Surgical options for Trigeminal Neuralgia

Trigeminal neuralgia is a disease of the nerve of the face called Trigeminal nerve, where the patient
experiences intense pain on one side of the face. Trigeminal nerve is the largest cranial nerve
emerging from the brain. Trigeminal nerve is responsible for carrying sensations like touch, pain,
temperature arising from face to brain. It also helps in biting and chewing by controlling the muscles
involved in these two actions.
Trigeminal neuralgia is a recurring, chronic and extremely painful condition. Patient experiences
sudden bout of extreme pain by mildest of stimuli like slight touch on the face, slight breeze or
brushing the teeth or shaving. It is also known as Prosopalgia. It was formerly known as suicide
disease as patients felt like committing suicide because of the severe pain associated with the
disease.
Treatment options for Trigeminal Neuralgia
This includes
I. Medical treatment: This includes prescribing certain painkillers and muscle relaxants for pain relief.
On a long run medical treatment becomes less effective with considerable side effects of the
prescribed drugs.
II. Surgical treatment: Once medical treatment becomes ineffective, patient of trigeminal neuralgia
has to consider the surgical option. Trigeminal neuralgia surgeries are indicated in patients who
experience the pain despite of the best medical treatment. It is more viable and effective treatment for
trigeminal neuralgia where the medical line of treatment fails to offer any relief. It includes following
methods.
1. Microvascular Decompression (MVD): It is also known as Janetta procedure. It is a type of
open surgery for trigeminal neuralgia wherein a small incision is made into ears and a small
hole in the skull. With the help of microscope the trigeminal nerve is visualized and exposed.
One can see a blood vessel either an artery or nerve compressing and irritating the trigeminal
nerve. This is moved away from the nerve and a small padding is put between the nerve and
the vessel.
MVD is the most effective surgical option for the trigeminal neuralgia. It makes the patient of
trigeminal neuralgia pain free.
Risk involved with MVD: Although MVD is a very effective surgical option for the patients of
trigeminal neuralgia; it has some risk of decreased hearing, double vision, facial numbness
and stroke in the patient.
2. Gamma knife radiosurgery: This is a least invasive surgical option for trigeminal neuralgia.
Technically, we cannot term it as a surgery as no incisions are taken on the patients body for
this procedure.
Gamma knife is a device with which a surgeon directs a focused, precise and controlled dose
of radiation to the root of trigeminal nerve where it enters the brainstem.

It damages the trigeminal nerve itself so that the nerve is unable to carry any painful stimuli.
This procedure is done on outpatient basis. And it successfully eliminates pain in most
patients.
If the pain recurs, the doctor can repeat the same procedure.
This is a risk free, nonsurgical option. So it is widely used for the patients of trigeminal
neuralgia.
Risk involved in Gamma Knife surgery: Mild tingling and numbness on the face is the only side
effect produced by Gamma Knife surgery.
3. Rhizotomy: It is a neurosurgical procedure where the nerve fibers causing facial numbness
are destroyed by the surgeon. There are different ways of doing Rhizotomy.
Glycerol injections: In this procedure the doctor inserts a needle or a tube through the
cheeks and it is guided up to the Gasserian ganglion (a point from where the trigeminal
nerve divides into three branches.) and a small amount of glycerol is injected which
damages the nerve and thus blocks the signals of any kind of pain.
Balloon compression: The trigeminal nerve is damaged by inflating the balloon with
enough pressure.
Radiofrequency thermal lesioning: In this procedure the Gasserian ganglion is
heated and damaged with the help of a mild electric current passing through the tip of
an electrode.
Above procedures are aimed at damaging the trigeminal nerve itself which is unable to carry any
painful stimuli to the brain. The patient can go home same day after undergoing the above
procedures.
This is all about the surgical ways of managing Trigeminal neuralgia. The surgical procedures do
carry some risk of side effects like numbness of the face, bleeding, difficulty in moving the facial
muscles.

What is trigeminal neuralgia? What causes trigeminal neuralgia?

