SURGICAL TREATMENTS
FOR FACIAL NEURALGIAS

Disclaimer.

| Nerve Blocks | Neurotomy | Rhizotomy |
Microvascular Decompression | Neurostimulation | Experimental |

A special caveat must be made about this section: the terminology may be confusing and confused. The medical jargon in the field of neurosurgery is complicated (and occasionally inconsistent) such that it can be difficult for  non-professionals to understand. Please read these pages with a skeptical mind.

Surgical treatments are generally attempted only when drug treatments are not effective or there are serious side-effects. According to the Trigeminal Neuralgia Association, there are five surgical treatments that are commonly used to treat trigeminal neuralgia and some related facial neuralgias.

• Microvascular Decompression
• Balloon Compression
• Radiofrequency Rhizotomy
• Glycerol Rhizotomy
• Radiosurgery  (using the Gamma Knife or Linac)

Neurostimulation is a newer treatment that is being used to treat difficult-to-treat facial pain and is one of the few treatments that may help anesthesia dolorosa.

In many cases, the five standard surgical procedures are not as successful for atypical trigeminal neuralgia or for atypical facial pain and can actually make the pain worse. Thus, it is important to identify whether a condition is "atypical."  One way is by looking at the effectiveness of Tegretol.  If tegretol relieves the pain, at least in the beginning, the condition is considered to be typical TN.  If the pain is constant or has a burning component, the condition could have atypical features.

As with most procedures, these surgeries have risks, can be expensive and in some cases, can aggravate a condition. In all of the above procedures, pain can recur afterwards. 

Several recent studies analyze the effectiveness and safety of surgical procedures for trigeminal neuralgia.

Taha et al. - Analyzes the five-year effectiveness of some of the surgical treatments.

Taha and Tew - Summarizes reported results for ten years of medical literature on neurosurgery outcomes for eight types of face pain:

Jannetta et. al. - The Long-Term Outcome of Microvascular Decompression for Trigeminal Neuralgia 

Deciding on Surgery

There is major disagreement as to which treatment is the "best." TN and some related facial neuralgias respond to all of the above surgical procedures but none of them works for everyone. 

When making a decision about surgery and on which procedure, you should ask your doctors questions about  the different procedures and about their experience with these procedures. Some questions you might want to ask are: 

• What studies have been done on the procedure?
• What are possible complications?
• How safe is the procedure
• What is a realistic success rate?
• How many procedures has the surgeon performed? Does he or she perform the procedure often? 

The surgeon's skill often makes the difference in what surgical procedures the patient is offered. If surgeons do not have success with a certain procedure, they tend not to offer it as a option to the patient.  

For an excellent overview of surgical options, see The UK Trigeminal Neuralgia Association's webpage: Considering Surgery for TN,

Drs. John F. Alksne, MD and Jeffrey P. Harris, MD, PhD of the UC San Diego Cranial  Nerves Disorder Program have an interesting take on how to determine which surgical procedure is appropriate based on the life expectancy of the patient. See their discussion at: Trigeminal Neuralgia  

Non-Destructive Surgical Treatments: Nerve Blocks

Although not strictly surgical procedures, nerve blocks are most appropriately included in this section. In a nerve block, the nerve is anesthetized with a local anesthetic. When repeated several times, nerve blocks may give long-time relief.

Nerve blocks.

Neurotomy

The term neurotomy refers to the cutting of the nerve to prevent pain signals from traveling along it. This treatment does not have a very good long-term track record because of the scarring it can result in. It appears to be going out of fashion.

Neurotomy

Gangliolytic Surgical Treatments (Rhizotomy)

The term gangliolysis or rhizotomy refers to a small lesioning of the nerve. The effectiveness of this technique lies in the fact that pain-carrying nerves are damaged more easily than are other nerve fibers. Therefore, pain relief may be attained without disturbing numbness of the face.

A rhizotomy has some of the same problems as a neurotomy, but to a much lesser extent. In the best case, the lesion blocks the pain impulse and causes pain relief without side effects. However, a frequent side effect is partial or total numbness of the affected side of the face. One major problem is that these methods sometimes require cutting open the skin, causing a possibility of disfigurement. On the other hand, these procedures are far less dangerous than major surgery such as MVD.

Several different methods have been used. The neurolytic block is the oldest, and rarely used today. RFT and RFL are more commonly used. The gamma knife operation is expensive, but similar in principle. Balloon decompression is also occasionally used.

Neurolytic Block ( Glycerol / Alcohol Injection ).

Radiofrequency Lesioning/Thermocoagulation (RFL/RFT).

Balloon rhizotomy ( Balloon Decompression ).

Gamma Knife Operation.

Microvascular Surgical Treatments

Some cases of TN appear to be caused by a small blood vessel constricting the trigeminal nerve near its root. These cases can often be effectively treated by MVD, an operation in which the blood vessel is carefully separated from the nerve. MVD is a major and difficult surgical operation, with all the risks involved in an operation. It is thus rarely if ever a first-choice treatment.

Microvascular decompression ( MVD )

Neurostimulation

Neurostimulation is a medical treatment for people suffering from chronic pain, including Trigeminal Neuralgia and other facial neuralgias. A small device, much like a pacemaker delivers low voltage electrical stimulation to the spinal cord or targeted peripheral nerve to block the sensation of pain. Once experimental, this treatment is being used more often to treat intractable facial pain. 

Neurostimulation

Experimental Surgical Treatments

A few experimental surgical-type treatments have been suggested.

    NICO Surgery