Benefits of Innovative Enhanced Recovery Protocol After Trigeminal Neuralgia Surgery

A study by researchers with Cleveland Clinic in Florida found that implementation of an enhanced recovery after surgery (ERAS) protocol for patients with trigeminal neuralgia (TN) undergoing microvascular decompression (MVD) significantly reduced hospital length of stay (LOS) and rate of transient postoperative subjective hearing alteration while improving postoperative verbal pain scores reported by patients. The findings were published in the journal Neurosurgery.

The retrospective matched cohort analysis is the first to demonstrate the benefits of a multimodal, evidence-based protocol for MVD, the most common surgical treatment for drug-resistant TN, says senior author Hamid Borghei-Razavi, MD, a board-certified neurosurgeon with the Headache & Facial Pain Center at Cleveland Clinic Weston Hospital and Director of Cleveland Clinic’s Brain Tumor and Pituitary Center in Florida.

Classic trigeminal neuralgia

Trigeminal neuralgia is a chronic neuropathic disorder characterized by recurrent, unilateral, transient electric shock-like facial pains. It is one of the most prevalent facial pain syndromes, and an estimated 15,000 people in the United States are diagnosed with TN each year.

Of the three types of TN – classic, secondary and idiopathic – classic TN (type 1) accounts for about 80% of cases. It is caused by vascular contact on the trigeminal nerve. Pharmacotherapy is usually the first-line treatment, while an estimated 25% to 40% of patients choose surgery within 2 years of symptom onset.

“Microvascular decompression is the most effective and durable treatment for classic trigeminal neuralgia,” states Dr. Borghei-Razavi. “In our experience at Weston Hospital about 90% of patients achieve pain relief and some for as long as 10 years.”

ERAS protocol

The ERAS protocol for patients with typical TN undergoing MVD surgery was first introduced in June 2020 at Weston Hospital, one of the highest volume centers in southeast Florida. It was developed by a multidisciplinary team of neurosurgeons, anesthetists and nurses and consists of nearly a dozen components.

The protocol calls for structured preoperative patient counseling to manage expectations regarding recovery and pain management, with an emphasis on early mobilization. It incorporates multiple opioid-sparing pain management strategies, including administration of a scalp block 20 minutes before the skin incision, the use of total intravenous anesthesia (TIVA), and non-narcotic analgesia options for postoperative pain.

“Our protocol entails the use of smaller incisions and craniotomies and reduced muscle dissection to lessen surgical trauma,” describes Dr. Borghei-Razavi, who helped develop the protocol. “We also conduct immediate postoperative imaging to rule out surgical complications.”

Study design

To determine the impacts of the ERAS protocol, the Cleveland Clinic team looked at patients who received MVD for type 1 TN at Weston Hospital between January 2018 and January 2023. A total of 240 patients were initially included, of whom 65 patients received the ERAS protocol and 175 received conventional perioperative care.

All patients underwent a retrosigmoid craniotomy with muscle flap technique and were admitted to the ICU for one night following surgery for close monitoring. Patients were then either transferred to the general floor or discharged home, depending on their postoperative condition.

“We used one-to-one propensity score matching for the main analysis, which compared 65 patients in the ERAS group to 65 in the control group,” explains Mohammadmahdi Sabahi, MD, MPH, the study’s first author and a Postdoctoral Research Fellow in the Department of Neurosurgery at Cleveland Clinic in Florida. “This was a robust study design that controlled for comorbidities, demographic factors and pre-op verbal pain scores.”

Key findings

The researchers found that ERAS-treated patients had significantly reduced LOS (p< 0.001) compared to the control group with a mean of 1.46 and 2.95 days, respectively. The control group LOS aligns with an analysis of the National Surgical Quality Improvement Program registry (2006–2017), which also found that the mean LOS was 3.0 days among 1,005 patients who underwent MVD.

“Just over half of the ERAS group was discharged after one day and none stayed in the hospital more than two days,” reports Dr. Sabahi. “That is an important benefit for patients and more cost-effective.”

In terms of pain control, the study found ERAS patients had similar postoperative Barrow Neurological Institute (BNI) pain scores to non-ERAS patients, with significantly lower verbal pain scores (p= 0.034). Among patients in the ERAS group who were discharged at 24 hours, a subanalysis found even lower postoperative verbal pain levels (p = 0.003) when compared to non-ERAS patients.

“One of the more unexpected findings was the significantly lower rate of transient postoperative subjective hearing alteration,” Dr. Sabahi notes. No patients in the ERAS group reported experiencing muffled hearing versus 6 patients in the control group (p= 0.028).

“Reduced mastoid air cell opening in ERAS patients may have contributed to lower rates of temporary hearing alterations, which is one of the known complications of posterior fossa surgery,” adds Dr. Borghei-Razavi.

Future ERAS research

ERAS was first developed for colorectal surgery and later adapted for other surgical specialties, including spine surgery. “Our study demonstrates there is broader potential for this approach, which is not commonly used for cranial procedures,” says Dr. Sabahi.

He shared the study’s findings during a podium presentation at the annual meeting of the North American Skull Base Society (NASBS) held this past February in New Orleans.

While the researchers at Cleveland Clinic in Florida acknowledge future large-scale, multicenter randomized controlled trials are needed to further validate the benefits of ERAS protocols in the context of MVD for TN, Dr. Borghei-Razavi says at Cleveland Clinic, it’s the new standard care.

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