OBLITERATING FORAMINA FOLLOWING PERIPHERAL NEURECTOMIES CAN PROLONG
REMISSION OF NEURALGIA UP TO 10 YEARS
a post-ganglionic surgical procedure that involves
the alvusion of a peripheral branch of the trigeminal
nerve after its exit from the cranium. It has been
described as a simple, low-risk, repeatable surgery
that can be applied to the terminal branches of
the trigeminal nerve. 9, 10 It is an ancient procedure,
apparently was performed by Marechal, surgeon
to Louis XIV in the fifteenth century.11 There were
conflicting reports on the first person credited
to have performed authenticated peripheral
neurectomy. One report has it that Nicholas André
performed it in 173212, while another claimed
Schlichting performed this procedure in 1748.9
This procedure was extensively reported in the
late 19th century in both surgical and dental
literatures11, 13 Among neurosurgeons, Fowler
credited A. Wagner of Germany for popularising
this procedure.11 Fowler himself documented the
outcome of peripheral neurectomy of 83 cases
in his 1886 publication.11 The peripheral nerves
were avulsed as closed to the ganglion as possible
by these neurosurgeons. Wagner’s and Fowler’s
results were variable, but some of the subjects
were reported to achieve remission between 1 and
3 years, while in several, for life. The oral surgeons
instead removed the nerve nearer to its exit at
the distal end.13 Thereafter, there was a paucity of
reports on peripheral neurectomies between the
two World Wars.14 Khanna and Galinde reported a
success rate of 75%.15 Most patients achieved pain
relief that ranges from 24 months for infraorbital
and supraorbital neurectomies to 26 months
for mental neurectomy.10, 13, 15-17 However, up to
31% of these patients may still require additional
medicinal support to relieve symptoms after
peripheral neurectomy, but usually at a lower
dosage.7, 18
One of the problems that may arise following
peripheral neurectomy is spontaneous peripheral
nerve regeneration. This problem has been
reported ever since the early publications on
neurectomy9 and has been confirmed in animal
studies.19 This process may subsequently result in
the re-emergence of trigeminal neuralgia as early
as 3-6 months post surgery.7, 15 The extent to which
axons succeed in regenerating is dependent on
several factors, among which the severity of the
injury and the method of neurectomy.
So, axonal regeneration in neurotmesis (as resulting
from peripheral neurectomy) is less predictable
because of the disruption of the connective tissue
sheaths that is important to guide regeneration.12
Nevertheless, in patients with trigeminal neuralgia,
it has been reported that peripheral nerves
regenerated 24-26 months after transection.9 It
is unclear why the sensation more commonly
returns (usually manifesting as pain) in patients
with trigeminal neuralgia as opposed to those who
have undergone surgical repair for nerve damage,
where the outcome is often unpredictable (9, 20).
As a result, an overall failure rate of 36% and 74%
has been reported at the end of the first and fourth
years post-neurectomy.17
Therefore, various attempts have been made to
block peripheral nerve regeneration in such cases,
using materials such as gold foil, silver plugs, bone,
fat, bone wax, plexiglass, rubber, sterile wood
points, silastic plugs, silicone rubber, steel screws
and amalgam to obliterate the canal or foramen
where nerves were alvused.9 , 10, 18, 19, 21-23 Bone wax
was among the more popular material used as
reported by several authors.23-25
Hong-Sai found that titanium screws were useful
to obliterate various maxillofacial foramina as they
are biocompatible and were technically easy to
use10 Obliterat [ۈو H