The Changing Face of Trigeminal Neuralgia

A Narrative Review

Stine Maarbjerg MD, PhD; Rafael Benoliel BDS (Hons)


Headache. 2021;61(6):817-837. 

In This Article

Central Procedures

Percutaneous Trigeminal Rhizotomy

Three techniques are available: radiofrequency, glycerol injection, and balloon compression. The basis of these techniques is that controlled heat (69–90°C), a neurotoxin or ischemic and mechanical pressure, respectively, will damage trigeminal neurons. Advantages to percutaneous techniques include shorter procedure duration and minimal anesthesia risk. A recent pooled analysis revealed that 55%–80% of patients are pain free at 4–11 years after balloon compression, 26%–82% after radiofrequency thermocoagulation, and 19%–58% after glycerol injection.[57] Initial pain relief (around 90%) across these is approximately equal, but each one is associated with different rates of recurrence and complications.[194–199]

With the large difference in success rates reported across centers for the same procedures, it is hard to unequivocally recommend a superior intervention. Radiofrequency thermocoagulation reaches high rates of pain relief but is associated with high frequencies of facial and corneal numbness.[200] Radiofrequency does allow for somatotopic nerve mapping and selective division lesioning.[198] Multiple treatments not only improve outcomes but also increase morbidity. Balloon compression is similar in outcomes with potentially high, long-term success rates.[57] Glycerol injection offers similar pain-free outcomes, but complication rates have been reported as higher (25% vs. 16%)[198] and lower (11% vs. 23%)[201] compared with balloon compression. Median time to recurrence was 21 months for the balloon procedure and 16 months for the glycerol procedure.[201] In summary, data suggest that these procedures may be dependent on patient selection and/or may be surgeon sensitive.