrammet        Odontologiska Fakulteten

 

Mars, 2012      205 06 Malmö

 

(2)

The Value of Cryosurgery in the Management of Trigeminal

Neuralgia: a Systematic Review

M. Lindström1*, N. Thuring2*, S. Isaksson3§, M. Rohlin4

1

Dental student, Faculty of Odontology, Malmö University, Malmö, Sweden

2

Dental student, Faculty of Odontology, Malmö University, Malmö, Sweden

3

Department of Oral and Maxillofacial Surgery, Halland hospital, Halmstad, Sweden

4

Department of Oral Radiology, Malmö University, Malmö, Sweden

*These authors contributed equally to this work

§ Corresponding author Email addresses: ML: otl07030@student.mah.se NT: otl07019@student.mah.se SI: Sten.G.Isaksson@regionhalland.se MR: madeleine.rohlin@mah.se Key words

Trigeminal Neuralgia, Cryosurgery, Cryotherapy, Freezing, Treatment Outcome,

Adverse Effects, Systematic Review

(3)

Abstract

The aim of this study was to evaluate the evidence for pain relief and adverse effects

following cryosurgery in the treatment of patients with trigeminal neuralgia through a

systematic review. A praxis investigation was carried out in order to establish how

common this treatment is among 44 Oral and Maxillofacial clinics in Sweden. The

systematic review was conducted according to Goodman’s systematic approach. The

search for literature was conducted in Medline, The Web of Science and the Cochrane

Database. Out of 45 retrieved studies, six met the pre-determined inclusion criteria.

The reported duration of pain relief following cryosurgery varied in a wide range

(from zero days to four years). No conclusions regarding the pain relief could be

drawn from the included studies. The reported adverse effects following cryosurgery

was minor and consisted of temporary sensory loss, migration of pain to another

division of the trigeminal nerve and small oedema. Five clinics that currently use a

cryosurgical treatment in the management of trigeminal neuralgia were identified.

Introduction

Trigeminal neuralgia is defined by the National Institute of Neurological Disorders

and Stroke (NINDS) as “a chronic pain condition that causes extreme, sporadic,

sudden burning or shock-like face pain.” The pain occurs in paroxysms, with each

interval ranging from a few seconds to two minutes and the pain can be both

physically and mentally incapacitating (1). Even suicides associated with the

diagnosis have been reported (2). The pain may be triggered spontaneously or by

stimulation of certain trigger points and is typically felt on one side of the jaw or

cheek. Daily activities such as eating, tooth brushing and talking may stimulate these

(4)

Trigeminal neuralgia is a relatively rare condition with a prevalence around 4-6 per

100,000 people in 1990’s in the US (9). More recent studies in the UK suggest that

trigeminal neuralgia is more common with a prevalence of 29 per 100,000 people

(10). Age is a primary risk factor and symptom manifestation is more likely to occur

after the age of 50 years (1, 11).

There are different theories about the mechanism causing the pain in trigeminal

neuralgia. Dever et al 2002, described that the trigeminal nerve, at the root entry zone

(where the trigeminal nerve enters the pons), is very sensitive to compression from the

surrounding tissue (Figure 1). Vessels that pass through this zone might lead to

demyelination and result in an abnormal firing of impulses (4).

Multiple Sclerosis is seen in 2-4% of the patients with trigeminal neuralgia, where a

demyelination also is present (5). A recent study described a high ratio of A/C-fibers

in the superior part of the nerve in the root entry zone. A compression of the superior

area which has been observed in more than 50% of the compression injuries caused

by vessels could explain the characteristics of the pain associated with trigeminal

neuralgia (6, 7). Other aetiologic factors might be neoplasms, trauma or viral

infections (8).

The first line of treatment of trigeminal neuralgia is often comprised by medication of

antiepileptic drugs. When medical treatment fails i.e lack of pain relief or exaggerated

adverse effects, surgical treatment might be considered as the next available treatment

option (12). Surgical methods may also be considered when patients are heavily

(5)

Surgery can be performed peripherally on nerves or centrally in the posterior fossa of

the skull. Peripheral surgical techniques are less invasive then central ones and do not

require a medically fit patient (14).

