What is trigeminal neuralgia surgery?

Trigeminal neuralgia surgery is a procedure to decompress the trigeminal nerve that may cause pain and discomfort in the face.
Trigeminal neuralgia surgery is a procedure to decompress the trigeminal nerve that may cause pain and discomfort in the face.

Trigeminal neuralgia surgery is a treatment for facial nerve pain (neuralgia) that is caused by irritation in the trigeminal nerve. The trigeminal nerve has three main branches on each side of the face, which combine as a bundle of nerves (Gasserian ganglion). Trigeminal neuralgia surgery is performed to eliminate the irritation in the nerve when medications are not effective.

Surgical treatment for trigeminal neuralgia is of three types:

  • Microvascular decompression
  • Percutaneous procedures
  • Gamma knife surgery

Microvascular decompression (MVD) procedure

MVD is an open surgery performed by a neurosurgeon with the patient under general anesthesia.

Preparation

The patient may be required to

  • Undergo blood tests.
  • Undergo magnetic resonance imaging (MRI) and/or magnetic resonance angiogram (MRA) of the brain to evaluate blood vessel malformation or blood vessel impingement on the trigeminal nerve.
  • Avoid eating and drinking for eight hours prior to the procedure.
  • Check with the doctor before taking any regular medication.
  • Inform the doctor of any allergies.

Procedure

The anesthesiologist

  • Attaches an IV line and administers general anesthesia.
  • The anesthesiologist monitors the patient’s vital signs during the procedure.

The neurosurgeon 

  • Makes an incision in the skin behind the ear.
  • Makes a 3-cm opening in the skull (craniotomy).
  • Opens and retracts the brain’s membrane (dura) to access the trigeminal nerve.
  • Moves the blood vessel and releases the trapped trigeminal nerve.
  • Places a Teflon sponge between the nerve and the blood vessel.
  • May also cut or destroy a part of the trigeminal neve.
  • Closes the dura with sutures and applies a surgical glue to prevent leakage of cerebrospinal fluid (CSF).
  • May replace the bone piece using surgical glue or use a titanium plate to close the hole in the bone.
  • Closes the incision with sutures.

Post-surgery

  • The patient’s vital signs are monitored in the recovery room.
  • The patient is weaned off the anesthesia and administered painkillers.

Percutaneous trigeminal neuralgia procedures

Percutaneous procedures are usually performed by pain management specialists as an outpatient procedure, using local anesthesia and mild sedation or brief general anesthesia.

  • The patient undergoes blood tests and MRI.
  • The doctor inserts a needle lateral to the corner of the mouth into the Gasserian ganglion, with the guidance of continuous X-ray (fluoroscopy).
  • The doctor may perform one of the following:
    • Pass an electric current through the needle and produce a thermal lesion with the heat, disrupting the pain signals (Percutaneous radiofrequency trigeminal gangliolysis [PRTG] or radiofrequency rhizotomy).
    • Insert a balloon and inflate it for up to 10 minutes to damage the Gasserian ganglion and block the pain signals (Percutaneous balloon decompression [PBM]).
    • Inject glycerol to destroy the nerve’s pain fibers (Percutaneous retrogasserian glycerol rhizotomy [PRGR]).
  • The doctor withdraws the needle and applies a bandage.
  • The patient can leave for home the same day.

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Gamma knife surgery for trigeminal neuralgia

  • Radiation therapists perform the Gamma Knife therapy as an outpatient procedure.
  • A frame is fixed to the head with four pins to keep the head immobile. 
  • A local anesthetic is used at the pin site.
  • The radiologist uses stereotactic MRI for targeting the precise location of the trigeminal nerve where it connects to the brain stem.
  • The radiologist uses the Gamma Knife device to deliver controlled beams of radiation on the point where the trigeminal nerve connects to the brain stem, to block the transmission of pain signals.

What is the recovery time for trigeminal neuralgia surgery?

A microvascular decompression may require up to four days of hospitalization. Most people return to normal activities in about three weeks but may have to avoid strenuous activities for a while longer.

Most people can resume normal activities within two days after percutaneous procedures or a Gamma Knife surgery.

What are the risks and complications of trigeminal neuralgia surgery?

Lack of relief and recurrence of neuralgia are the primary risks with all trigeminal neuralgia treatments. Other complications include:

  • Abnormal facial sensation (facial dysesthesia)
  • Facial numbness
  • New facial pain
  • Loss of sensation in the cornea (corneal anesthesia)
  • Weakness in jaw muscles (masseter weakness)

Microvascular decompression has additional risks that include:

  • Anesthetic side effects such as
  • Surgical risks such as
    • Hemorrhage
    • Blood clots
    • Wound infection
    • Injury to brain stem
    • Injury to a part of the brain (cerebellum)
    • Cerebrospinal fluid leakage
    • Pain in an area that is completely numb to the touch (anesthesia dolorosa)

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Medically Reviewed on 5/14/2020
References
Medscape Medical Reference
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