Trigeminal neuralgia is one of the most painful and debilitating nerve disorders you can encounter. While many patients find success through medical management using a variety of medications, some cases are simply too complex or intractable for this approach. When that happens, a variety of surgical procedures should be considered.
The right treatment for trigeminal neuralgia will depend upon your overall health and the specifics of your case, including what options have already been exhausted.
1. Microvascular Decompression
Microvascular decompression is often considered the first choice treatment for trigeminal neuralgia because it boasts a very high success rate with limited risk of symptom recurrence. This procedure is typically performed on patients whose radiological imaging shows clear impingement on the trigeminal nerve by a vein or blood vessel. It is, however, an invasive surgical technique, and so you must be carefully screened before it is designated the optimal choice. You must be healthy enough overall to both undergo anesthesia, and withstand and recover from a major surgical event.
During microvascular decompression, you will be fully sedated. Your neurosurgeon will create a round opening into the back of your skull, and will use real-time imaging to carefully locate the site of the impingement. Then he or she will place a surgical sponge between the nerve and impinging vessel, effectively ending the disruption along the nerve line. A piece of titanium will be used to close your skull and your scalp will be carefully stitched back into place.
After microvascular decompression, you’ll be carefully monitored first in post-op and later in the ICU. This is a precaution, due to the extreme sensitivity of surgery involving your head. Once you’ve stepped down to a regular hospital room, you’ll be encouraged to sit up, stand up and begin taking nutrition orally again.
After several days, you’ll be released to return home, where your complete recovery may last several weeks or longer. Although this may sound very intense or extreme, microvascular decompression has the highest rate of success as a surgical treatment for trigeminal neuralgia.
2. Gamma Knife Radiosurgery
Gamma Knife Radiosurgery is technically not a surgery — it’s not an invasive procedure, but rather the strategic use of radiation to reduce or eliminate the pain caused by trigeminal neuralgia. If you are not a good candidate for microvascular decompression because of your health, or because clear impingement has not been imaged, this will be the next option you and your neurosurgeon will discuss.
During Gamma Knife Radiosurgery, your head will be fixed within a headframe. This is to ensure that your involuntary movements do not harm the accuracy of the radiation that will be used. Using imaging, your neurosurgeon and a team of radiation specialists will locate the target area against which several beams of radiation will be applied. At this time, the correct dosage of radiation will also be calculated. The radiation will destroy a portion of the trigeminal nerve, working over time to greatly reduce, or completely eliminate, the transmission of pain.
After your Gamma Knife Radiosurgery, you’ll likely be able to go home once you’ve been observed in post-op for a short period of time. The full effect of the radiation may take several weeks to reach optimal results, but your overall physical recovery time will be brief. You and your doctor will work together to begin lowering your reliance on medication as the radiation’s results take effect.
3. Percutaneous Rhizotomy
Percutaneous rhizotomy involves the application of heat through a very small electrode against the portion of your trigeminal nerve where your pain is originating. This is a minimally invasive procedure, which you may be better suited to undergo if you are not a good candidate for either microvascular decompression or Gamma Knife Radiosurgery.
During percutaneous rhizotomy, you’ll first be sedated. Your neurosurgeon will begin by threading a thin needle — actually, an electrode disguised as a needle — into your cheek on the side of your face where your trigeminal neuralgia originates. You’ll then be briefly woken to work with your surgeon to find the correct spot from which your pain is emanating. Once this location is determined, you’ll be sedated again. Then, heat will be transmitted to destroy that portion of the nerve line and disrupt the future transmission of pain.
Depending on your health, you may remain in the hospital for a day or two following percutaneous rhizotomy, or you may be released faster if you are ready and able. As you begin to recover, you might notice that you’re left with a numb spot on your face, near where you originally felt great pain. In many cases, this numbness wears off over time. Some patients do, however, report longer-lasting numbness. Fortunately, this is far less life-disrupting than your former trigeminal neuralgia pain.
4. Pain Stimulator Implant
The last line of surgical treatment for trigeminal neuralgia is the implantation of a pain stimulator. This is never a frontline approach; rather, it is used if other techniques have failed to provide optimal results. A pain stimulator sends signals down the trigeminal nerve line, confusing it from sending further pain signals to your brain.
Implanting a pain stimulator happens in two steps: First, a temporary one will be embedded to determine if it is effective in reducing your pain. If it is, you’ll next be implanted with a permanent stimulator that can provide long-lasting results.
After your pain stimulator is embedded, you and your doctor will work to step down your medication dosages as the stimulator works to become effective. The stimulator can be tuned over time to provide an accurate response to your trigeminal neuralgia.