The central procedures involves separation of the trigeminal ganglion from

surrounding compressing arteries, veins or tumors (micro vascular decompression

(15)), electrical induced heating of the ganglion (percutaneous radiofrequency

thermocoagulation (16)), compression of the ganglion (percutaneous ballon

compression (17)) or radiation of the ganglion (gamma-knife radiosurgery (18)).

The peripheral procedures involves injection of alcohol, glycerol or local anesthetic

agents in the peripheral branches of the trigeminal nerve. Excision of the peripheral

branch (peripheral neurectomy) or freezing (cryosurgery) may be optional treatments

(13). In cryosurgery, a cryoprobe with either nitrous oxide or liquid nitrogen, as a

refrigerant, is applied peripheral to the isolated nerve (Figure 2).

Cryosurgery as a treatment for trigeminal neuralgia, first described by Lloyd et al.

1976 (19), has not been extensively evaluated. It is not clear how efficient it is as a

pain relieving method, nor what side effects are associated with the treatment (20).

The aim of this study was to evaluate evidence for the outcomes of cryosurgery as a

pain relieving method in the treatment of trigeminal neuralgia. Furthermore, the

praxis of this method in Oral and Maxillofacial Surgery clinics in Sweden will be

(6)

Methods and Material

The systematic review was conducted according to Goodman’s systematic approach

(21) and comprised the following steps (1) problem specification, (2) formulation of a

plan for the literature search, (3) literature search and retrieval of publications, and (4)

data extraction, interpretation of data and evaluation of evidence from literature

retrieved.

(1) Problem specification:

- What evidence is available for the treatment of trigeminal neuralgia with

cryosurgery as a pain relieving method?

- If initial successful, what is the duration of pain relief?

- What risks and adverse effects are associated with this treatment?

- How many Oral and Maxillofacial surgery clinics in Sweden implement cryosurgery

in the management of trigeminal neuralgia?

Formal definitions for the following elements were sought prior to the literature

search by means of Medical Subject Heading terms (MeSH) in Medline:

- Trigeminal Neuralgia: A syndrome characterized by recurrent episodes of

excruciating pain lasting several seconds or longer in the sensory distribution of the

trigeminal nerve. Pain may be initiated by stimulation of trigger points on the face,

lips, or gums or by movement of facial muscles or chewing. Associated conditions

include Multiple Sclerosis, vascular anomalies, aneurysms, and neoplasms.

- Cryosurgery: The use of freezing as a special surgical technique to destroy or excise

(7)

- Cryotherapy: A form of therapy consisting in the local or general use of cold. The

selective destruction of tissue by extreme cold or freezing is cryosurgery.

- Treatment outcome: Evaluation undertaken to assess the results or consequences of

management and procedures used in combating disease in order to determine the

efficacy, effectiveness, safety, practicability, etc., of these interventions in individual

cases or series.

- Adverse effects: Used with drugs, chemicals, or biological agents in accepted dosage

- or with physical agents or manufactured products in normal usage - when intended

for diagnostic, therapeutic, prophylactic, or anesthetic purposes. It is used also for

adverse effects or complications of diagnostic, therapeutic, prophylactic, anesthetic,

surgical, or other procedures, but excludes contraindications for which

"contraindications" is used.

Definitions of elements, not according to MeSH terms:

- Freezing: Liquids transforming into solids by the removal of heat.

- Cryoanalgesia: The relief of pain by application of cold by cryoprobe to peripheral

nerves.

(2) Formulation of a plan for the literature search

Literature search was conducted in three databases, Medline, the Cochrane Library

and the Web of Science. The search in Medline is presented in Table 1 and the search

in Web of Science in Table 2. The searches were conducted in November 2011 with

the help from a librarian at the Malmö University. A search through the reference lists

(8)

limited to studies on humans and to those written in the English, Swedish, Danish or

Norwegian language.

