There are many options of medical treatments for trigeminal neuralgia, but the choice of treatment has to be individualized for each patient. When pain is not adequately controlled, quality of life is compromised and psychological problem such as depression can occur. In our cases, both patients had secondary trigeminal neuralgia which was caused by tumor lesion and tumor removal remained as definitive treatment. However, both patients had unfavorable conditions for surgery or declined open neurosurgical procedure, rendering tumor removal unfeasible.
Microvascular decompression (MVD) was proven effective in most trigeminal neuralgia cases, but prior studies proved that in 3–20% patients required re-treatment after 2–3 pain-free years.[4, 5] It remained the definitive therapy for primary trigeminal neuralgia including cases where medications are no longer satisfactory. However, this procedure carries some risks, including facial numbness, deafness, facial palsy, CSF leak, meningitis, and death, with total periprocedural complication rate as high as 19.3%. Secondary trigeminal neuralgia caused by tumor treated with open surgery for removal showed immediate pain relief without neurologic deficit.
Percutaneous radiofrequency rhizotomy is another form of modality to treat trigeminal neuralgia. Indications include bilateral trigeminal neuralgia, elderly patients, recurrence after failed MVD, vertebrobasilar dolichoectasia and multiple sclerosis. Initial pain-relief effect reach 95%, but over half of patients who had rhizotomy needed re-treatment after pain-free period of 3–4 years.[3, 5] This procedure is most commonly done compared to other options due to the feasibility and is relatively easier compared to open surgery as it is minimally invasive. Overall, recurrence rate after 6 months of all trigeminal neuralgia cases reached 13.5% and most often occur along the V1 distribution. For secondary trigeminal neuralgia, reoccurrence was as much as 37.5%.
Gamma knife surgery is one of the available options for trigeminal neuralgia treatment, however, pain-relief effect is not immediate and may take approximately 1–3 weeks after the procedure. This treatment is least invasive and good for patients with co-morbidities, high-risk medical illness, or refractory pain after prior procedures. However Gamma Knife may not be available in many medical centers. In Indonesia, there are only two centers with gamma knife facilities. Furthermore the cost of treatment is outside the coverage of the national health insurance which is the sole health insurance of about 80% of Indonesian people.
Based on all the available modalities in our center, authors and patients decided to choose the most effective personalized treatment for patients’ condition. Quality of life improved greatly and patient could resume the daily activity for a short period of time before continuing to the definitive treatment. PRFR can be used as an alternative to alleviate pain in situations where surgical procedures or medications are unlikely for short period of time.