What types of surgical interventions are used 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

The success rate varies according to the experience of the surgeon or the anesthesiologist, and, therefore, surgical correction should be performed only by experienced surgeons. Surgical therapy can be divided into procedures on the nerve or gasserian ganglion (external or percutaneous, usually performed by pain management specialists) and on the nerve root (open skull surgery called microvascular decompression and performed by neurosurgeons, and gamma-knife radiation performed by radiation therapists).

Three operative strategies now prevail: percutaneous procedures, gamma knife surgery (GSK), and microvascular decompression (MVD). Ninety percent of patients are pain-free immediately or soon after any of the operations, [2] although the relief is much more long-lasting with microvascular decompression. Percutaneous surgeries make sense for older patients with medically unresponsive trigeminal neuralgia. Younger patients and those expected to do well under general anesthesia should first consider microvascular decompression—presently, this is the most cost-effective surgery although it is also more invasive.

Pain-free intervals after percutaneous procedures (percutaneous retrogasserian glycerol rhizotomy [PRGR] and percutaneous balloon microcompression [PBM]) last 1.5-2 years, 3-4 years after another (percutaneous radiofrequency trigeminal gangliolysis [PRTG]), and 15 years commonly after microvascular decompression. [52] Those in whom the first percutaneous procedure fails may undergo a repeat procedure, which usually provides relief.

More recently, however, posterior fossa exploration has frequently revealed some structural cause for neuralgia (despite normal findings on computed tomography [CT] scans, magnetic resonance images [MRI], or arteriograms), such as an anomalous artery or vein impinging on the trigeminal nerve root. In such cases, simple decompression and separation of the anomalous vessel from the nerve root produces lasting relief of symptoms.

In elderly patients with limited life expectancy, radiofrequency rhizotomy is sometimes preferred, as it is easy to perform, has few complications, and provides symptomatic relief for a period.


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