(3) Literature search and retrieval of publications

Studies found were identified and processed with application of inclusion and

exclusion criteria. The inclusion and exclusion criteria are presented in Table 3.

Patients had to be diagnosed with trigeminal neuralgia. Prior to treatment, a diagnostic

blockade had to be administered to verify the affected nerve branch. To be able to

assess the pain relieving ability of the cryosurgical method, the surgical procedures

exclusively had to be cryosurgical. Cryosurgical techniques other than those

administered peripherally were also excluded. It was fundamental that a post

treatment evaluation (minimum three months) was conducted – in order to estimate

the length of patient’s pain free periods.

(4) Data extraction, interpretation of data, and evaluation of evidence from literature retrieved

To assess the quality of included publications, each study was read and scored, by

both authors, independently using a protocol based on the STROBE-statements used

to assess observational studies (22). The STROBE-protocol included 22 criteria to

evaluate the methodological quality of each study. Each criterion was given equal

weight and considered to be met or not met. Evidence was rated according to GRADE

guidelines in one of four quality levels – high, moderate, low or very low (23). When

there is no study of moderate quality evidence will be assessed as insufficient.

Investigation of praxis

In order to establish the praxis of cryosurgical technique amongst Oral and

(9)

Maxillofacial Surgery clinics registered as members of the Swedish Association of

Oral and Maxillofacial Surgeons.

Each clinic was asked two questions:

- Are patients with diagnosed trigeminal neuralgia treated in your clinic?

- If yes, are these patients treated with cryosurgery?

The questionnaire was sent via mail. Clinics which did not answer via mail were

contacted by phone.

Results

Literature identification

The number of publications retrieved, read, and interpreted are presented in Figure 3.

The Medline search yielded 32 studies and the Web of Science yielded 24 studies.

The Cochrane Library search yielded 4 systematic reviews, out of which one met the

problem specification. As 17 publications of the Web of Science search was

duplicates of the Medline search, totally 43 original studies were found. Two

publications were also found searching the reference lists of included publications.

Six studies were found relevant for inclusion (Figure 3). Thirty-nine studies were

excluded. Four were excluded due to language restrictions, 15 not being clinical

studies, 11 not meeting the problem specification, 4 case reports, 4 due to prior

treatment with alcohol injections or surgery and 1 study with inclusion of MS

patients.

Interpretation of data

The results are presented in Table 4.

The duration of pain relief in patients receiving cryosurgery ranged from 0 days (19)

to 4 years (24). Median duration of pain relief could not be assessed in 3 (24-26) of

(10)

235 days (27) and 18 months (28). The other 3 studies (24-26) presented the number

of patient’s pain free in annual intervals. The reported frequency of patients with pain

relief after one year varied between 32% (26) and 50% (24). The number of patients

free of pain after two years was reported as 14.5% (25) but reported by the same

research group as 18 % after four years in another study (24).

The reported adverse effects were temporary sensory loss (24-28), migration of pain

to another division of the trigeminal nerve (24, 25), post-operative infection (25) and

small oedema (26, 28). The most commonly reported adverse effect was temporary

sensory loss, which was reported in five out of six studies. Sensory loss ranged

between two to four months. None of the studies presented any case of permanent

sensory loss or anesthesia dolorosa.

Evaluation of evidence

The study quality of the included studies was low therefore evidence is insufficient to

determine the pain relieving effect of cryosurgery in patients with trigeminal

neuralgia. There is low evidence that the most frequent adverse effect following

cryosurgical treatment of trigeminal neuralgia patients is sensory loss.

