Trigeminal Neuralgia
Surgery
There are several effective surgeries for trigeminal neuralgia (TN). The surgery that your neurosurgeon recommends will depend on a number of factors. Some of these include your age, general medical condition, life expectancy and past surgeries for TN. You also have a choice of operations. Ask your neurosurgeon to explain the different procedures that are available along with the risks and benefits of each. The following is a list of surgical treatment of TN:
MVD is a surgery in which a surgeon will move compressing blood vessels away from your trigeminal nerve. You will have general anesthesia during surgery. A small incision (cut) is made behind your ear, and a small opening is made in the skull bone. Your surgeon will use a high-powered microscope and other tools to remove the pressure from your trigeminal nerve. He or she will place a small piece of sponge-like padding between an artery and nerve to keep them apart. If the compression is caused by veins, they are coagulated and cut.
In most people, pain relief is immediate and medications can be decreased over a period of a few weeks. MVD often provides pain relief that lasts many years.
Percutaneous "Needle" Procedures
Three different procedures can be done using a needle. All of these are called “ablative procedures,” or procedures that destroy nerve fibers. These procedures can give short-term pain relief ranging up to a few years.
During each procedure, you will have an intravenous line (IV) to receive medications that will keep you pain-free and comfortable. A special needle is inserted through the skin outside the corner of your mouth and into a small opening in the base of your skull (the foramen ovale). Once the needle has been placed, the proper position is checked with an x-ray. Your neurosurgeon will injure specific areas of the trigeminal nerve with medicine, heat or a balloon device. This should cause you to feel numbness instead of pain.
This is an outpatient procedure in which relatively high doses of radiation are delivered to very specific areas of the brain without hurting surrounding tissues. This type of therapy has been used for a number of years to treat certain types of brain tumors. More recently it has been used in some patients with TN. For the treatment of TN, the radiation is focused on the trigeminal root entry zone or “REZ.”
For the procedure, a metal structure called a “stereotactic frame” is attached to your head. A helmet is then placed over the frame. An MRI scan is done to find the REZ. The MRI is then fed into a special computer that points a small, powerful beam of radiation at the REZ. This type of surgery may be referred to as gamma knife, linear accelerator (LINAC) or cyber knife surgery. Once the treatment is finished, the frame is removed and you can go home.
Radiosurgery for TN is a relatively new therapy compared to MVD and percutaneous procedures. Therefore, there is not as much information about the long-term results with this treatment. Radiosurgery is less invasive than the other surgeries and less likely to cause facial numbness. However, there is often a delay between the treatment and the time when pain relief occurs. This can be as short as several days but may take as long as several weeks or a few months.
This is a less common procedure than MVD. It may be done if you have little to no compression of your trigeminal nerve, or if MVD is an unsafe surgery for you. Like MVD, this is called an “open” surgery because an opening is made in your skull and the trigeminal nerve is exposed. This surgery has similar risks and complications to MVD.
Peripheral Branch Neurectomy
During this procedure, a neurosurgeon will excise (cut) one or more parts of the trigeminal nerve branch(es). A neurectomy is most often done in outpatient setting with local anesthesia. This procedure will cut the nerve pathways and replace your pain with numbness. Your pain may return over time.
Medical Illustration by R. Annie Gough, CMI © 2008, All Rights Reserved
- Microvascular decompression (MVD)
- Percutaneous procedures
- Stereotactic radiosurgery
- Open partial sensory rhizotomy
- Peripheral branch neurectomy
Microvascular Decompression (MVD)
MVD is a surgery in which a surgeon will move compressing blood vessels away from your trigeminal nerve. You will have general anesthesia during surgery. A small incision (cut) is made behind your ear, and a small opening is made in the skull bone. Your surgeon will use a high-powered microscope and other tools to remove the pressure from your trigeminal nerve. He or she will place a small piece of sponge-like padding between an artery and nerve to keep them apart. If the compression is caused by veins, they are coagulated and cut.
