Brain Surgery

Trigeminal Neuralgia - Microvascular Decompression


Microvascular decompression (MVD) surgery is primarily performed to relieve the symptoms of trigeminal neuralgia and hemifacial spasms.

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No. According to Dr. Peter Janetta and his team, who did great work in MVD surgery field in the last century, the efficacy of surgery is higher when done EARLY in the course of the disease. That is, it is prudent not to keep on taking medicines numbing the nerve and the entire nervous system for a long period of time, if you want to increase your chances of being cured. Also, this surgery should be done BEFORE any of the destructive procedures like radiofrequency lesioning (RFL) is attempted. The success rate also is better in the hands of a team which does this surgery routinely. This means that the team which is experienced in this surgery, and does this surgery frequently is likely to give better results.

A common misconception is that this surgery is not for the elderly. On the contrary, to quote Janetta, “this surgery is eminently suitable for the elderly sufferers as the cerebellum is atrophic and the corridor to the nerve wide open for the surgeon.” Our personal experience confirms it emphatically and over half of our patients were elderly.

Radio-Frequency Lesioning (RFL) is another option, though I personally keep it reserved only for the occasional patient who does not benefit from MVD surgery, or who is not fit for this surgery or anaesthesia.
This is because, if RFL is done primarily, the chances of the MVD becoming successful is reduced by more than ten percent. RFL, unlike MVD is a destructive procedure. At first instance, it does seem to be an attractive option to MVD, as it seems a very simple procedure. It is one of the weapons in the armamentarium to treat trigeminal neuralgia no doubt, but it is by no means a simple procedure. It destroys a part of the nerve and has complication rates akin to surgery.
Radiofrequency lesioning of the trigeminal nerve is done at the trigeminal ganglion. The Trigeminal ganglion is a small pea-sized nubbin of nerve tissue present in the middle of the skull base from where the three divisions of the trigeminal nerve branch out. These divisions travel forward under the brain in the skull.
To perform the technique of RFL, a thin long needle is inserted through the cheek towards the ganglion through an opening in the base of the skull. This procedure is done under local anaesthesia; and during the actual lesioning, a small dose of general anaesthetic or sedative may be given. A machine that can shoot X –rays continuously (C-arm) is used to direct the needle to its proper position through the ‘foramen ovale’ which is a small hole at the base of the skull. Once the needle is appropriately positioned, the pain is elicited and confirmed. Then, the needle is connected to the RFL machine. The machine then transmits radiofrequency waves through the needle to its tip. These waves generate heat and destroy the nerve fibers that are responsible for causing the pain.



1.  Mrs Naseebunnissa, a 67 year old housewife came to us with history of Trigeminal neuralgia since ten years. She had undergone Radio-frequency lesioning twice before in the last two and a half years, with some decrease in pain for about six months after procedure. She was severely diabetic and had a heart which was only pumping at 50 percent of normal. Since she was unfit for anaesthesia, and she was unwilling to accept the risks associated with her medical condition, we offered to repeat a Radio-frequency lesioning of the ganglion. She was sedated, the bony landmarks of her skull identified on X-ray ( Image intensifier) in the operating room, and a RF needle introduced. Once we reached the ganglion, stimulation led to severe trigeminal neuralgia-like pain. A short-acting general anaesthetic was given to her and a lesion was made in her ganglion using the RFL machine. After the procedure, which took about 45 minutes, she woke up and was pain-free. The effect of the RFL lasts about six months to a year, and needs to be repeated.

2.  Mr Parikh, a 55 year old businessman came to us on being referred by another neurosurgeon. He had suffered from Trigeminal Neuralgia for almost 15 years and had undergone RFL twice before. On both
the occasions he had only transient pain relief for about one or two months. He had learnt to live with the pain, though quite often, he would get frustrated and desperate for a permanent solution. He was counseled about Micro-Vascular Decompression and its results after RFL procedure, but he was adamant and insisted that the operation be attempted for permanent pain relief. He underwent the surgery. During surgery he was found to have a short, stubby trigeminal nerve with severe vessel compression from both front and behind. The operation was more intricate than usual and needed a slightly longer time. However, at the end of surgery, he woke up pain-free and with great disbelief that the pain had actually disappeared!


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