Investigation of praxis

Forty-four clinics answered the questionnaire i.e. 100%. The answers regarding

treatment of trigeminal neuralgia were diverse and insufficient to analyze. Five clinics

reported that they currently use cryosurgery in the management of trigeminal

(11)

Discussion

Methodological considerations

The search limitations regarding language restrictions may have resulted in that a few

relevant publications were excluded. This may have resulted in loss off valuable data

for this review. The studies included in this review were both prospective and

retrospective. No study was designed as a randomized controlled trial (RCT). The

quality of studies concerning cryosurgery in trigeminal neuralgia could be questioned

as RCT studies would have been preferable to strengthen the scientific value.

However due to patients’ severe pain associated with the disease, RCT studies might

be unethical. The STROBE protocol (22) was used to evaluate the quality of the

included studies. All studies were scored low, indicating the need for well structured

and higher quality studies.

Discussion of results

Diagnosis of trigeminal neuralgia relies almost entirely on the basis of clinical

diagnostic criteria, except for some cases where imaging studies can identify lesions

along the trigeminal sensory pathway (7).

The usage of strict diagnostic criteria is crucial to ensure a correct trigeminal

neuralgia diagnosis, since the diagnosis of primary (idiopathic) and secondary (i.e.

tumours or multiple sclerosis) trigeminal neuralgia may have different success rates

(29). The included studies in this review mainly originated from the eighties where

the research methodology was not as developed as it is today. These studies lack a

(12)

The assessment of pain relief was deficient and the studies did not use any systematic

measurements of pain, pre- or postoperatively. Since none of the studies presented a

baseline of experienced pain relief it is difficult to draw any conclusions. The

assessment of patient’s quality of life is more frequently used in contemporary

research, and is of great importance when evaluating the success of a method. None of

the included studies evaluating cryosurgery for trigeminal neuralgia did measure

patient’s quality of life following treatment. Patients were considered either relieved

of pain or not, but the studies did not take into consideration that a partial relief may

have a great improvement in a patient’s quality of life. At least two studies included in

this review (26, 30) have reported of patients being able to reduce their dosage of

antiepileptic drugs following cryosurgery.

The treatment with antiepileptic drugs is associated with adverse effects such as

drowsiness, dizziness, vomiting, constipation, ataxia and leucopenia (9, 20).

A reduction of the dosage could offer a great improvement in patient’s quality of life

because of these adverse effects. Zakrzewska and Thomas 1993 reported that 74% of

patients who underwent cryosurgery treatment were willing to undergo a repeated

treatment (30).

The included studies reported pain relief using different assessment. Lloyd 1976 (19) ,

Bernard 1980 (27) and Goss 1984 (28) presented days of pain relief in median and

range, contrary to Zakrzewska 1986,1987 (24, 25) and Pradel 2002 (26) who

presented the percentage of pain relieved patients in intervals of one year. The results

of the studies could not be compared for pain relief as the studies used different

freeze-thaw cycles and temperatures during the cryosurgery. A larger number of

patients would have been advantageous regarding conclusions about pain relief, since

(13)

Other surgical techniques have shown greater success in pain relief, e.g. micro

vascular decompression (MVD), where relief of pain (without medication) in 71% of

the patients has been reported over a period of 10 years (15). Despite the higher

success rate, MVD is a more invasive method with a risk of severe adverse effects

such as hearing loss, meningitis, infarcts or haematomas (30, 31) and could be

contradictive when treating patients who are heavily medicated and weak. In these

patients, the minimal invasive method of cryosurgery can be acomplement to the

medical treatment.

Five studies out of six (24-28) reported sensory loss with a range of two to four

months. All patients regained normal sensory function; no permanent sensory loss

was reported. A sensory loss must be considered as an acceptable complication in

relation to the severity of the pain. Occurrence of small oedema (26) following

surgery and a post op infection in one patient (25) was also reported. An important

finding was the occurrence of pain migration reported by Zakrzewska et al (24, 25).

