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Microvascular Decompression for Trigeminal Neuralgia
This video shows the view down our microscope of a trigeminal nerve being hit from above (loop of red artery curving to the right hitting the nerve on its left). Eventually, I pushed the artery up (to the left) and put some Teflon on it so that nothing was touching the trigeminal nerve. The patient was cured of TN and had no complications.
This video is a .mp4 file and should run on most PCs and MACs.
Download a pamphlet on Microvascular Decompression
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Introduction
Patients should speak directly with their neurosurgeon to fully understand the benefits and risks of this surgery.
If the TN is due to pressure on the trigeminal nerve by a nearby artery, the MVD operation is designed to move the artery away from the nerve. This operation is done under a general anesthetic and takes approximately three hours. Patients typically go home after two days in hospital. The scalp behind the ear (on the side of the pain) is shaved and an incision made through the skin and muscles. A small hole is drilled through the skull. The surgeon operates around the outside of the brain until the nerve is seen through the microscope. The offending artery or vein is identified and moved away from the nerve. A small patch of padding is placed between the nerve and artery to prevent further compression. The hole in the skull is replaced with acrylic and the muscles and scalp sutured closed. After surgery, the previously compressed trigeminal nerve is now free to heal. Some nerves are so badly damaged they do not heal completely and some nerves can get re-compressed over the years. Most patients do very well.
Benefits
The cause of the TN is fixed and the patient is left with normal sensation in the face (i.e. no numbness like the rhizotomy).
Risks
Patients are urged to speak directly with their surgeons about complication rates, which can vary among institutions. This is a more complex operation and has more potentially serious risks than the rhizotomy. With the general anesthetic and operating close to the brain stem there is the rare chance of death or stroke. We have never had a death in our 450 cases but it is well reported in the literature to occur at approximately 1%. A stroke could cause a devastating neurological injury. Injury to the surrounding cranial nerves could cause permanent facial numbness, deafness, facial droop, double vision, or difficulty swallowing. There is a risk of infection or delayed CSF leak (salt water-like fluid escaping from around the brain and draining through the middle ear into the back of the throat). Patient can temporarily complain of discomfort or numbness around the incision. Permanent pain at the incision site has been reported but we have not seen this.
Post-operative Instructions
Patients typically leave hospital after two nights. There will be a small wound behind their ear covered with a bandage and a tensor bandages wrapped around the head. Keep the wound dry (no swimming or shower but bath is OK if bandage stays dry) until the family doctor removes the stitches. Stitches should be removed after 10 days and the tensor bandage can be thrown away at that time as well. There should be no strenuous activity for 6 weeks. “Strenuous activity’ means anything where you might grit your teeth in order to lift something. Lifting a bag that does not change the way you breath is OK. Walking is fine. Avoid any activities where you might fall and hit your head (e.g. bicycling, roller-bladding, skiing ect.) We expect that you will have some headache or wound discomfort for a few weeks. This discomfort responds to Tylenol not to your anti-neuralgia medications (e.g. Tegretol or Neurontin).
If there are any problems with the wound (your family doctor thinks it might be infected) please call us. If you develop a severe headache a few days after discharge from the hospital, please call us.
We expect to see you in our office 6 weeks after surgery for a follow-up examination.
If you are pain free after surgery (i.e. no trigeminal neuralgia) you may begin to reduce your anti-neuralgia medications. Typically reduce one pill a day each week that you are pain free. If you were taking 6 pills a day for your neuralgia, it will take you 6 weeks to get off the pills – each week reducing the daily amount by one pill. If you neuralgia comes back, do not reduce the pills any further. Increase the pills back to the level where you were painfree.
A word about MVD and MS (multiple sclerosis)
We do not believe MVD is an appropriate treatment for the trigeminal neuralgia associated with multiple sclerosis (MS). The neuralgia associated with MS is due to immune system-induced demyelination of the nerve pathway and not due to compression-induced demyelination of the nerve by a vessel. Since there is no compression of the nerve, it does not make sense to try a decompress it with a MVD operation. Interestingly, if an MVD is performed – and the surgeon manipulated the nerve enough – there will be a temporary benefit in pain. This is because the manipulation of the nerve causes a ‘micro-rhizotomy effect’. A rhizotomy of the nerve can be performed more safely percutaneously rather than during an open craniotomy. Rarely, however, the nerve may need to be partially cut under direct vision. That operation is not a MVD but rather a direct surgical rhizotomy.