Definition

Trigeminal neuralgia (TGN), sometimes called tic douloureux, is a chronic pain condition that causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long as 2 minutes per episode. The intensity of pain can be physically and mentally incapacitating. TGN is a disorder of the fifth cranial (trigeminal) nerve that causes episodes of intense, stabbing, electric shock-like pain in the areas of the face where the branches of the nerve are distributed - lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw. TGN pain is typically felt on one side of the jaw or cheek. Episodes can last for days, weeks, or months at a time and then disappear for months or years. The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), tooth brushing, eating, drinking, talking, or being exposed to the wind, heat or cold. TGN occurs most often in people over age 50, but it can occur at any age, and is more common in women than in men.

Treatments

There are several surgical interventions available to treat TGN. Procedures include both ablative and non-ablative procedures. Ablative procedures are designed to injure or partially destroy the Trigeminal nerve, thereby lessening the transmission of pain impulses. These procedures are "minimally invasive" in their use of radiation, chemicals, electricity, or compression to ablate the nerve. Non-ablative procedures spare function of the nerve and address the primary cause of trigeminal neuralgia, vascular compression. For the ablative procedure some degree of facial numbness is expected. TGN has a high recurrence rate. The main advantage of the ablative procedures is that they can be performed with minimally invasive access to the nerve.

Microvascular decompression (MVD) is a non-ablative technique performed by Dr Joshua Bederson, Professor and Chairman of the neurosurgery department. The procedure is performed under general anesthesia and leaves the trigeminal nerve intact. The cause of pain is addressed by carefully displacing the compressing artery or vein away from the nerve and protecting the nerve with a Teflon sponge to prevent recurrence.

Microvascular decompression (MVD) is the most invasive of all surgical treatment for TGN, but it also offers the lowest probability that pain will return. The nerve is left intact. Dr. Joshua Bederson, Director of Cerebrovascular Surgery at Icahn School of Medicine, has had excellent success in a carefully selected population of patients with TGN using MVD. The operation is performed under general anesthesia. A small opening is made in the back of the skull on the side with the pain. The trigeminal nerve is viewed with a microscope and the compressing blood vessels are moved. The nerve is then padded with a soft pad (typically shredded Teflon).

It is important to first rule out any possible underlying causes of the pain (multiple sclerosis, tumor, infections, etc.). Post-herpetic neuralgia & cluster headaches can mimic the pain of TGN and are unlikely to be relieved by MVD. Good candidates for MVD are patients who meet the following criteria:

  • pain is on one side of the face only
  • an initial, if not permanent, response to anticonvulsant therapy was experienced
  • pain follows the distribution of the trigeminal nerve
  • patient is pain free between episodes

Although patients generally try less invasive treatments prior to open surgery, one consideration when medical or complementary interventions have failed is that the ablative procedures increase the risk of complications if MVD ultimately becomes necessary. Of course, any surgery involves risks, such as infection, bleeding, and more serious complications, but fortunately, the risks associated with MVD are quite low, as the brain itself is not manipulated during the surgery. A good diagnostic self-test can be found on https://neurosurgery.ohsu.edu/tgn.php. If you think you have TGN, feel free to call us to schedule a consultation.

Joshua B. Bederson, M.D.
5 East 98th Street, 7th Floor
New York, NY 10029
Tel: 212-241-2377
Fax: 212-241-7388

Some of the information contained in this article was adapted from:
http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/trigeminal_neuralgia.htm.