Trigeminal Neuralgia, also known as Tic Douloureaux, is a nerve disorder that causes abrupt,
searing, electric-shock-like facial pains, most commonly the pain involves the lower face and jaw, but
symptoms may appear near the nose, ears, eyes or lips. Many experts say trigeminal neuralgia is the
most unbearably painful human condition.
Neuralgia is severe pain along the course of a nerve. The pain occurs because of a change in
neurological structure or function due to irritation or damage of a nerve.
Approximately 1 in every 15,000 people is estimated to suffer from trigeminal neuralgia. About 45,000
people have trigeminal neuralgia in the USA. It is thought to affect about one million people
worldwide.

Two main types of pain, nociceptive and non-nociceptive pain

An example of nociceptive pain is when something very hot touches your skin; specific pain receptors
sense the heat. Nociceptive pain is when pain receptors sense temperature, vibration, stretch, and
chemicals released from damaged cells.
Non-nociceptive pain, or neuropathic pain, comes from within the nervous system itself. The pain is
not related to activation of pain receptor cells in any part of the body. People often refer to it as
pinched nerve, or trapped nerve. The nerve itself is sending pain messages either because it is faulty
(damaged) or irritated. People with neuralgia have neuropathic pain (same meaning as nonnociceptive pain).
People with neuralgia describe it as intense burning or stabbing pain, which often feels as if it is
shooting along the course of the affected nerve. There are two types of neuralgia - Trigeminal
Neuralgia and Postherpetic Neuralgia. This article focuses on Trigeminal Neuralgia.

Description of trigeminal neuralgia (also called tic douloureux)

There is sudden and severe facial nerve pain. Patients typically describe it as a stabbing, shooting
pain; like an electric-shock-like facial pain. Bouts of pain can last a few minutes. 97% of patients
experience pain just on one side of the face, while 3% are affected on both sides.
Trigeminal neuralgia is twice as common in women as in men. It is extremely rare for people under 40
to be affected, and becomes slightly more common as people get older.
Trigeminal neuralgia is a long-term condition - a chronic condition - which usually gets gradually
worse.

What are the causes of trigeminal neuralgia?

The human face has two trigeminal nerves, one on each side. Each nerve splits into three branches
which transmit sensations of pain and touch from the face, mouth, and teeth to the brain.
Most cases of trigeminal neuralgia are believed to be caused by blood vessels pressing on the root of
the trigeminal nerve. This is said to make the nerve transmit pain signals which are experienced as

the stabbing pains of trigeminal neuralgia. However, experts are not completely sure of the cause.
Pressure on the trigeminal nerve may also be caused by a tumor or multiple sclerosis.
Below is a list of known and suspected causes:

A blood vessel presses against the root of the trigeminal nerve.

Multiple sclerosis - due to demyelinization of the nerve. Trigeminal neuralgia typically appears
in the advanced stages of multiple sclerosis.
A tumor presses against the trigeminal nerve. This is a rare cause.
Physical damage to the nerve - this may be the result of injury, a dental or surgical procedure,
or infection.
Family history (genes, inherited) - 4.1% of patients with unilateral trigeminal neuralgia (affects
just one side of the face) and 17% of those with bilateral trigeminal neuralgia (affects both
sides of the face) have close relatives with the disorder. Compared to a 1 in 15,000 risk in the
general population, 4.1% and 17% indicate that inheritance is probably a factor.

What are the symptoms of trigeminal neuralgia?

Typically, a patient will have one or more of these symptoms:

Intermittent twinges of mild pain.

Severe episodes of searing, shooting, jabbing pain that feel like electric shocks.
Sudden attacks of pain which are triggered by touching the face, chewing, speaking or
brushing teeth.
Spasms of pain which last from a couple of seconds to a couple of minutes.
Episodes of cluster attacks which may go on for days, weeks, months, and in some cases
longer. There may be periods without any pain.
Pain wherever the trigeminal nerve and its branches may reach, including the forehead, eyes,
lips, gums, teeth, jaw and cheek.
Pain which affects one side of the face.
Pain on both sides of the face (much less common).
Pain that is focused in one spot or spreads in a wider pattern.
Attacks of pain which occur more regularly and intensely over time.
Tingling or numbness in the face before pain develops.

