General Comments about Surgery:
Surgeries for TN tend to be recommended primarily for patients who have “Classic” or “Type 1”, also called “Typical” TN.
Some surgeons may get good results with atypical (also called “Type 2”) pain , however, the positive effects of surgery tend to be greater and more consistent for typical TN than for atypical TN.Surgeons use the terms “invasive” and “non-invasive”
When referring to surgical procedures, the term “invasive” relates to how much actual tissue, bone, etc. is removed or disturbed during the surgery. However, you must not be lulled into believing that a surgery called “non-invasive” has fewer possible negative side effects. All brain surgery is significant, and may result in negative side effects that you want to understand and consider before making your decision on whether or not to proceed.Do not feel pressured into making a quick decision for surgery.
Always seek a second opinion, perhaps even a third opinion. When it comes to the brain, the consequences are large enough that it is worth taking the time to make the best decision, even if it means living in pain for a bit longer.You are likely to get the best “bang for your buck” with whatever you choose as your first surgical procedure.
Second and following procedures tend to be less successful than a first procedure of the same type -- while also increasing the possibility of surgery-related side effects such as nerve damage and numbness. So, take your time to make your first surgical decision, using all of the information resources you can find.Become familiar with the possible risks or negative side effects of surgery.
Although surgical results are improving all the time, it is important to recognize that all of the present options have the potential for serious negative side effects. A friend, whom I’ll call “Anne” found herself shocked and dismayed when she suffered an ill effect as the result of surgery. I hope you will gain from her experience:New YorkTN patient
Note: "Dysesthesia" refers to unpleasant sensations, such as burning, a creepy-crawly sensation, or severe itching, caused by lesions on nerves.
Most Common Surgical Options for the Treatment of Facial Pain
Microvascular Decompression (MVD)
MVD is presently the only surgery which actually attempts to get at the cause of TN, by isolating the intruding vessels/arteries which are compressing the nerve and causing problems. “If the patient is healthy overall, and is a good surgical candidate in general, the MVD offers the best chance at long-term pain reduction for ‘Classic’ or ‘Type 1’ TN,” according to Dr. Mark Linskey, a neurosurgeon at the Irvine Medical Center through the University of California.
MVD is “invasive” surgery, however. The surgeon must cut a small hole through your skull behind your ear to hunt down intruding vessels/arteries that are causing the problems. The nerve is isolated by placing a cushion (often a tiny shredded piece of Teflon) between it and nearby blood vessels, to keep them separated. The procedure does not, however, cut into the brain itself.
MVD’s require top-notch surgeons because of their delicacy. I suggest that you try to find a surgeon who has performed at least 200 of them, and who continues to perform them several times each month. As a friend who has helped me with some of the editing of this site has phrased it, “the last thing you need is to be on the front end of a doctor's learning curve!”.
This is the only surgery that does not cause any destruction to the nerve itself, and that also allows the surgeon to visualize the nerve to see what compressions exist, if any.
If you have a MVD, you may be in the operating room for 3 to 5 hours, and in the hospital for 3 to 4 days. Once home, you may need help for about a week, as you will likely be on pain medication and also will need to spend most of your time resting.
Other cranial nerves, located near the trigeminal nerve may be impacted negatively from the surgery, causing a temporary impairment in function such as a feeling of fullness in their ears, or double vision. In rare cases, patients have experienced loss of hearing and vision as the result of surgery.
It is not unusual for patients who undergo MVD’s to travel great distances in order to get the surgeon with whom they feel most confident. If you decide to travel for this purpose, you will likely need someone to assist you in getting home.
MVD’’s may “wear off” over time. (Some neurosurgeons explain this by saying that our brains, just like the rest of our bodies, “sag” as we age, causing new vascular compressions.) Some surgeons will perform a second MVD if pain recurs. Only a few doctors are comfortable performing a third MVD because of increased risks and reduced likelihood of success.
Patients who have arterial compressions may tend to fare better over the long[]term, as arteries seem to be less likely to “grow” back following surgery; whereas veins may form collateral vessels that may wrap themselves around the nerve [] later.
Glycerol Rhizotomy (GR) and Radiofrequency Lesioning (RL)
The purpose of both the GR and a RL is to damage the trigeminal nerve at just the right place and to just the right degree to reduce the ability of the nerve to transmit TN pain. Both kinds of rhizotomy are called “per-cutaneous” procedures (through the skin).
See Wikipedia: http://en.wikipedia.org/wiki/Percutaneous.
Rhizotomy is often an out-patient procedure. A long needle is carefully threaded through the skin and bones of the cheek and into an interior cavity of the skull where the trigeminal nerve divides into its three branches. The nerve is then damaged (lesioned) either by injecting glycerol (a form of alcohol) or applying high heat into the ganglion (junction) of the nerve.
It should be noted that the two forms of Rhizotomy may have significantly different outcomes over time. The positive effects of GR tend to wear off more quickly, with many patients reporting that the procedure may be effective only for a few months to two years. The outcomes of RL are much longer-lasting, with a higher initial success rate. Some published papers indicate that the initial results and long-term success rate for Radio Frequency Rhizotomy may be comparable to those of MVD.
The procedure takes about 45 minutes to an hour typically. Most patients will wake up with an awful head-ache running like a band horizontally across their forehead. The headache usually goes away within a few hours and patients will usually find a few days of rest is sufficient for recovery.
