Trigeminal Neuralgia Treatment
Trigeminal neuralgia is a severe and often debilitating disorder in which patients suddenly experience extreme facial pain. Unlike other types of facial pain, trigeminal neuralgia usually begins spontaneously without warning. It causes sudden shock-like pains in the face, usually starting in one area and spreading to other areas. Certain actions can elicit this pain, such as chewing or talking movements, wind brushing against the face, or certain positions. It often starts with infrequent episodes that typically become more frequent. Some patients can go into remission for long periods, with pain resolving spontaneously for months or years. If the pain returns, it is often more frequent and severe than before. Trigeminal neuralgia most often is believed to be due to an artery pressing on the nerve that controls sensation to the face (the trigeminal nerve) near where it enters the brain. Some medications can be helpful, particularly anti-epileptic medications or anti-depressant medications, since these quiet down hyperactive nerves and dull pain signals from the trigeminal nerve.
Dental work can cause facial pain that is not trigeminal neuralgia. On occasion, however, dental patients can have true trigeminal neuralgia, which was not yet symptomatic and yet brought on following dental work. Other diseases, such as multiple sclerosis and some tumors, can cause facial pain, which can occur as well following radiation therapy to the head or neck. It is important to distinguish classical trigeminal neuralgia from more atypical facial pain conditions, since surgical intervention has a high success rate for classical trigeminal neuralgia but is rarely effective for atypical conditions.
If the patient has been diagnosed with classical trigeminal neuralgia, and does not have an adequate response to the appropriate medications or cannot tolerate these medications, then surgery may be a good option if the pain is severe and is limiting activities of normal life.
There are three general types of surgical procedures, all of which are offered at Weill Cornell.
Microvascular DecompressionMicrovascular decompression is an effective microsurgery procedure to reposition a blood vessel pressing on or irritating a cranial nerve. The procedure allows the surgeon to visualize the exact location where the pressure is occurring. There may be more than one blood vessel pressing on the nerve and all should be located. Once the area of compression is located, the blood vessel(s) is separated from the nerve and a small pad is placed on the nerve to prevent further contact. Most studies indicate this procedure provides the best long-term maintenance of pain relief, since it directly addresses the source of the problem. Microvascular decompression can be effective in the treatment of:
- Trigeminal neuralgia
- Hemifacial spasm
Weill Cornell neurosurgeons and neurologists are highly skilled in this technique, which has a high success rate when performed by a qualified neurosurgeon. Serious complications are rare, but this is an invasive neurosurgical procedure which will manipulate arteries and nerves at the base of the brain. The most frequent complication is loss of hearing on the same side, but this occurs in fewer than 10% of patients and is typically slight. Facial weakness can also occur and this too is usually temporary. The nerves controlling hearing and facial function are both monitored by expert neurologists during surgery to minimize the risk of permanent injury. On occasion, patients can also experience some numbness in one or more parts of the face following surgery, but this is usually temporary. Some imbalance when walking can also occur in patients immediately following surgery, but usually resolves within one to two weeks.
Stereotactic Radiofrequency Lesion (RFL)
Radiofrequency lesion is another method with a long history of success for patients with trigeminal neuralgia. This is a much less invasive method than microvascular decompression. The procedure is performed in the radiology suite, rather than the operating room. Patients are heavily sedated and a small needle is passed under x-ray guidance until the tip is at the point where the trigeminal nerve enters the face. A radiologist experienced in these procedures assists the neurosurgeon to pinpoint the exact location. A modern advance incorporates a three-dimensional CT scan into the pre-surgical plan, so that the location of the correct spot can be identified in advance, which speeds the procedure and in some cases helps localize the correct spot when it is not readily obvious on the x-ray. After the needle is correctly placed, patients are awakened and a small wire it passed through the needle until it touches the nerve. A low current is then passed through the wire until the patient reports a tingling sensation in the face. When that sensation is in the area of the pain, the wire is properly positioned. Patients are again sedated and a higher current is passed to heat the nerve. The goal is to destroy pain portions of the nerve, which are very sensitive to heat, while preserving the rest of the nerve so that normal sensations (touch, vibration, etc.) can remain intact. Patients are then awakened and tested for sensation. This procedure may be repeated several times until adequate pain relief is obtained.
The short-term results of this procedure are excellent, with approximately 75% of patients having a good or excellent response. Pain relief is usually immediate, although some patients do not achieve full pain control for 24-48 hours after surgery. There is a slightly higher recurrence rate compared to microvascular decompression, but some patients have reported permanent relief of pain for 10 years or more. Since it is a minimally invasive procedure, the risks are fairly low. There is a slight risk of infection as with any surgical procedure. The use of proper radiology methods substantially reduces this slight risk. Patients generally go home within 1-2 hours after this procedure. There can be some facial swelling for one or two days after the procedure. On occasion, patients notice a bit more numbness one or two days after the procedure compared with what they felt during the procedure. This is usually restricted to a small area of the face and often resolves to some degree.
Radiosurgery is the least invasive of the three options. It is the most recent method, so there is less long-term experience with this procedure compared with the others. Some centers report very high success rates with this procedure, and low complications, but both the short and long-term success rates remain somewhat unclear today. The goal is to damage the trigeminal nerve by radiation, without destroying the nerve. This is essentially a non-invasive procedure, in which a stereotactic "frame" is fixed to the patient's head with local anesthesia. This helps focus the radiation on the trigeminal nerve and does not influence other brain structures. As with radiofrequency lesioning, patients go home the same day. Because of the nature of how radiation influences nerves, pain relief may not be achieved for several weeks or months. Because there is no open surgery or invasion of the body in this procedure, it can be a good option for patients who are at high risk for more traditional surgery or for those who require ongoing blood thinners for a heart condition.
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