Trigeminal Neuralgia

Trigeminal neuralgia may also be referred to by its historical name, tic doloureux. The incidence of this disorder is four cases per 100,000 people per year. It is characterized by a sharp, lancinating pain involving a portion of one side of the face. It may be associated with trigger points on the skin, gum or teeth that can reproduce the pain. Often patients may be forced to not wash a portion of their face, or shave an area owing to fear of triggering the pain.

This discomfort can be severe and associated with suicidal thoughts. It does not respond well to typical prescription pain medications. Often patients attribute the discomfort to a dental disorder. It is not unusual for patients to have one or more teeth extracted in the course of trying to eradicate the pain.

The cause of this disorder is believed to be the presence of a loop of a small blood vessel that is touching the trigeminal nerve near the brainstem. The vessel transmits pulsations to the weak point in the insulating sheath of the nerve fibers and allows short-circuiting to occur, sometimes referred to as electrical cross-talk or ephaptic transmission. If this point of contact between the nerve and the vessel can be eradicated, the pain will frequently go away.

There are certain medications that can be effective. These include medications in the anticonvulsant category such as Tegretol, Neurontin and Lyrica. Sometimes Baclofen can be used. Sometimes, the medication is required at very high dosage and this can be associated with side effects of severe drowsiness. Sometimes, the medication ceases to be effective with prolonged use. This can lead to consideration of surgical treatments.

The most effective treatment that is directed at the cause of the disorder is posterior fossa microvascular decompression. This procedure was historically proposed by Dr. Gardner and was popularized in the microsurgical era by Dr. Jannetta at the University of Pittsburgh. Dr. Stechison formerly practiced at the University of Pittsburgh with Dr. Janetta and brings his expertise in the surgical management of trigeminal neuralgia to Atlanta and the Brain and Spine Institute.

This procedure of microvascular decompression involves making an incision that is usually about two inches long and located behind the ear. A small area of bone, the size of a quarter, is removed and the cerebellar portion of the brain slightly retracted to allow exposure of the trigeminal nerve as it enters the brainstem. Using the operating microscope, the tiny blood vessel is microsurgically dissected and moved away from its point of contact with the nerve. A small piece of Teflon felt is inserted between the vessel and the nerve to keep them separated. The incision is closed.

Generally, patients will wake up and feel that the pain is better. In many cases they will be able to be weaned off the medications that they were taking to treat the pain. A small percentage of patients might need to remain on a very low dose. Most patients will be in the hospital for one or two nights postoperatively.