Facial Pain Clinic

Microvascular decompression (MVD) is a type of brain surgery. This is considered the gold standard surgical treatment for trigeminal neuralgia. Benefits include the fact that it is the only procedure to address the underlying cause of the pain, usually a small blood vessel touching the nerve. The surgery is done under an operating microscope with the patient asleep under general anesthesia and involves moving the blood vessel off the nerve and placing some Teflon cotton padding to keep it separated. Success rate and pain relief is about 90% soon after the surgery. When successful, the benefit generally lasts for many years, and is often permanent. Risks include the possibility of hearing loss on the same side as the surgery, numbness, weakness, stroke, or death, as well as leakage of spinal fluid from the wound requiring additional repair. All of these risks are small, at 1 to 2% or less. This surgery requires an overnight stay in the intensive care unit and usually about 2 to 3 days in the hospital. Usually the surgical incision, which is behind the ear, is closed with glue so that there are no stitches or staples to be removed. Patients may shower, bathe, and shampoo as normal. There are no restrictions on physical activities. The only restriction is to avoid scratching the area of the incision or picking at the glue. This glue will soften and peel off on its own after a few weeks. Postoperatively patients may be given a short course of pain medication, as well as medications for inflammation or maintaining good blood flow. No special care is needed after the surgery; however, patients are recommended to stay off work for 4 weeks. Any aspirin or NSAID (ibuprofen, Aleve, Excedrin Migraine, or Advil) should be stopped one week before surgery.

Rhizotomy is second surgical option. There are several ways of doing this. At Mass General, our preferred method is called a balloon compression of the Gasserian ganglion. This procedure is also done with the patient asleep under general anesthesia but is an outpatient procedure that takes only a few minutes, and after which the patient may go home the same day. It involves placing a needle up along the course of the nerve in the face, starting from a tiny puncture next to the corner of the mouth. The nerve is compressed against the skull bone for a minute or two using a tiny balloon. The balloon is then deflated and removed. This procedure preferentially blocks the part of the nerve carrying the abnormal pain signals. It always produces some degree of numbness on that side of the face which is incomplete and improves over time. It is possible that the facial numbness may never fade completely. This is not bothersome to most people. It has a success rate of 85 to 90%. In addition to the numbness, risks include temporary discomfort when chewing and temporary double vision in about 3% of patients. The effect of the procedure tends to wear off after a few years, but the procedure can be repeated. Risks of permanent numbness or numbness with persistent pain increase if the procedure is done repeatedly. As with MVD, aspirin and NSAID medications should be stopped one week before the procedure.

Stereotactic radiosurgery (SRS) is a third surgical option. This can be done with a variety of machines that deliver computer guided radiation such as gamma knife, CyberKnife, or linear accelerators (LINAC). The procedure is noninvasive and does not require anesthesia. At Mass General, we used the LINAC procedure. A special MRI scan is obtained a few weeks in advance and a special bite block is made to help hold the patient's head still during the treatment. This treatment is done in the outpatient radiation department and takes about 45 minutes. The patient bites down on the bite block while the head is held in position with the frame using suction cups. Most people listen to music and fall asleep while the treatment happens. Following the treatment, the patient can leave immediately. This treatment is successful in 70 to 75% of patients. Like rhizotomy, it tends to wear off after a few years, but can be repeated one time. Risks of this procedure include about a 10% chance of numbness on the side of the face where the pain had occurred. It is very important to understand that with SRS, the effect is not immediate. In people who benefit from this procedure, the improvement in symptoms begins between 2 and 6 weeks following the treatment and may take up to 6 to 8 months for the maximal effect. It is important to know that about 10% of the patients will develop numbness in the face from the procedure, which commonly shows up at 6 to 8 months. It is not necessary to change any of your usual medications before to prepare for this treatment.

For all three of the procedures described above, we encourage our patients to remain on their pretreatment facial pain medication regimen until the effect of the treatment is clear. It is usually not advisable to stop these medications abruptly. Following treatment patients can work with their neurologist to gradually taper or wean off their medication as tolerated. It is important to keep in mind that the goal of all of these treatments is pain control, and not complete freedom from medication use.

It is also important to keep in mind that no surgical procedure is risk-free, and that no surgical procedure carries a guaranteed success. We encourage our patients to ask us many questions as they need to help make decisions before surgery and to address concerns that arise after surgery.