Trigeminal neuralgia surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There is no cure for trigeminal neuralgia but most people find relief from one of the five surgical options. Surgery may result in varying degrees of numbness to the patient and lead occasionally to "anesthesia dolorosa," which is numbness with intense pain. However, many people do find dramatic relief with minimal side effects from the various surgeries that are now available.[1]

Surgery

Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain signals from getting through to the brain. In trained hands, surgical success rates have been reported at better than 90 percent. Surgical procedures can be separated into non-destructive and destructive.

Non-destructive:

Microvascular compression is the only non-destructive surgical procedure and appears to result in longest pain relief.

Microvascular Decompression

Of the five surgical options, the microvascular decompression is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a 25mm (one-inch) hole behind the ear. The nerve is then explored for an offending blood vessel, and when one is found, the vessel and nerve are separated or decompressed with a small pad. When successful, MVD procedures can give permanent pain relief with little to no facial numbness.

Destructive:

All destructive procedures can cause post surgical facial numbness. These include:

Balloon Compression

Three other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions. Excellent success rates using a cost effective percutaneous surgical procedure known as balloon compression have been reported.[2] This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression.

Glycerol Injections

Similar success rates have been reported with glycerol injections and radiofrequency rhizotomies. Glycerol injections involve injecting an alcohol-like substance into the cavern that bathes the nerve near its junction. This liquid is corrosive to the nerve fibers and can mildly injure the nerve enough to hinder the errant pain signals.

Radiofrequency Rhizotomy

In a radiofrequency rhizotomy, the surgeon uses an electrode to heat the selected division or divisions of the nerve. Done well, this procedure can target the exact regions of the errant pain triggers and disable them with minimal numbness.

Stereotactic Radiation Therapy

The nerve can also be damaged to prevent pain signal transmission using Gamma Knife or a linear accelerator-based radiation therapy (e.g. Novalis, Cyberknife). No incisions are involved in this procedure. It uses radiation to bombard the nerve root, this time targeting the selective damage at the same point where vessel compressions are often found. This option is used especially for those people who are medically unfit for a long general anaesthetic, or who are taking medications for prevention of blood clotting (e.g., warfarin). A prospective Phase I trial performed at Marseille, France, showed that 83% of patients were pain-free at 12 months, with 58% pain-free and off all medications. Side effects were mild, with 6% experiencing mild tingling and 4% experiencing mild numbness.[3]

References

  1. Weigel, G (2004). "Striking Back: The Trigeminal Neuralgia and Face Pain Handbook". Trigeminal Neuralgia Association ISBN 0-9672393-2-X. Unknown parameter |coauthors= ignored (help)
  2. Natarajan, M (2000). "Percutaneous trigeminal ganglion balloon compression: experience in 40 patients". Neurology (Neurological Society of India). 48 (4): 330–2. PMID 11146595.
  3. Régis J, Metellus P, Hayashi M, Roussel P, Donnet A, Bille-Turc F (2006). "Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia". J. Neurosurg. 104 (6): 913–24. PMID 16776335.



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