Some patients may experience bouts of pain regularly for days, weeks or months at a time. Attacks of
pain may occur hundreds of times each day in severe cases. Some patients may have periods
without any symptoms which last for months or even years.
Some patients will have specific points on their face that if touched trigger attacks of pain. It is not
uncommon for many patients to avoid potential triggering activities, such as eating, brushing their
teeth, shaving, and even talking.

Area of pain
The area of pain can be broken down into the three branches of the trigeminal nerve. In medicine the
trigeminal nerve is known as the fifth cranial nerve. It is often referred to using the Roman numeral
'V'. Below are the three branches broken down - 'V' refers to the trigeminal nerve:

V1, ophthalmic, the first branch of the trigeminal nerve.

Affects the forehead, nose and eye.
V2, maxillary, the second branch of the trigeminal nerve.
the lower eyelid, side of nose, cheek, gum, lip, and upper teeth.
V3, mandibular, the third branch of the trigeminal nerve.
Affects the jaw, lower teeth, gum, and lower lip.

Some people with trigeminal neuralgia may have just one branch affected, while others are affected
by more branches.
The pain felt by people with Typical Trigeminal Neuralgia differs from what people with Atypical
Trigeminal Neuralgia experience:

Typical trigeminal neuralgia pain (Typical facial pain)

Pain is extremely sharp, throbbing, and electric-shock-like. There is no facial weakness or

numbness.

Atypical trigeminal neuralgia pain (Atypical facial pain - ATFP)

As well as extremely sharp, throbbing, and electric-shock-like, patients may experience other
types of pain. Their condition does not have just the hallmark symptoms of classic trigeminal
neuralgia pain. Facial pain is often described as burning, aching or cramping. It may occur on
one side of the face, often in the region of the trigeminal nerve and can extend into the upper
neck or back of the scalp. The pain can fluctuate in intensity from mild aching to a crushing or
burning sensation. It is much harder to diagnose people with Atypical Trigeminal Neuralgia.

How is trigeminal neuralgia diagnosed?

If the GP (general practitioner, primary care physician) believes the symptoms indicate trigeminal
neuralgia the patient's face will be examined more carefully to determine exactly which parts are
affected. The doctor will also attempt to eliminate other conditions which sometimes have similar
symptoms, such as tooth decay, a tumor, or sinusitis.
MRI (magnetic resonance imaging scan) - this device uses a strong magnetic field and radio waves to
create images of the inside of the patient's brain and the trigeminal nerve - it can help the doctor
determine whether the neuralgia is caused by another condition, such as multiple sclerosis or a
tumor. Unless a tumor or multiple sclerosis is the cause, the MRI will rarely reveal why the nerve is
being irritated. It is very difficult to see the blood vessel next to the nerve root, even on a high quality
MRI.

What is the treatment for trigeminal neuralgia?

Medications are typically the first treatment for trigeminal neuralgia, and most patients respond well
and require no subsequent surgery. However, some may find that their medications become less
effective over time, or they experience undesirable side effects. In such cases injections and/or
surgery may be required.
Medications
These medications lessen or block the pain signals sent to the brain.

Anticonvulsants - normal painkillers, such as Tylenol (paracetamol) do not relieve the pain in
trigeminal neuralgia, so doctors prescribe anticonvulsant medication. Although these
medications are used to prevent seizures (epilepsy), they are effective in calming down nerve
impulses, which helps people with neuralgia.
The most common anticonvulsants for trigeminal neuralgia are carbamazepine (Tegretol,
Carbatrol), phenytoin (Dilantin, Phenytek) and oxcarbazepine (Trileptal). Doctors sometimes
prescribe lamotrigine (Lamictal) or gabapentin (Neurontin).
Sometimes the anticonvulsant begins to lose its effectiveness over time. If this happens the
doctor may either up the dosage or switch to another anticonvulsant.
Side effects of anticonvulsants include:

Dizziness
Confusion
Drowsiness
Vision problems
Nausea

Suicidal thoughts - some studies indicate anticonvulsants may be linked to suicidal thoughts in
some cases. The patient and doctor should monitor mood closely.
Carbamazepine allergy - some patients, especially those of Asian ancestry, may have a
serious drug reaction to Carbamazepine. Genetic testing may be recommended beforehand.

