In Reply: Tobacco Use and Trigeminal Neuralgia: Clinical Features and Outcome After Microvascular Decompression

To the Editor: We appreciate the detailed letter to the editor1 regarding our article, “Tobacco Use and Trigeminal Neuralgia: Clinical Features and Outcome After Microvascular Decompression.”2 The insights shared are valuable and contribute to an important dialogue on the impact of tobacco use in trigeminal neuralgia treatment. We acknowledge the concerns about the variability in pain assessment methods. We agree that an outcome scale like the Barrow Neurological Institute (BNI) Pain Intensity Score may have been useful to report our results in a more nuanced and standardized way; however, the outcome of pain-free off-medication (corresponding to BNI 1) is a widely used benchmark for evaluating success after trigeminal neuralgia surgery. We agree that longitudinal data about smoking habits—specifically, the timing and duration of cessation—would be helpful to obtain a full understanding of their impact on surgical outcomes. We did monitor whether smokers had quit at least 6 months before surgery, but recent discontinuation (within a month) may indeed add a component of withdrawal that could affect outcomes, which was not captured in our retrospective analysis. Likewise, we were not able to control for comorbid psychiatric conditions or other unrecorded variables that may have affected the outcome. These are all important considerations that should be examined in future work. Finally, we recognize the importance of exploring the biological mechanisms by which smoking may influence trigeminal neuralgia. The role of microvascular changes in the trigeminal nerve myelination offers a potential pathophysiologic explanation for the impact of tobacco. An investigation examining this relationship in an animal model would be useful but is outside the scope of this retrospective investigation. In summary, we concur with many of the future investigations pointed out in the letter to the editor and hope to address these in future work. The relationship between tobacco use and outcome after surgical treatment of trigeminal neuralgia is an important area of research that deserves attention.