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EDITORIALS: Andria F A Merrison and Geraint Fuller Treatment options for trigeminal neuralgia BMJ 2003; 327: 1360-1361 [Full text]

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Patient centered objective evalautions of surgical treatment for trigeminal neuralgia are needed.

Joanna M Zakrzewska, Benjamin Lopez   (21 December 2003)

Mortality rates for MVD: more recent results

Fred G Barker   (6 January 2004)

Patient centered objective evalautions of surgical treatment for trigeminal neuralgia are needed. 21 December 2003
Joanna M Zakrzewska, Senior Lecturer/hon Consultant Barts and the London, Queen Mary's School of Medicine and Dentistry, Turner Street Londddon E1 2AD, Benjamin Lopez Send response to journal: Re: Patient centered objective evalautions of surgical treatment for trigeminal neuralgia are needed.	It was helpful to have a further follow-up Editorial 1 on Trigeminal Neuralgia as small but significant differences are being made in the management of this rare facial pain 2. As Merrison and Fuller 1 point out there are no randomised control trials or treatments at the level of the Gasserian Ganglion or posterior fossa. It is because of this that we undertook a systematic review of the whole surgical literature last year using evidence based medicine methodology to assess the quality of the published studies. Anyone with an interest in this subject should familiarise themselves with this study as it lays down the recommendations of how case series should be assessed and provides data on the quality criteria 3. It needs to be noted that very few studies reach the required standard. For example it is our opinion that if the aim of these procedures is to provide pain relief and improvement of quality of life then these should be measured pre and post operatively in order to show how these outcomes have been achieved objectively. In the entire published literature there is only one study, done by an independent research worker, that attempted to use validated reliable questionnaires, (used in other areas of pain) to assess outcome after Gasserian ganglion surgery 4. Patients need to be actively involved in these evaluations. Merrison and Fuller 1 also refer to the need for a systematic review on the use of radiosurgery. This is now in press in the Journal of Neurology Neurosurgery and Psychiatry (Lopez et al ). The role of support groups in helping patients obtain a diagnosis, get treatment and most importantly provide psychological support is not mentioned. There is a large organisation in the US, founded in 1990 with others in the UK, Australia and they all have excellent web sites (http://www.tna.org.uk/, http://www.tna-support.org/ ). The US Trigeminal Neuralgia Support Group has published a best selling book on Trigeminal Neuralgia written by a patient with the help of a neurosurgeon 5. These support groups not only provide help for patients but are also increasing awareness of trigeminal neuralgia among healthcare professionals, and have been sufficiently influential to persuade the NIH to release funds for research in this area. They have also contributed to the preparation of a patient centred outcome questionnaire after posterior fossa surgery ( Zakrzewska et al submitted for publication). Merrison and Fuller1 have highlighted the need for randomised controlled trial especially in the field of surgery but without adequate funding research in this area is hampered. Reference List 1.Merrison,AFA, Fuller G Treatment options for trigeminal neuralgia BMJ 2003;327:1360-1 2. Walchenbach R,.Voormolen JH. Surgical treatment for trigeminal neuralgia. BMJ 1996;313:1027-8. 3. Zakrzewska JM,.Lopez BC. Quality of reporting in evaluations of surgical treatment of trigeminal neuralgia: recommendations for future reports. Neurosurgery 2003;53:110-20. 4. Zakrzewska JM, Sawsan J, Bulman JS. A prospective longitudinal study on patients with trigeminal neuralgia who underwent radiofrequency thermocoagulation of the Gasserian ganglion. Pain 1999: 79: 51-58, 5. Weigel G, Casey KF. Striking Back. the trigeminal neuralgia handbook. Barnegat light: The trigeminal neuralgia association, 2000. Competing interests: None declared
Mortality rates for MVD: more recent results 6 January 2004
Fred G Barker, Assistant Visiting Neurosurgeon Massachusetts General Hospital, Fruit Street, Boston, MA, USA02114 Send response to journal: Re: Mortality rates for MVD: more recent results	Merrison and Fuller's editorial calling for objective comparisons between the many non-medical treatment options for trigeminal neuralgia (TN) is timely and persuasive. Such studies would indeed be a boon to clinicians who counsel patients with this disease. The reference for mortality rates of microvascular decompression surgery (MVD), however, could usefully be updated. The study quoted was based on a survey conducted by Sweet, a major proponent of surgical TN treatments other than MVD, and reflects surgical experience from the early 1980's. A more current, population-based mortality rate for United States centres (1996-2000) of 0.3% was recently reported by our group [1]. The mortality rate was inversely related to surgeon caseload, with no deaths in the cohort of patients whose surgeons performed 2 or more MVD operations per year. Fred G. Barker II, M.D. [1] Kalkanis SN, Eskandar EN, Carter BS, Barker FG. Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery 52:1251-61, 2003 Competing interests: None declared