If medications are not able to control the pain of trigeminal neuralgia, there may be options for surgical treatment. There are multiple techniques with varying degrees of invasiveness. Percutaneous procedures are performed through the skin and involves precise placement of a needle into the opening through which the trigeminal nerve travels. The open approach is reserved for younger and healthier patients. These procedures have different success rates and side effects.
Microvascular decompression is an open surgery whereby the trigeminal nerve is delicately exposed through an incision behind the ear. Typically, a blood vessel is found pushing on the nerve. The blood vessel is carefully dissected away from the nerve and a piece of Teflon can placed in between them to prevent contact. Taking the pressure off the nerve prevents it from becoming activated abnormally and can lead to pain freedom. This is the most durable procedure but because it is also the most invasive, there are more significant risks involved. These include continued pain, decreased hearing, facial weakness, facial numbness, spinal fluid leak, stroke or death. This procedure is the surgery of choice for hemifacial spasm as well except the facial nerve is decompressed instead of the trigeminal nerve.
Percutaneous rhizotomy involves placement of a needle through the cheek and into the opening that the trigeminal nerve exits. A glycerol rhizotomy is a technique involving injection of glycerol into this region causing the nerve to be damaged and preventing it from sending pain signals into the face. Balloon compression rhizotomy is similar in that the needle is placed in the same area as in the glycerol rhizotomy however instead of injecting glycerol, a small balloon is inflated which compresses and damages the nerve with pressure. Since these only involve placement of a needle instead of an open surgery, there are fewer risks. These include continued pain, facial numbness, meningitis, but rarely stroke or death as well.
Stereotactic radiosurgery involves delivering high dose focused radiation to the root of the trigeminal nerve as identified on a high resolution MRI. While it does involve placement of a frame onto the head, it is a single dose and because it is noninvasive, it is possible to avoid many of the risks and complications of a surgical procedure. Over time, radiation damage occurs on the nerve and prevents transmission of pain signals into the face. Unlike the more invasive procedures, the results are not as robust and it may take time to take effect.