Patient Reports of Satisfaction after Microvascular Decompression and Partial Sensory Rhizotomy for Trigeminal Neuralgia

We agree with Dr Nugent that the reasons for why patients may or not may not be satisfied are varied and, although we were measuring satisfaction with the outcome rather than with the process, we still cannot be sure how patients interpreted our question on overall satisfaction with their current situation. As Dr Nugent points out, sensory changes do alter satisfaction, although some patients consider it a small price to pay for relief of severe TN pain. He also points out that some patients are not concerned about sensory loss. This has also been demonstrated in patients undergoing radiofrequency thermocoagulation (2). It is for this reason that we have argued the need to record baseline data, such as intensity of pain, character of pain, its effect on quality of life, and sensory changes, as it can be postulated that patients with more disabling pain before surgery are less likely to complain of sensory loss than patients who were less disabled (3). The degree of sensory deficits produced by partial section ranged from a small area of mild circum oral numbness to one case with total unilateral facial anesthesia and loss of corneal reflex. Approximately 80% of the patients experienced unilateral hypoesthesia affecting the lower part of the face, usually extending from mid-cheek to the chin. In this area, they could usually feel tickle and could discriminate between sharp and blunt stimuli. In our extensive questionnaire (12 pages), we listed all possible complications and asked patients to grade the severity of the complication (very mild, mild, moderate, severe, or very severe). And, we asked them “Does this affect the quality of your life?” (scale: not at all, a little bit, quite a bit, moderately, or not at all). We asked all patients to complete two well-validated questionnaires, the Hospital Anxiety and Depression Scale and the SF12 to gauge whether the pain or complications were having an effect on the patients' quality of life. We also assessed the type of medications the patients were using and their comments and, in some cases, long letters. All this data was used to determine whether a patient had anesthesia dolorosa. In this study, we have just provided some basic data on the complications after surgery, and other reports are being prepared that will include more details, including details about eye and hearing problems. We were particularly keen to record patients' views rather than clinicians' views, as there is ample literature to show that clinicians and patients do not always agree on outcomes. Concerning the surgical details of the partial sensory rhizotomy, these have been referenced in our study (1). It was not appropriate to describe the full surgical details in our article, but they are as follows: The orientation of the trigeminal root entry zone (the ‘footprint’ on the pons) is variable and needs to be inspected carefully. The cordal portion is precisely opposite of the motor root insertion. The incision is made in the cordal portion very close to the pons using micro scissors. In mandibular division neuralgia, the caudal path of the root is divided; when the maxillary division is involved, two-thirds is divided. The methodology of the development of the questionnaire is the subject of a separate report that has not yet been published. And, our experience has led us to propose a modified questionnaire other than the one we used, which is included in the publication. There are currently no validated scales being used to assess outcome after surgery for TN. Measuring satisfaction is complex and it is better done by clinical psychologists and sociologists than surgeons and physicians. However, we feel that the use of the new questionnaire combined with preoperative assessments, as already detailed (3), will give us a better idea of outcomes after different forms of surgery than anything that has been available hitherto.