In most people, pain relief is immediate and medications can be decreased over a period of a few weeks. MVD often provides pain relief that lasts many years.
Percutaneous "Needle" Procedures
Three different procedures can be done using a needle. All of these are called “ablative procedures,” or procedures that destroy nerve fibers. These procedures can give short-term pain relief ranging up to a few years. - Percutaneous radiofrequency (RF) trigeminal gangliolysis (PRFTG) – This surgery is usually done as an outpatient procedure. You will be given medicine to make you sleep while the needle is inserted. Once the needle is in place, the medicine will wear off and you will be fully awake.
Your neurosurgeon will heat specific areas of the trigeminal nerve with energy similar to microwaves. He or she will try to create enough numbness so the tip of a safety pin no longer feels sharp or just barely feels sharp. It is usually possible to limit the numbness to a specific area. However sometimes, the numbness can spread to other areas of your face. Although this procedure causes numbness, it does not cause any weakness of the face. After PRFTG, your face should continue to move normally.
- Percutaneous glycerol rhizolysis – During this procedure, a medication called glycerol is injected around the trigeminal nerve. Like PRFTG, it is usually an outpatient procedure. You will be asleep while the needle is inserted. Once the needle is in the proper place, you will be allowed to awaken and sit up. Your neurosurgeon will inject a small amount of contrast dye to learn how much glycerol to use. You may feel a twinge of pain as the neurosurgeon slowly injects the glycerol. This usually decreases and goes away over a few minutes. After the injection, you must sit in a bent-over position for about two hours to allow the medicine to work.
- Percutaneous trigeminal balloon compression – Unlike PRFTG or glycerol rhizolysis, this procedure is done while you are under general anesthesia. Once again, a special needle is inserted and positioned just in the foramen ovale. A small balloon-tipped catheter is then inserted through the needle and inflated for a period of about one minute. This can sometimes cause a decreased heart rate and/or blood pressure. For this reason, an external pacemaker is sometimes used along with medications that can raise blood pressure and heart rate. The balloon and needle are then removed, and you will be allowed to recover from the anesthesia before being discharged.
Stereotactic Radiosurgery
This is an outpatient procedure in which relatively high doses of radiation are delivered to very specific areas of the brain without hurting surrounding tissues. This type of therapy has been used for a number of years to treat certain types of brain tumors. More recently it has been used in some patients with TN. For the treatment of TN, the radiation is focused on the trigeminal root entry zone or “REZ.”
For the procedure, a metal structure called a “stereotactic frame” is attached to your head. A helmet is then placed over the frame. An MRI scan is done to find the REZ. The MRI is then fed into a special computer that points a small, powerful beam of radiation at the REZ. This type of surgery may be referred to as gamma knife, linear accelerator (LINAC) or cyber knife surgery. Once the treatment is finished, the frame is removed and you can go home.
Radiosurgery for TN is a relatively new therapy compared to MVD and percutaneous procedures. Therefore, there is not as much information about the long-term results with this treatment. Radiosurgery is less invasive than the other surgeries and less likely to cause facial numbness. However, there is often a delay between the treatment and the time when pain relief occurs. This can be as short as several days but may take as long as several weeks or a few months.
Open Partial Sensory Rhizotomy
This is a less common procedure than MVD. It may be done if you have little to no compression of your trigeminal nerve, or if MVD is an unsafe surgery for you. Like MVD, this is called an “open” surgery because an opening is made in your skull and the trigeminal nerve is exposed. This surgery has similar risks and complications to MVD.
Peripheral Branch Neurectomy
During this procedure, a neurosurgeon will excise (cut) one or more parts of the trigeminal nerve branch(es). A neurectomy is most often done in outpatient setting with local anesthesia. This procedure will cut the nerve pathways and replace your pain with numbness. Your pain may return over time.
Medical Illustration by R. Annie Gough, CMI © 2008, All Rights Reserved