They presented pain migration in as much as nineteen out of thirty-nine patients, who

following surgery experienced pain in an untreated nerve in the same division or in an

ipsilateral, untreated division. The occurrence of pain migration might implicate a

contraindication when performing cryosurgery, however, only two studies (24, 25)

(14)

Recommendations for the future

At least five Swedish Oral and Maxillofacial Surgery clinics are currently using

cryosurgery as a treatment for trigeminal neuralgia. This advocates the need for

further research concerning treatment indications and the evaluation of pain relief.

Appliance of strict diagnostic criteria in prospective studies with a sufficient number

of patients will contribute to a greater understanding concerning the pain relieving

ability of cryosurgery. The collection and presentation of data must be carried out in a

standardized manner in order to have comparable results. Assessment of pain pre- and

postoperatively with a pain evaluating model e.g. VAS is of great importance in

understanding the amount of achieved pain relief. A quality of life measurement may

identify patients who fail to sustain a total pain control but still gain improvements

post treatment.

Conclusions

Cryosurgery is a minimal invasive procedure and the reported adverse effects

following surgery are minor and reversible. There is a pain relieving effect in some

patients diagnosed with trigeminal neuralgia undergoing cryosurgery though the

effectiveness of the cryosurgical procedure needs to be further assessed.

(15)

References

1. National Institute of Neurological Disorders and Stroke (NINDS),

http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/trigeminal_neuralgia.htm#

What_is ; accessed 2012-02-15.

2. Zakrzewska JM, Harrison SD. Assessment and Management of Orofacial Pain. The

Netherlands: Elsevier Science B.V.; 2002.

3. Headache Classification Subcommittee of the International Headache Society. The

International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;

24 Suppl 1: 9-160.

4. Devor M, Amir R, Rappaport ZH. Pathophysiology of trigeminal neuralgia: the

ignition hypothesis. Clin J Pain. 2002; 18: 4-13.

5. Nurmikko TJ, Eldridge PR. Trigeminal neuralgia--pathophysiology, diagnosis and

current treatment. Br J Anaesth. 2001; 87: 117-132.

6. Sindou M, Howeidy T, Acevedo G. Anatomical observations during microvascular

decompression for idiopathic trigeminal neuralgia (with correlations between

topography of pain and site of the neurovascular conflict). Prospective study in a

series of 579 patients. Acta Neurochir (Wien). 2002; 144: 1-12; discussion 12-3.

7. DaSilva AF, DosSantos MF. The role of sensory fiber demography in trigeminal

and postherpetic neuralgias. J Dent Res. 2012; 91: 17-24.

8. Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain.

2001; 124: 2347-2360.

9. Zakrzewska JM. Medical management of trigeminal neuropathic pains. Expert

Opin Pharmacother. 2010; 11: 1239-1254.

10. Dieleman JP, Kerklaan J, Huygen FJ, Bouma PA, Sturkenboom MC. Incidence

rates and treatment of neuropathic pain conditions in the general population. Pain.

(16)

11. Fisher A, Zakrzewska JM, Patsalos PN. Trigeminal neuralgia: current treatments

and future developments. Expert Opin Emerg Drugs. 2003; 8: 123-143.

12. Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K et al.

AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008; 15:

1013-1028.

13. Toda K. Operative treatment of trigeminal neuralgia: review of current techniques

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 788-805, 805.e1-6.

14. Zakrzewska JM. Surgical management of trigeminal neuralgia Br Dent J. 1991;

170: 61-62.

15. Sarsam Z, Garcia-Finana M, Nurmikko TJ, Varma TR, Eldridge P. The long-term

outcome of microvascular decompression for trigeminal neuralgia. Br J Neurosurg.

2010; 24: 18-25.

16. Huibin Q, Jianxing L, Guangyu H, Dianen F. The treatment of first division

idiopathic trigeminal neuralgia with radiofrequency thermocoagulation of the

peripheral branches compared to conventional radiofrequency. J Clin Neurosci. 2009;

16: 1425-1429.

17. Abdennebi B, Mahfouf L, Nedjahi T. Long-term results of percutaneous

compression of the gasserian ganglion in trigeminal neuralgia (series of 200 patients).

