Pharmacological versus microvascular decompression approaches for the treatment of trigeminal neuralgia: clinical outcomes and direct costs

Abstract

In idiopathic trigeminal neuralgia (TN) the neuroimaging evaluation is usually normal, but in some cases a vascular compression of trigeminal nerve root is present. Although the latter condition may be referred to surgery, drug therapy is usually the first approach to control pain. This study compared the clinical outcome and direct costs of (1) a traditional treatment (carbamazepine [CBZ] in monotherapy [CBZ protocol]), (2) the association of gabapentin (GBP) and analgesic block of trigger-points with ropivacaine (ROP) (GBP+ROP protocol), and (3) a common TN surgery, microvascular decompression of the trigeminal nerve (MVD protocol). Sixty-two TN patients were randomly treated during 4 weeks (CBZ [n = 23] and GBP+ROP [n = 17] protocols) from cases of idiopathic TN, or selected for MVD surgery (n = 22) due to intractable pain. Direct medical cost estimates were determined by the price of drugs in 2008 and the hospital costs. Pain was evaluated using the Numerical Rating Scale (NRS) and number of pain crises; the Hospital Anxiety and Depression Scale, Sickness Impact Profile, and satisfaction with treatment and hospital team were evaluated. Assessments were performed at day 0 and 6 months after the beginning of treatment. All protocols showed a clinical improvement of pain control at month 6. The GBP+ROP protocol was the least expensive treatment, whereas surgery was the most expensive. With time, however, GBP+ROP tended to be the most and MVD the least expensive. No sequelae resulted in any patient after drug therapies, while after MDV surgery several patients showed important side effects. Data reinforce that, (1) TN patients should be carefully evaluated before choosing therapy for pain control, (2) different pharmacological approaches are available to initiate pain control at low costs, and (3) criteria for surgical interventions should be clearly defined due to important side effects, with the initial higher costs being strongly reduced with time.

Keywords: carbamazepine; clinical outcomes; direct costs; gabapentin associated with ropivacaine; microvascular decompression; trigeminal neuralgia.

Figure 1

Effect of the three protocols (GBP+ROP, CBZ, and MVD) on the pain intensity of patients 6 months after day 0. For significant differences see the Results section. Abbreviations: GBP+ROP, gabapentin+ropivacaine; CBZ, carbamazepine; MVD, microvascular decompression; NRS, National Rating Scale.

Figure 2

Effect of the three protocols (GBP+ROP, CBZ, and MVD) on number of daily episodes of pain before (day 0) and after a 5-month follow-up (month 6). For significant differences see the Results section. Abbreviations: GBP+ROP, gabapentin+ropivacaine; CBZ, carbamazepine; MVD, microvascular decompression.

Figure 3

Effect of GBP+ROP, CBZ, and MVD protocols on the total SIP score of quality of life (A) and on the anxiety (B) and depression (C) scores measured by the HADS questionnaire. For significant differences see the Results section. Abbreviations: GBP+ROP, gabapentin+ropivacaine; CBZ, carbamazepine; MVD, microvascular decompression; HADS, Hospital Anxiety and Depression Scale; SIP, Sickness Impact Profile.

Figure 4

Satisfaction of patients submitted to GBP+ROP, CBZ, and MVD, for treatment (A) and the clinical team (B). Abbreviations: GBP+ROP, gabapentin+ropivacaine; CBZ, carbamazepine; MVD, microvascular decompression.