This procedure may be an option for people who are not good candidates for MVD’s due to their age or health conditions, as it is less invasive.
These procedures may be repeated as long as a patient has not had a significant negative side effect.
These procedures may have a higher chance of causing new facial pain such as burning, tingling, or “creepy crawling” sensations, than MVD. This is believed to occur because the surgeon may inadvertently strike and damage a branch of the trigeminal nerve when pushing the needle through the patient’s cheek.
Balloon Compression (BC) Also called Balloon Gangliolysis or Percutaneous Microcompression
Like GR and RL, this procedure is done through the cheek, however with a larger needle which inserts a tiny balloon into the ganglion of the trigeminal nerve. The balloon’s purpose is to squeeze the nerve against bone and tissue, damaging it just enough to disrupt the pain signals.
Good to Know:
Like the GR, and RL, Balloon Compression can be done on an outpatient basis and may be performed on patients who are not good candidates for the MVD due to age, medical history, and health risks.
BC rarely results in burning or “creepy crawly” pain that is sometimes experienced with GR or RL.
BC may be particularly worth considering if you have pain in your upper (V1) branch since it does not have as great a chance of causing eye problems as does the GR.
May be repeated if the pain comes back, with about 1 in 4 patients having a return of pain within the first three years [Editorial Note: further outcomes research pending]
Judi Notes:
Never feel pressured to make a surgical decision right away. As bad as your pain might be in the moment, it will most likely ease at least partially in a few days to weeks, as all pain has natural cycles. Take time to get a second opinion; talk with your family about the pros and cons; check out the resources mentioned on this site. Pray.
Gamma Knife (GK) (Also called Stereotactic Radiosurgery)
GK does not involve a “knife” at all, but instead it uses gamma radiation administered from multiple directions against a small target area of the brain. The patient lies down in the GK machine, which looks much like a machine used to perform a MRI (Magnetic Resonance Imaging). The desired outcome is for the gamma rays add up in the target area, with sufficient intensity to form a lesion in the nerve at just the right location to stop the pain transmission, while minimizing damage to surrounding areas of the brain.May be done on an out-patient basis, usually taking from 1 to 3 hours. Patients will most likely want to rest up at home for about three days.
Patients may wake up with an awful head-ache, running like a horizontal band across your forehead—similar to headaches produced by other surgeries-- which usually lasts only a few hours.
Like other surgeries summarized above, people who have other health issues and cannot undergo a MVD, may be candidates for the GK.
GK does not usually provide immediate relief, as the radiation needs to “grow” a lesion in order to kill pain cells. It may take from two to six weeks to experience a reduction in pain.
The radiation from GK may cause negative side effects including: brain tumors, teeth or tissue damage, or other unknown effects. [Editorial Note: further outcomes research pending]
This procedure is relatively new as compared with the previous ones discussed. Long-term effects are still being established. However, it now appears that long term outcomes for GK may not be as successful as was initially anticipated by advocates of the procedure.
Motor Cortex Stimulation (MCS)
MCS is somewhat analogous to pacemaker technology, utilizing a pace-maker-like device to deliver low voltage electrical stimulation to the motor cortex area of the brain, with the intention of manipulating or stimulating neural circuits, resulting in lessened pain. In the surgery, the skull is opened, so that electrodes can be placed on the “dura” (the leather-like membrane covering of the brain) over the area of the motor cortex region, which regulates many of the senses. These electrodes are then guided through the neck and attached to a pulse generator, placed somewhere below the collarbone. The electrodes are monitored regularly to assure proper placement and the pulse generator can be adjusted, according to the need for pain coverage.Judi Notes:
MCS is a new procedure that the facial pain community watches with great hopes, as more neurosurgeons and patients test and evaluate it. We particularly hope it will become a more viable and affordable option for those who suffer from constant atypical-type pain who suffer on a daily basis. Hats off to physicians and researchers who are dedicated to helping the men and women who fall into the “atypical pain” and “hard to treat” category!
This is emerging surgery, with only a handful of neurosurgeons actively performing surgery.
It is very expensive because it is still regarded as “experimental”, and less likely to be covered by insurance than other surgical procedures.
It is less invasive than a MVD, since the surgeon does not need to cut through the “dura” (the leather-like covering of the brain” but instead, places electrodes on the surface of the dura.
It may require a double surgical procedure; first a temporary placement of the electrodes, followed by a later permanent placement.
This surgery may require more frequent follow up with the surgeon than the other surgeries.
It is reversible, as the electrodes can be removed.
Surgical Summary:
Surgeries for treating facial pain, have come a long, long way. If medication is not sufficient, and/or if you and your family have carefully researched your options, and understand all the pros and cons of the different procedures; and if you are a good surgical candidate and if you have good reason to have confidence in the ability of your surgeon, who says you are likely to receive good outcomes from surgery, then surgery may offer you many years of effective pain management. Please check out TNA’s website for current research on surgery at www.endthepain.org.
Also, “google” provides lots of useful information on surgical research. For example, today as I wrote this, I googled “mvd vs other surgeries for tn research,” and came upon this article which may interest you: It was published by Dr. Ronald Brisman at the Columbia University Medical Center, New York NY and compares MVD with GK: Click here to see article
