Trigeminal neuralgia – Know your treatment options
Facial pain can come in a variety of forms. People use many different words to describe their facial pain like “stabbing”, “electrical”, and “sharp”. Many patients have facial pain that comes in short bursts with episodes lasting for just a few seconds. Unfortunately, the facial pain can often be set off by some very regular activities such as talking, eating, or brushing your teeth. These basic activities are often called facial pain “triggers” and are avoided at all costs when people have trigeminal neuralgia.
At first blush, patients think they have a tooth problem (cavity) or a jaw problem (TMJ) and seek out the advice of a dentist or an oral surgeon. Other times people think they have a headache or a nerve problem and seek out the guidance of a Pain Management specialist or a Neurologist. Hopefully, the correct diagnosis of trigeminal neuralgia can be made by these specialists before patients try invasive procedures such as tooth extraction or pain injections.
After consulting with a facial pain expert, people are often given the diagnosis of trigeminal neuralgia. At this early stage of their journey, most patients are started on first-line oral medications like tegretol or trileptal.
Treating facial pain successfully always starts with making the correct diagnosis. In the early stages of making a diagnosis, many patients are worked up for multiple sclerosis or other potential causes for facial pain. Oftentimes, an MRI scan of the brain is ordered looking for primary causes of the pain such as a tumor or multiple sclerosis (MS). More often than not, the MRI scan does not show a tumor or MS, but does show the presence of a “normal” blood vessel touching or compressing a cranial nerve, like the trigeminal nerve (5th cranial nerve).
At first blush, patients think they have a tooth problem (cavity) or a jaw problem (TMJ) and seek out the advice of a dentist or an oral surgeon. Other times people think they have a headache or a nerve problem and seek out the guidance of a Pain Management specialist or a Neurologist. Hopefully, the correct diagnosis of trigeminal neuralgia can be made by these specialists before patients try invasive procedures such as tooth extraction or pain injections.
After consulting with a facial pain expert, people are often given the diagnosis of trigeminal neuralgia. At this early stage of their journey, most patients are started on first-line oral medications like tegretol or trileptal.
Treating facial pain successfully always starts with making the correct diagnosis. In the early stages of making a diagnosis, many patients are worked up for multiple sclerosis or other potential causes for facial pain. Oftentimes, an MRI scan of the brain is ordered looking for primary causes of the pain such as a tumor or multiple sclerosis (MS). More often than not, the MRI scan does not show a tumor or MS, but does show the presence of a “normal” blood vessel touching or compressing a cranial nerve, like the trigeminal nerve (5th cranial nerve).
Pain relief is the ultimate goal of treating trigeminal neuralgia.
When medications are started, patients are closely followed to see if they respond favorably or if they develop medication side effects (balance problems, feeling “cloudy”, feeling “off”). Many patients will experience a good amount of pain relief with medications alone. This is wonderful. As long as the pain is well-controlled on medications and the patient is not experiencing side effects, medications might be enough.
Trigeminal Neuralgia Surgery – When medicine fails you
If taking medicine for trigeminal neuralgia fails you, you must understand that very effective surgical options exist. Not every available surgical option is available to every patient, but most of them are safe and effective when performed by an experienced team.
Microvascular decompression surgery or MVD is a surgical procedure designed to create space between the cranial nerve that’s causing pain and the blood vessel that is pushing on the nerve. MVD surgery is a surgical treatment performed under general anesthesia by an experienced team. Patients are fully asleep during this surgical procedure. During an MVD, space between the blood vessel and nerve is created by placing a few small teflon sponges between the cranial nerve and the blood vessel. For trigeminal neuralgia, sponges are placed in between the SCA and the trigeminal nerve using an operative microscope.
MVD surgery is always performed by an experienced neurosurgical team. This team of experts includes a brain surgeon, a neuro-anesthesiologist, neurosurgical surgical “scrub” technicians, operating room nurses and an experienced neurophysiologist. The surgery is performed by first making a small incision behind the ear (on the same side of the pain). Throughout the surgical procedure, patients are kept safe by using special monitoring equipment designed to ensure that functions of the brain and brainstem are protected throughout the surgical procedure. Critical cranial nerves for facial movement, hearing, and swallowing are in play, so an experienced neurosurgical team is critical to preventing hearing loss, facial numbness, or other potential side effects. With an expert team, MVD surgery can be extremely safe and beneficial to patients. Long term, most successful MVD patients remain pain free and off medications.
Gamma Knife Radiosurgery (GKRS) is not traditional surgery. Rather, Gamma Knife Radiosurgery is a minimally invasive form of “stereotactic radiosurgery” used to treat painful nerve disorders like trigeminal neuralgia without a knife. Using highly focused, pin-point radiation, GKRS is an effective way to treat facial pain that has not responded to medications.
GKRS places a focused dose of radiation on the cranial nerve that is causing pain. In the case of trigeminal neuralgia, a small “shot” of radiation is placed on the trigeminal nerve where the blood vessel is touching the nerve. In many cases, this location is on the trigeminal nerve just before the nerve plugs into the brainstem. GKRS is painless and general anesthesia is not required. Patients leave the Gamma Knife facility on the same day of treatment, often before lunch, and have very few restrictions after the procedure is complete.
Long-term, approximately 70-80% of patients experience durable pain relief. Many patients can be pain-free and off medications anywhere from 6-12 weeks after GKRS. Potential complications of GKRS include facial numbness. This can occur in anywhere from 5-10% of patients. Gamma Knife Radiosurgery can be repeated in the future should the facial pain come back long-term.
Percutaneous rhizotomy is a minimally invasive procedure designed to treat facial pain by targeting specific branches of the trigeminal nerve. Again, this procedure is most often reserved for patients who have failed medicine for one reason or another. To perform a percutaneous rhizotomy for trigemnial neuralgia, a needle is passed through the inside of the mouth into the base of the skull using real-time images to guide the needle. Once the needle is next to one of the branches of the trigeminal nerve, the branch is intentionally damaged using either heat (aka, radiofrequency rhizotomy), a chemical (aka, glycerol rhizotomy) or a balloon (aka, balloon compression rhizotomy).
This procedure is often considered when gamma knife radiosurgery and microvascular decompression surgery are not recommended or when other surgical options have failed. Complications of the rhizotomy procedure include facial numbness and anesthesia delorosa.