We must have a direct, randomised comparison between decompression and thermocoagulation

Trigeminal neuralgia or tic douloureux is a debilitating syndrome consisting of mainly unilateral short bursts of lancinating pain in one or more branches of the trigeminal nerve. Typically, these bouts of pain can be provoked by touching specific trigger points, speaking, or eating. The incidence is reported to be 4.3 per 100 000 with a predominance in women.1 The initial treatment is medical: carbamazepine is the first drug of choice, though diphantoine or baclofen, or a combination, can also be used. Most patients initially respond to medical treatment, but 30–75% do not obtain long term pain relief or experience side effects of the drugs.2 3 For these patients, surgical intervention should be considered.

Although, or perhaps because, the pathogenesis of trigeminal neuralgia has not been fully elucidated, various invasive procedures have been described over the years. There is a continuing struggle between supporters of percutaneous ablation of the ganglion of Gasser (percutaneous controlled differential thermocoagulation being the most widely used procedure) and supporters of microvascular decompression of the trigeminal nerve root by way of an exploration of the posterior fossa. If no vascular compression is found at operation, the sensory root can be partially transected as described by Dandy.4 Advocates of both …