Brain Surgery

Hemifacial Spasms (twitching of face, winking disease)

Information

Hemifacial spasm is a neuro-muscular disorder that causes a twitching of the facial muscles on one side of the face. The twitching of the facial muscles is involuntary, appears like winking, and can cause considerable embarrassment to the patient. Hemifacial spasms typically begin with infrequent twitching of the eyelid muscles, and then gradually spreads to one half of the face. Though it can occur in both men and women, the percentage of women getting affected is more. The most common cause of hemifacial spasms is a blood vessel pressing the facial nerve just where it exits the brainstem.
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Faqs

Ans.
Hemifacial spasms, facial twitching, repeated winking or blinking, or twitching of facial muscles all mean the same thing - repeated,   uncontrolled contractions of facial muscles on one side of the face. These spasms usually appear when the patient starts talking. They can also occur when not talking.

Ans.
One side of the person's face appears to be repeatedly contracting. It usually starts in the muscles surrounding the eye. The muscles surrounding the eye appear to be repeatedly contracting. The eye shuts and opens again repeatedly. Slowly the cheek on that side also starts to contract repeatedly. Angle of the mouth gets pulled to the same side.
For an observer, it appears as if the person is repeatedly winking with that eye and making strange gestures, giving it the name ‘winking disease’.

The disease is generally progressive and as the months pass by, the spasms appear as soon as the person starts talking.

Ans.
Hemifacial spasms can occur due to a variety of problems. The commonest and most effectively treatable cause is the compression of the nerve by a blood vessel at a very vulnerable area called as the root entry zone (REZ). This is the area where the nerve exits from the brainstem (lower part of the brain).

Some people genetically have blood vessels very close to this region and as age advances, these blood vessels elongate (increase in length). This condition is medically called ectasia. Such elongation occurs in every person with age, but in patients with hemifacial twitching, this causes the already close blood vessel to progressively compress or 'burrow" into the REZ region of the nerve. This in turn causes persistent pulsatile compression of the nerve leading to internal changes in the nerve (demyelination). This actually causes hemifacial spasms. This also explains why, when the offending blood vessel is gently moved away and kept separated (as is done in Micro vascular Decompression surgery) the hemifacial spasms disappear.

Ans.
Rarely, compression of the REZ by tumours (growths) can cause hemifacial spasms, but it is rare as compared to the more common blood vessel pressing on the REZ. In our research study we found that even if a tumour is causing hemifacial spasms, it usually does so by pushing a blood vessel against the nerve.

Ans.
Facial nerve trauma or Bell's palsy, followed by internal nerve repair by the body can occasionally lead to HFS. Old stroke, multiple sclerosis are other uncommon causes.

Ans.

At Dr. Jaydev Panchawagh’s Hemifacial Spasms Centre, we believe in aiming at permanently curing the hemifacial spasms with Micro-Vascular Decompression surgery.

When a progressively elongating artery has lodged and burrowed into the facial nerve, it continuously beats against the nerve fibres causing damage by progressive demyelination. It has been proven that this indeed happens. The longer the period for which the artery is allowed to beat against the nerve, more will be the severity of the spasms and worse will be the chances of complete cure by MVD surgery. So, considering a long-term perspective, we feel that Micro-Vascular Decompression surgery should be performed rather early in the course of the disease.

When a patient comes to us with the symptom of hemifacial spasm, typically, we elicit a detailed history to rule out causes other than vessel compression (like Bell's palsy, stroke, etc). Then, the patient is asked to undergo a high quality (3 Tesla) MRI with specific to study the facial nerve in the REZ region. The final step is to actually perform the micro vascular decompression surgery.

Ans.
Unfortunately, there is no other treatment which removes the basic cause of the hemifacial spasms. Botox (Botulinum toxin) injections have been tried, but are short lived and do not remove the basic cause of the problem ( vessel compression). It has no potential of offering permanent cure. Micro-Vascular Decompression on the other hand has a very high chance of offering permanent cure (more than 98%) when the selection is done meticulously.
Botulinum toxin (Botox) is actually a toxin that is poison from bacteria. It is injected in the twitching muscles and it causes incomplete paralysis of the face. So, the spasms stop temporarily for about 3 months. The problems of mask­-like face after injection and very short duration of effect. But more importantly, the blood vessel compressing the nerve continues to silently cause progressive nerve damage and demyelination. The spasms come back with increased intensity, sabotaging the possibility of permanent cure by micro vascular decompression. And therefore, We believe that there is no alternative to early micro vascular decompression.

Ans.
This surgery is performed under General anaesthesia. A small incision behind the ear inside the hairline is used. Surgery is performed with a high-end neuromicroscope. In essence, the offending compressing blood vessel is carefully dissected off and dislodged from the REZ and is kept separated by teflon sponge.
The surgery typically takes two hours at Dr. Jaydev Panchawagh’s Hemifacial Spasms centre.

A Highly trained team, a neurosurgeon experienced in this type of surgery, and top class equipments are mandatory to deliver excellent results. The spasms stop totally almost immediately after surgery in most cases (in 90 percent according to our study), and in others slowly go on reducing over the next fifteen days or so and then disappear in the remaining 9 percent. Thus, the final success rate is about 99 percent.

      
Facial Nerve and Vessel exposed   Teflon sponge inserted between
                                                             nerve & vessel

                                                          
Typical hospitalization time after surgery is three to four days. Ambulation is allowed twenty four hours after surgery.

