Medication management is always the first line of treatment for trigeminal neuralgia. Patients who continue to experience pain despite the best medical management will be evaluated for surgery. Our surgeons offer a variety of surgical approaches, listed below.
Microvascular decompression (MVD), also known as the Janetta procedure, is the most common surgical procedure for treating trigeminal neuralgia. In the procedure, the surgeon makes a small incision behind the ear and drills a small hole in the skull. Using microscopic visualization, the trigeminal nerve is exposed. In most cases, there is a blood vessel — typically an artery, but sometimes a vein — compressing the trigeminal nerve. By moving this blood vessel away from the nerve and interposing a padding made of Teflon felt, the pain is nearly always relieved.
While MVD is considered to be the most invasive surgery for trigeminal neuralgia, it is also the best procedure for fixing the underlying problem: vascular compression. MVD also causes the least damage to the trigeminal nerve and provides, on average, the longest pain-free periods and the best chance of being permanently off medication. MVD has a long-term success rate of approximately 80 percent as a stand-alone treatment. The procedure requires an average hospital stay of two to three days, and four to six weeks to return to normal daily activities.
MVD is a major surgery, and includes craniotomy, cutting a small hole in the skull. Typical surgical risks for any open-skull neurosurgical procedure include infection, excessive bleeding, spinal fluid leakage, and risks of anesthesia. Rare neurological injury can include damage to hearing, vascular injury (stroke), and, very rarely, death.
Gamma Knife is the least invasive surgical option for trigeminal neuralgia. In fact, it is technically not surgery at all. The Gamma Knife is a device that delivers precise, controlled beams of radiation to targets inside the skull, including the brain and associated nerves. For trigeminal neuralgia treatment, the radiation beams are aimed at the trigeminal nerve where it enters the brainstem.
Gamma Knife treatment does not target the root cause of trigeminal neuralgia, but instead damages the trigeminal nerve to stop the transmission of pain signals. The procedure requires little or no anesthesia, and is performed on an outpatient basis.
This procedure provides significant pain control or reduction in approximately 80 percent or more of patients, but response is usually slower than for other treatments. Patients usually respond within four to six weeks post-treatment, but some patients require as much as three to eight months for the full response. Most patients remain on full doses of medication for at least three months after treatment.
Side effects may include tingling or numbness in the face, seen in up to 20 percent of patients. If it does occur, it is usually quite mild.
This is a good option for severe pain in high-risk patients, such as patients with an additional illness that would make an open surgical procedure too dangerous. It is also a good option for patients with multiple sclerosis (MS), whose trigeminal neuralgia often is not caused by vascular compression.
Like Gamma Knife treatment, radiofrequency rhizotomy does not treat the root cause of trigeminal neuralgia, but instead damages the trigeminal nerve to stop the transmission of pain signals. In the procedure, an electrode inserted through the cheek is used to heat the nerve and cause selective damage to stop pain signals from traveling to the brain.
The treatment provides immediate pain relief in up to 90 percent of patients. It does cause more facial numbness than the other procedures. Forty percent of patients will experience pain recurrence two to three years post-surgery. If necessary, the procedure can be repeated.
Radiofrequency rhizotomy is less invasive, less risky, and requires less time in the hospital than MVD. However, it also carries a greater risk of minor to severe post-surgical numbness, which can often be permanent, in addition to the risk of pain recurrence. This procedure also carries the rare general surgical risks of infection and excessive bleeding, as well as excessive nerve injury, corneal numbness, anesthesia dolorosa and intracranial hemorrhage.
Reviewed by health care specialists at UCSF Medical Center.
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