Stereotact Funct Neurosurg. 1997; 68: 190-195.

18. Nicol B, Regine WF, Courtney C, Meigooni A, Sanders M, Young B. Gamma

knife radiosurgery using 90 Gy for trigeminal neuralgia. J Neurosurg. 2000; 93 Suppl

3: 152-154.

19. Lloyd JW, Barnard JD, Glynn CJ. Cryoanalgesia. A new approach to pain relief.

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20. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Clin Evid (Online). 2009;

2009: 1207.

21. Goodman C. Literature Searching and Evidence Interpretation for Assessing

Health Care Practices. SBU, The Swedish Council on Technology Assessment in

Health Care. Norstedts Tryckeri, Stockholm 1993. ISBN 91-878890-22-4.

22. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP et

al. The Strengthening the Reporting of Observational Studies in Epidemiology

(STROBE) statement: guidelines for reporting observational studies. J Clin

Epidemiol. 2008; 61: 344-349.

23. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J et al.

GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011; 64:

401-406.

24. Zakrzewska JM, Nally FF, Flint SR. Cryotherapy in the management of

paroxysmal trigeminal neuralgia. Four year follow up of 39 patients J Maxillofac

Surg. 1986; 14: 5-7.

25. Zakrzewska JM. Cryotherapy in the management of paroxysmal trigeminal

neuralgia J Neurol Neurosurg Psychiatry. 1987; 50: 485-487.

26. Pradel W, Hlawitschka M, Eckelt U, Herzog R, Koch K. Cryosurgical treatment

of genuine trigeminal neuralgia Br J Oral Maxillofac Surg. 2002; 40: 244-247.

27. Barnard D. The effects of extreme cold on sensory nerves. Ann R Coll Surg Engl.

1980; 62: 180-187.

28. Goss AN. Peripheral cryoneurotomy in the treatment of trigeminal neuralgia Aust

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29. Zakrzewska JM, Lopez BC. Quality of reporting in evaluations of surgical

treatment of trigeminal neuralgia: recommendations for future reports. Neurosurgery.

2003; 53: 110-20; discussion 120-2.

30. Zakrzewska JM, Thomas DG. Patient's assessment of outcome after three surgical

procedures for the management of trigeminal neuralgia Acta Neurochir (Wien). 1993;

122: 225-230.

31. Piatt JH,Jr, Wilkins RH. Microvascular decompression for tic douloureux.

Neurosurgery. 1984; 15: 456.

32. AnesthesiaUK, http://www.anaesthesiauk.com/images/trigeminal_nerve.jpg;

accessed 2012-02-02, with permission from AnesthesiaUK.

Acknowledgements

We would like to thank the Oral and Maxillofacial Surgery clinics participating in our

(19)

Tables

Table 1 – Medline search

Search strategy in Medline, and number (n) of publications retrieved

Search Index (2011-11-01) n

#1 Trigeminal Neuralgia [MeSH] 3251

#2 Cryosurgery [MeSH] 6350

#3 Cryotherapy [MeSH] 8521

#4 Cryoanalgesia [Free text] 71

#5 Freez* [MeSH] 5831

#6 Treatment outcome [MeSH] 447355

#7 Adverse effects [Free text] 1078465

#8 #1 AND #2 18 #9 #1 AND #3 7 #10 #1 AND #4 1 #11 #1 AND #5 0 #12 #1 AND #6 420 #13 #1 AND #7 461 #14 #2 OR #3 OR #4 OR #5 33241 #15 #1 AND #14 32 #16 #6 AND #15 4 #17 #7 AND #15 4

(20)

