Trigeminal Neuralgia
Trigeminal neuralgia is a severe pain syndrome that is most often due to a blood vessel compressing the trigeminal nerve where it originates from the brain in an area called the cerebellopontine angle. The attacks of Trigeminal Neuralgia can be spontaneous or provoked by even mild stimulation of the face. Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50.
The pain from Trigeminal Neuralgia is debilitating and severely impairs the patient’s ability to function. The condition causes episodes of intense, shooting pain in the eye, lips, nose, scalp, forehead, cheek or jaw. Often initially misdiagnosed as a dental problem or temporomandibular joint (TMJ) disorder, many patients with Trigeminal Neuralgia undergo multiple dental or oral surgeries until ultimately the proper diagnosis is made. Other disorders can also be confused with Trigeminal Neuralgia including Facial Shingles/ Herpes Zoster and Facial Reflex Sympathetic Dystrophy. However a detailed patient history and physical exam can generally distinguish Trigeminal Neuralgia from these other face pain disorders. Other brain disorders can also cause the symptoms of Trigeminal Neuralgia including brain tumors and vascular malformations pressing on the Trigeminal nerve, multiple sclerosis plaques, or strokes in the brain stem. Thus, brain MRI’s are routinely obtained in all patients suspected of having Trigeminal Neuralgia not to look for vascular compression of the Trigeminal Nerve but to exclude other causes for the pain. Currently, three types of Trigeminal Neuralgia are commonly described. The classic form of Trigeminal Neuralgia is called Typical Trigeminal Neuralgia or Trigeminal Neuralgia Type I (TN1). With TN1 the patient has severe stabbing, electrical, jolting, knife-like debilitating facial pain that is paroxysmal, progressive and intermittent. The pain has what are called typical triggers which exacerbate the pain including talking, chewing, brushing teeth, drinking, shaving, washing face, wind in face, and putting on make-up. The second form of Trigeminal Neuralgia is called Atypical Trigeminal Neuralgia or Trigeminal Neuralgia Type II (TN2). With TN2 the patient may have similar symptoms and triggers as TN1 but they also have some qualities not generally seen with TN1. Often these are symptoms of achiness, throbbing or burning pain, constant pain as opposed to intermittent paroxysmal pain, or pain that is improved with activities that commonly exacerbated TN1 pain. The last form of Trigeminal Neuralgia is in patients with Multiple Sclerosis called by some as Symptomatic Trigeminal Neuralgia. These patients can have either TN1 or TN2 characteristics but the most common cause of the pain is due to demyelinating plaques involving the trigeminal tracts and not compression of the nerve by a blood vessel. A small percent of patients with Trigeminal pain and multiple sclerosis will respond to traditional Trigeminal Neuralgia treatments, but many will continue to have severe pain in spite of the various treatments.
At Florida Hospital, our neurosurgeons have extensive experience in managing all forms of Trigeminal Neuralgia and offer a multipronged approach to attack the pain using various surgical and non-surgical options. These options include surgical microscopic microvascular decompression, minimally invasive endoscopic microvascular decompression, various trigeminal rhizotomies, Gamma Knife Radiosurgery, and drug therapies.
In patients who are healthy enough to tolerate surgery, microvascular decompression has shown to be the most effective long-term treatment for Trigeminal Neuralgia. A microscopic, microvascular decompression involves a 3 to 5 hour surgery and 2-4 day hospitalization. The procedure is performed via a small 2-3 inch opening behind the ear where a small retractor is placed to create a channel between the cerebellum of the brain and the petrous temporal bone of the skull. A microscope is then used to identify the Trigeminal nerve and specially designed instruments are used to separate any vessels (arteries or veins) compressing the nerve. All microvascular decompression cases utilize intraoperative neurophysiological monitoring to minimize the risk of neurological injury. A small piece of Teflon felt is placed between the vessel and nerve to cushion and protect the nerve from additional compression by the vessel. The retractor is then removed and the wound is closed. Most patients awaken from surgery with their Trigeminal pain gone and many resume their regular activities 2-4 weeks after surgery.
Over the past five years, Florida Hospital neurosurgeons have also been performing endoscopic microvascular decompressions as an alternative to the microscopic approach for many patients. With this approach a 1-1 ½ inch opening is placed behind the ear and a 4-mm high-definition or 3D endoscope is advanced along a corridor between the brain and skull often with no retractors necessary. The surgeon then visualizes the Trigeminal nerve and uses specialized endoscopic microdissecting instruments to separate any compressive vessels (arteries and veins) from the nerve. A small piece of Teflon felt is placed between the offending vessel and the nerve to cushion and protect the nerve from additional vascular compression. The surgeon then advances the endoscope behind the nerve and uses angled lenses to ensure that no other compressive vessels are hiding in corners that can result in persistent pain if missed and not decompressed. Once satisfied that the Trigeminal nerve has no more vascular compression, the endoscope is removed and the wound is closed. The duration of surgery is approximately 3 hours and most patients remain in the hospital 1-3 days. 90% of patients undergoing an endoscopic microvascular decompression with Typical Trigeminal Neuralgia (TN1) at Florida Hospital awaken with their Trigeminal pain gone and without recurrence during their follow-up period.
In patients who are not surgical candidates or for those who do not wish to consider the surgical options, Florida Hospital physicians can offer Gamma Knife as a non-invasive, non-surgical highly effective alternative. With Gamma Knife, patients arrive to the Gamma Knife Center early in the morning undergo placement of a stereotactic cranial frame with twilight sedation and then use 3D computer assisted navigation to aim 201 beams of focused Gamma Knife Radiation. A highly precise 4mm beam is focused to the junction of where the nerve is most commonly compressed by blood vessels of the brain. The treatment itself generally takes 30-60 minutes and patients return home and resume their regular activities later that day. Many patients notice the Gamma Knife taking affect 8-16 weeks after the treatment with improved pain control, but may notice additional improvement up to 9 months after the treatment is complete.
In some cases, Trigeminal rhizotomies are offered to patients as a treatment option for their pain. These procedures are done with mild sedation and require the physician to place a fine needle in the cheek and direct the needle under x-ray fluoroscopic guidance to the base of the skull where the Trigeminal nerve exits to enter the face. Using various techniques of either radiofrequency thermal ablation, glycerol ablation, alcohol ablation, or balloon compression ablation the nerve is then treated creating varying degrees of facial numbness while at the same time often controlling or removing the pain. These procedures often taken approximately 1 hour and most patients go home later that day or the next morning. Patients resume their regular activities within 1 week of the procedure.
Finally, medicinal therapy is also offered to patients who have not already attempted this option. Drugs such as Tegretol, Neurontin, Elavil, Lyrica, and Baclofen have varying degrees of success. 90% of patients with Typical Trigeminal Neuralgia (TN1) initially respond to medicinal therapy, although breakthrough bouts of pain or intolerable side-affects are common with prolonged use. Many patients can be adequately managed for 2-7 years before requiring other Trigeminal Neuralgia treatments.
Because our physicians at Florida Hospital offer all the treatment options available for patients with Trigeminal Neuralgia, we can offer hope to many patients with this disabling pain disorder when other treatments have failed. At Florida Hospital Neuroscience Institute, highly trained specialists from Neurology and Neurosurgery work together and use their skills and extensive experience with the latest diagnostic tools to determine the most appropriate treatment for patients.
To learn more about trigeminal neuralgia and our treatment options, contact us.