Ans.
There are many large research studies available on treatment of hemifacial spasms by micro vascular decompression surgery. Considering the rapid improvements in the neurosurgical instrumentation, neuro-microscopes, neuro-anaesthesia and neuro-intensive-care, the results of these surgeries have remarkably improved in last few years and hence it would be prudent to refer to a large series done only after the year 2000.
One such series is summarised here, in a paper written by Hyun S J, Kong DS & Park K in 2010 July issue of Neurosurgery Review. It describes 1174 patients operated between 1997 and 2009. Out of 1174 patients, 1105 patients (that is 94.1% patients) were totally 'cured' (no spasms) and out of the remaining 5.9% patients, majority had good outcome with only few residual spasms.

In our personal series of 67 patients, operated between the year 2010 to 2014 by a single neurosurgeon ( Dr. Jaydev Panchawagh) with almost the same assisting and anaesthesiologist's team, 99% had complete relief ( follow up 7 months to 4 years) and 1% had remarkably improved status.
Majority of the large series reported before 2010, including that of Dr. Peter Jannetta, have emphasized that the success of Micro-Vascular Decompression surgery for hemifacial spasms tends to be long lasting and recurrence is rare. Complications are rare including transient facial paresis and transient hearing loss in 1 to 2 % of patients, and extremely rare incidence of permanent deficits. In short, Micro-Vascular Decompression for facial twitching in a modern-facility neurosurgical centre is a reasonably safe, effective and dramatic surgery; it has the potential to cure hemifacial spasms.

Ans.
The results of surgery for Micro-Vascular Decompression for hemifacial spasms tend to be far better when careful diagnosis, selection and workup has been done. Also, this peculiar surgery needs not only an experienced and skilled neurosurgeon, but also a team highly experienced in this operation, taking into account various factors. With these considerations, this centre for MVD surgery was established. Till date we have performed more than 850 Micro-Vascular Decompression surgeries (including those for Trigeminal neuralgia, Glossopharyngeal neuralgia and Hemifacial spasms), with the same team of surgical assistants and anaesthesiologists (operations performed by a single surgeon).

Ans.
In our opinion, this surgery is likely to be very successful if:

1) Patients are carefully chosen (e.g.hemifacial spasms post-facial nerve injury or post-stroke  patients, syndromes which look similar to hemifacial spasms etc should be excluded.)

2) The same team operates on the patient. The success rate is likely to be higher if a neurosurgeon and team experienced and interested in this surgery performs the surgery.

Please read the testimonials and view the actual results­­­­­

Dr. Jaydev Panchawagh (Neurosurgeon) who heads the Micro vascular Decompression unit will personally see you and discuss the treatment options.

case-studies

1.  Mr Prakash Girnar, was transferred to the Kutch division as Branch Manager of Dena Bank in 2001. A few days after he started his duties there, he noticed that his left eye was blinking automatically, especially during meetings and deadlines. He concluded that the stress of the job was the cause of the twitching. Over a period of a month it slowly progressed to involuntary twitching of the cheek, lips and the left side of the face. He also noticed that such episodes were followed by left sided headache. Soon he realized that this was no stress-related problem. He consulted many physicians and neurologists, most said that operation was not a treatment.They prescribed pain-killers and anti-anxiety medication and some even prescribed anti-convulsants. The result was that he began to feel sleepy during the day, and occasionally lost balance; but the blinking/winking/twitching did not g Micro-Vascular Decompression o away. In fact, over a period of a year, it only increased both in duration and frequency of the episodes.
In the meanwhile, his clients, especially female were annoyed at his ‘gestures’. He had to wear goggles even while inside the office, so his eyes could not be seen. Outside the bank, his social interaction decreased, to the extent of his remaining indoors and not accompanying his family for any social functions. He slowly became a recluse, and shunned human interaction because of embarrassment. He again visited famous hospitals and doctors in Mumbai and Gujarat, but to no avail.
He was eventually referred to Dr Jayadev Panchawagh, who he was told was an authority in this field. He visited our Hemifacial spasm centre in 2009. After undergoing an MRI to rule out other problems, he was counseled about the operation, its risks, benefits, course of hospital stay, what to expect etc. He also saw videos of the surgery and patient interviews. He was given phone numbers of people who had gone through a similar frustrating and depressing period, and who were back to their normal lives now. After he spoke to a couple of people, he had no doubt left in his mind about getting operated.
The spasms decreased considerably immediately after operation, and went away completely over the next week or so. Initially in the post-operative period, he was apprehensive that it would return, and spent hours waiting for the twitches to appear. It took him a few days to finally believe that they had actually disappeared for good and that he was as normal as could be! It is now many years after the operation( since 2009), and he is happy that he wears goggles only when he is out in the sun!!
Click here to watch video of Mr Prakash Girnar.

2.  Mr Mohan Yadav was an employee at Kirloskar factory. In 2005, he noticed that the right side of his face was being pulled to one side and his eyes winked automtically. He avoided going to get-togethers and parties, and eventually his vision became a problem because of the constant eye-blinking. Working with heavy machinery and driving became not only difficult but dangerous as well. He visited many doctors who advised him to ignore his problem and get on with life. When his quality of life worsened, and his family life began getting affected because of social avoidance, he went to a psychiatrist to consider taking anti-depressants.
In 2010, he was referred to Dr Jayadev Panchwagh by a relative who had undergone a removal of brain tumour by him. The appointment was fixed promptly by the team co-ordinator, and Dr Panchawagh spoke to him at length about his problem and dispelled all fears about the surgery and its outcome. He was made aware of the inherent risks in the operation, after all it was a major brain surgery. But he felt reassured and confident after talking to the team members, and decided to get operated the very next week. He was immediately relieved of his problems after the operation, and he felt like a changed man! He went off all medication and was back to work after a fortnight and hasn’t looked back since.

If you want to hear a patient’s story in their own words, please click here:

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