Table 2 – Web of Science search

Search strategy in Web of Science, and number (n) of publications retrieved

Search Index (2011-11-01) n

#1 Trigeminal Neuralgia [MeSH] 3976

#2 Cryosurgery [MeSH] 3233

#3 Cryotherapy [MeSH] 4466

#4 Cryoanalgesia [Free text] 106

#5 Freez* [MeSH] 82911

#6 Treatment outcome [MeSH] 234168

#7 Adverse effects [Free text] 118870

#8 #1 AND #2 4 #9 #1 AND #3 18 #10 #1 AND #4 6 #11 #1 AND #5 5 #12 #1 AND #6 260 #13 #1 AND #7 67 #14 #2 OR #3 OR #4 OR #5 89371 #15 #1 AND #14 24 #16 #6 AND #15 2 #17 #7 AND #15 0

Table 3 – Inclusion and exclusion criteria

Inclusion and exclusion criteria of studies of patients diagnosed with trigeminal neuralgia receiving cryosurgery

Inclusion criteria Exclusion criteria

Clinical study Case reports

Patients diagnosed with tic douloureux or trigeminal neuralgia

Patients previously treated with injections or surgery for trigeminal neuralgia

Surgical treatment with cryosurgery

Multiple sclerosis, neoplasm or trauma induced trigeminal neuralgia Post treatment pain evaluation Pain evaluation post treatment less

than 3 months Peripheral appliance of the

cryoprobe

Studies not written in English, Swedish, Norwegian or Danish. Usage of diagnostic blockade to

(21)

Table 4 - Results

Included studies, extracted data and outcomes of cryosurgery in treated patients. *Synonym to trigeminal neuralgia First Author Year Country Study design No of patients

Diagnosis Freeze thaw cycle and temperature

Follow up

Pain relief Adverse effects Study quality according to STROBE (22) (max. 22) Lloyd 1976 England (19) Prospective 6 Tic doloureux* 2x2 min

-60oC months >3 duration: Median

21 days Range: (0-112) None described 6 Barnard 1980 England (27) Prospective 8 Tic doloureux* 2x1 min -60oC 3 years Median duration: 235 days Range: (62-815) Sensory loss 6 Goss 1984 Australia (28) Prospective 11 Trigeminal neuralgia 2x1.5 min - 18 months to 3 years Median duration in 7 out of 11 patients: 15 months Range: (4-21) Median duration in 4 out of 11 patients: 24 months Range (18-36) Sensory loss, small oedema 7 Zakrzewska 1986 England (24) Prospective 39 Trigeminal neuralgia 3x2 min -120oC 4 years 1 year: 50% pain free 4 years: 18% pain free Sensory loss, Pain migration 10 Zakrzewska 1987 England (25) Retrospective 29 Trigeminal neuralgia 3x2 min -120oC 5 years >1 year: 41% >2 years: 14,5% Sensory loss, Pain migration , Post-op infection 11 Pradel 2002 Germany (26) Prospective 19 Trigeminal neuralgia 2x1.5 min -120oC 1 to 3 years 1 year: 32% pain free Sensory loss, Small oedema 9

(22)

Figures

Figure 1 – The trigeminal nerve

Retrieved from AnaesthesiaUK (32)

Figure 2 – Cryosurgery of the mental branch of the trigeminal nerve

In courtesy of Sten Isaksson, Halland hospital, Halmstad, Sweden

(a) Mental foramen with the mental nerve exposed

(23)

Figure 3 - Flowchart

Literature search in Medline and Web of Science. The included publications from the search in Web of Science were duplicates to included publications retrieved in Medline.

Medline

Abstract n = 32 Excluded abstracts n = 19

Fulltext articles n = 13 Excluded fulltext n = 9

Included original articles n = 4

Reference lists handsearch n = 9 Abstract n = 2 No abstract n = 7 Excluded abstracts n = 0 Fulltext articles n = 2 Total included non-duplicated articles n = 6 Included articles n = 2 Web of Science Abstract n = 24 Excluded abstracts n = 13 Fulltext articles n = 11 Excluded fulltext n = 8

Included original articles n = 3

Figure

Table 1 – Medline search
Table 3 – Inclusion and exclusion criteria
Table 4 - Results
Figure 2 – Cryosurgery of the mental branch of the trigeminal nerve
+2

References

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