Antispasticity agents - Baclofen is a muscle-relaxing agent which is sometimes prescribed

on its own, or together with Carbamazepine or Phenytoin. Some patients may experience
nausea, drowsiness and confusion as side effects.
Alcohol injection - this numbs the affected areas of the face and provides temporary pain
relief. The doctor injects alcohol into the part of the face where the trigeminal nerve branch is
causing the pain. As pain relief is only temporary, the patient may either require further
injections or a change of treatment later on.

Surgery for trigeminal neuralgia

Surgery for trigeminal neuralgia has two aims:
1. To stop a vein or artery from pressing against the trigeminal nerve.
2. To damage the trigeminal nerve so that the uncontrolled (random, chaotic) pain signals stop.
Surgery that damages the nerve may cause temporary or even permanent facial numbness.

In many cases surgery helps, but symptoms may return months or even years later. Surgical options
for trigeminal neuralgia include:

Microvascular decompression (MVD) - this involves relocating or removing the blood vessel
which is pressing against the trigeminal nerve - at its root - and separating the nerve root and
blood vessels.
The surgeon makes a small incision behind the ear on the same side of the head where the
pain is. A small hole is made in the skull and the brain is lifted, exposing the trigeminal nerve. A
pad is placed between arteries that touch the nerve and the nerve - effectively redirecting them
away from the nerve.
If the surgeon finds no blood vessels pressing against the nerve, the nerve may be severed
instead.
MVD has a good success rate at eliminating or significantly reducing pain. However, in some
cases pain may recur.
MVD carries a very small risk of some hearing loss, facial weakness, facial numbness, and
double vision. There is an extremely small risk of stroke, and even death.

Percutaneous glycerol rhizotomy (PGR) - also called glycerol injection. A needle is inserted
through the face and into an opening at the base of the skull. Imaging guides the needle to
where the three branches of the trigeminal nerve join and a small amount of sterile glycerol is
injected. Within a few hours the trigeminal nerve is damaged and the pain signals are blocked.
Most people experience significant pain relief with PGR. However, there are cases of later
recurrences of pain. Many patients experience facial tingling or numbness.

PBCTN (percutaneous balloon compression of the trigeminal nerve) - a hollow needle is

inserted through the face and into an opening in the base of the skull. A catheter (thin flexible
tube) with a balloon at the end goes through the hollow of the needle. The balloon is inflated.
The pressure from the balloon damages the nerve and blocks pain signals.
PBCTN is effective in treating pain for patients with trigeminal neuralgia. In some cases the
pain comes back later. Most patients experience some facial numbness, and over half
experience temporary or permanent weakness of the muscles used for chewing.

PSRTR (Percutaneous stereotactic radiofrequency thermal rhizotomy) - this procedure

uses electric currents to destroy specifically selected nerve fibers linked to pain. First the
patient is sedated. Then, a hollow needle is inserted through the face into an opening in the
skull. An electrode goes through the hollow of the needle to the nerve root. The patient is then
awakened from sedation so that he/she can tell the doctor when electric currents are felt - the
patient will have a tingling sensation. This helps the doctor locate the part of the nerve involved
in pain. When the doctor has found it the patient is sedated again. The electrode heats up and
damages the targeted nerve fibers - these are known as lesions. The doctor carries on doing
this, adding more lesions if necessary, until pain is eliminated.
Most patients undergoing PSRTR will experience some facial numbness afterwards.

PSR (partial sensory rhizotomy) - part of the trigeminal nerve at the base of the brain is
severed (cut). The doctor makes an incision behind the ear, makes a small hole in the skull,
and severs the nerve. As the base of the nerve is severed the patient will have permanent
facial numbness. Sometimes the doctor rubs the nerve instead of severing it.

GKR (gamma-knife radiosurgery) - a high dose of radiation is aimed at the root of the
trigeminal nerve. This results in nerve damage, which eliminates or reduces the pain. As the
damage from radiation is gradual, the patient will experience slowly improving pain relief over
several weeks. Initial benefits may take several weeks to appear.
GKR is effective for most patients, however some may experience recurrence of pain later on.