What is the role of surgery in the treatment of trigeminal neuralgia (TN)?

Updated: Jul 11, 2019
  • Author: Manish K Singh, MD; Chief Editor: Robert A Egan, MD  more...
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Answer

Over time, the drugs used for the treatment of trigeminal neuralgia (TN) often lose effectiveness as patients experience breakthrough pain. For patients in whom medical therapy has failed, surgery is a viable and effective option. According to Dalessio, 25-50% of patients eventually stop responding to drug therapy and require some form of alternative treatment. [28] The clinician then may consider referral to a surgeon for one of the procedures discussed below. Among patients who develop trigeminal neuralgia when younger than 60 years, surgery is the definitive treatment.

Many operations have been offered to patients in recent decades. Local ablation of the peripheral nerve and wide sectioning of the sensory roots largely have been abandoned. In the past, alcohol or phenol injection was given to the affected nerve, with the goal to destroy selective pain fibers. Although it was an easy procedure, the success rate is low, in part because of a low selectivity of effect on the fiber type with this substance; recurrence rates are around 50% at 1 year. Rhizotomy or tractotomy was recommended if pharmacologic treatment was unsuccessful.

In a review of surgical options by Tatli et al, which mostly included microvascular decompression and radiofrequency thermorhizotomy, each surgical technique for treatment of trigeminal neuralgia had merits and limitations. [50] The investigators also found that microvascular decompression provides the highest rate of long-term patient satisfaction with the lowest rate of pain recurrence. [50]

Neurosurgery is generally more helpful in those patients with paroxysmal rather than constant pain and in patients whose pain follows the anatomic distribution of one or more trigeminal distributions rather than being spread diffusely. The various operations often fail after 1 or several years of initial relief. This requires a repeat procedure, often with improved but still incomplete results. Thus, many patients eventually restart pain medication after surgery.

Surgery appears to be less effective for trigeminal neuralgia secondary to multiple sclerosis (MS).

For more information, see the following:

  • International RadioSurgery Association Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Harrisburg, Pa: IRSA; 2009. Harrisburg, Pa: IRSA; 2009. (Radiosurgery practice guideline report; no. 1-03). Available at: http://guideline.gov/content.aspx?id=14309. Accessed April 8, 2011. [51]

  • Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct 7;71(15):1183-90. Available at: http://www.neurology.org/content/71/15/1183.long. Accessed April 8, 2011. [23]


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