Surgery

Surgery is considered when (1) medical therapy fails to adequately control trigeminal neuralgia, (2) patients are unable to tolerate medications’ side-effects, or (3) patients do not like the prospect of being on long-term medications. 

Surgical Options:

A) Ablative (“to destroy a function by application of a noxious substance”) Surgery:

For some unknown reason, when a segment of the trigeminal nerve is “damaged” (by way of “lesioning” or “ablation” applied to it) by a noxious agent, trigeminal neuralgia pain disappears or improves.  There are several surgical means of creating a focal area of “ablation” to the trigeminal nerve, and these include:

Gamma Knife (GK) Radiosurgery –

A single shot, focused radiation targeted to the trigeminal nerve

Balloon Compression Rhizotomy –

Lesioning by way of a mechanical compression to the nerve

Glycerol Rhyzotomy –

Chemical lesioning to the nerve by a type of alcohol

Radiofrequency (RF) Rhizotomy

Thermal (heat) lesioning to the nerve by RF

Long-term success rates:  Glycerol 60%, Gamma Knife 65%, Balloon 67%, RF 75%

Advantages:

Short operative time (15 to 45 minutes)

Avoids general anesthesia, performed under IV sedation/local anesthetic

Good initial pain relief

Same-day procedure and quick recovery

Disadvantages:

Permanent facial numbness – RF 80%, Balloon 50%, Glycerol & GK 30%

Significant pain during surgery (performed without general anesthesia)

Need to repeat procedures due to relatively high pain recurrence rates

      Indications for Ablative Surgery:  (When to proceed with ablative surgery?) 

1. Trigeminal neuralgia patients with MS (multiple sclerosis).
2. Trigeminal neuralgia patients with no clear vascular compression on the preoperative MRI.
3. Trigeminal neuralgia patients with significant medical illnesses which preclude major surgery under general anesthesia.
4. Patient’s personal choice after thorough discussion of all options.
5. Which specific ablative procedure to be done depends on the individual surgeon’s personal experience and choice.

 

B) Non-Ablative Surgery: Microvascular Decompression (MVD)        

The only non-ablative surgical technique available for trigeminal neuralgia patients is microvascular decompression (MVD).

Indications for MVD: 

1. Trigeminal neuralgia patients with clear vascular compression on preoperative MRI.
2. Patients healthy enough to undergo 1 hour of surgery under general anesthesia.
3. Patient’s personal choice after discussion of all treatment options.

Advantages:

High success rate (95% when patients are carefully selected)

Low risk of permanent facial numbness

Minimal complications (when surgeon is experienced)

45-minutes of operative time, avoiding Foley catheter or blood transfusion

Small incision and craniotomy (bone opening)

Fast recovery (1-2 days of hospital stay) 

Disadvantages:

            “Brain surgery” with its associated risks (very small, but present)

            Requires general anesthesia (<1 hour)

Personal Recommendation:  Based on treating trigeminal neuralgia patients for nearly 30 years, my personal recommendation is MVD as it guarantees a high success rate with a low risk of permanent facial numbness.  (95% success rate initially, 75-80%  long-term success rate, <5% permanent numbness)