Trigeminal neuralgia is an eminently treatable condition.
The first line of therapy consists of medications such as Carbamazepine and Gabapetin. In most cases, medical treatment is effective.
If medical treatment fails or is limited by significant side effects, we have good surgical options for patients with trigeminal neuralgia. Surgery is usually ineffective for atypical trigeminal neuralgia.
Microvascular Decompression - surgery through the skull, which removes or insulates the responsible blood vessel(s) using microsurgery - is an effective method of treating many people with this disorder. This is done under general anaesthesia. After the operation, the majority of patients have no facial numbness and are pain-free, requiring no further medications. It is a major operation, and is not without danger. Most of the serious and life-threatening complications have occurred in patients above 65-70 years of age. It is less effective for patients who have had other operations in the past.
Percutaneous Radiofrequency Gangliotomy uses a special needle inserted in the face and radiofrequency-generated heat energy to selectively damage the preganglionic trigeminal rootlets in Meckel's cave. It is carried out in the awake patient and requires his co-operation and accurate feedback for proper positioning of the needle. It causes irreversible facial numbness. Precise control of the extent of the lesion is not always possible. Abnormal, unpleasant sensations of itching, burning or crawling (20% patients) can accompany facial numbness. When severe (0.3%), they are as distressing to the patient as their original pain, since they can be present continuously as a severe burning discomfort (anaesthesia dolorosa or analgesia dolorosa) which does not respond to treatment. Loss of feeling in the first Trigeminal division makes the cornea insensate, and leaves the patient at risk for corneal ulceration and can lead to loss of vision.
Percutaneous Glycerol Chemoneurolysis is also carried out using a needle inserted in the face and can be performed under general anaesthesia. There is usually only mild sensory loss and rare oculomotor or dysesthetic sequelae. Of course, it has the same risks of meningitis and needle misdirection injury as any percutaneous technique. Compared with radiofrequency gangliotomy, the pain recurrence rate is higher, but this is not a significant disadvantage, as the procedure can be easily repeated and is well tolerated.
Gamma Knife Radiosurgery i.e. radiation treatment performed without opening the skull, using intense gamma rays directed at the Trigeminal nerve root, has been carried out recently. However long-term data comparable to that reported for other procedures is lacking. Reports so far have considered 50-90% reduction of pain as good and 10-50% as fair. No pathologic data is available regarding the immediate and long-term effects of high dose radiation (70-90 gy) to the nerve adjacent to the brain stem.
The choice of operation depends on the patient's age, associated illness and assessment of the risks he is willing to assume. For most "younger" patients, microvascular decompression is the best option. Younger patients have a better chance of tolerating surgery without complications, and a longer future life expectancy in which to deal with problems that can follow percutaneous lesioning. They also have a higher risk of pain recurrence following such procedures and will likely need more future treatments resulting in an increased cumulative side-effects.
Older patients (>65-70 years of age) have increased risks of surgical complications. But because of shorter overall life expectancy, they likely will require fewer repetitions of percutaneous procedures with less cumulative denervation sequelae. Significant associated illness such as chronic obstructive pulmonary disease, coronary artery disease and diabetes mellitus can also increase the risks of such major surgery.