Introduction: Trigeminal neuralgia (TN) is a debilitating condition that can be refractory to medical management. Neurosurgeons have a wide variety of procedures to offer patients when treating medically-intractable TN. We reviewed the national trends in overall procedural volume for the treatment of TN from 1988 to 2010.
Methods: The Nationwide Inpatient Sample (NIS) data represent a twenty-percent stratified sample of U.S. community (non-federal) hospitals. The NIS (1988 to 2010) provided data on patients hospitalized with a principal diagnosis of TN and a related principal procedure. We categorized principal procedures as open, percutaneous, radiosurgery, or other. The “open” category represents MVD and presumed nerve root sectioning. The “other” category includes procedures appropriate for the treatment of TN but the identification of an “open” or “percutaneous” procedure is uncertain.
Results: We identified 13,466 relevant hospital admissions. The volume for open procedures remained relatively constant (linear regression slope -18 discharges per year; p-value 0.377), whereas percutaneous procedures decreased (slope -63; p-value < 0.001) over time. Mean age of patients undergoing percutaneous and radiosurgery procedures (67.9 and 69.5 years) was higher than open and other procedures (60.4 and 63.4 years) (one-way ANOVA p-value < 0.001). The mean total in-hospital inflation-adjusted charges for all four categories increased over time (linear regression slope: open $1,752 per year; other $1,515; percutaneous $795; radiosurgery $2,324; all p-values < 0.001). The mean total in-hospital inflation-adjusted charge for radiosurgery ($37,666) was higher than open ($28,046) procedures (ANOVA p-value < 0.001).
Conclusions: Patients who undergo an open procedure to treat TN are much younger than those who undergo a percutaneous or a radiosurgery procedure. The risk of MVD in the elderly population may be driving the selection of less invasive percutaneous and radiosurgical procedures. In addition, the in-hospital inflation-adjusted charges for all procedures increased over time, with radiosurgery higher than those of open procedures.
Patient Care: The research affirms that open surgery for treating trigeminal neuralgia is reserved for younger patients as compared to radiosurgery and percutaneous techniques. The age relationship is in accordance with observations by Rughani et al. that elderly patients suffer more complications after microvascular decompression. In addition, the research will help clinicians understand time-based trends in procedural choice along with hospitalization charge disparities between different treatment modalities.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the volume trends in procedural treatment of trigeminal neuralgia over time.
2) Understand the variety of procedural codes categorized in the open, percutaneous, radiosurgery, and other categories.
3) Identify which treatment option is most costly during the inpatient hospital stay.
References: 1) Barker FG, 2nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD: The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 334:1077-1083, 1996.
2) Cole CD, Liu JK, Apfelbaum RI: Historical perspectives on the diagnosis and treatment of trigeminal neuralgia. Neurosurg Focus 18:E4, 2005.
3) Kalkanis SN, Eskandar EN, Carter BS, Barker FG, 2nd: Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery 52:1251-1261; discussion 1261-1252, 2003.
4) Rughani AI, Dumont TM, Lin CT, Tranmer BI, Horgan MA: Safety of microvascular decompression for trigeminal neuralgia in the elderly. Clinical article. J Neurosurg 115:202-209, 2011.