Trigeminal Neuralgia Surgery

Medicine first, then surgery

The first treatment is always medicine. Carbamazepine and related drugs that calm nerve signals relieve the pain for most patients at the start, and a good response to them is itself a clue that the diagnosis is right. The problem is that, over the years, higher doses are often needed, and side effects such as drowsiness, unsteadiness, dizziness and low sodium become hard to live with. When the medicine no longer works, or works only at a dose that makes normal life impossible, surgery becomes the sensible next step.

Dr. Salman Falak reviews the medicines already tried and the pattern of the pain, and looks at the MRI before discussing any operation. He also checks that the pain is truly trigeminal neuralgia and not a dental or jaw-joint problem, because the operations described below only help the nerve pain.

The surgical options, in plain words

There are two families of operation, and the choice depends on the patient's age, general health, the MRI findings and what the patient wants.

Microvascular decompression treats the cause. Through a small opening behind the ear, under general anaesthesia and with the operating microscope, the surgeon finds the vessel pressing on the nerve and places a small soft pad between them, so that the nerve is no longer compressed. The nerve itself is not cut, so feeling in the face is usually preserved. It is the option most likely to give long-lasting relief, and it suits patients who are fit enough for a general anaesthetic and an operation at the base of the skull.

Percutaneous procedures treat the symptom. A fine needle is passed through the cheek, under X-ray guidance and with sedation or a short anaesthetic, to the point where the nerve passes through the base of the skull. The nerve is then partly quietened, most often with heat through the needle tip or by pressing it briefly with a small balloon. A chemical injection is a third, less common method. There is no incision and the patient usually goes home the same day or the next. Relief is often quick, but some numbness in the face is expected and the pain can come back later, when the procedure can be repeated. These procedures suit older or less fit patients, and anyone who wants the smaller procedure first. Focused radiation is a further option that is available in some centres.

Who is a candidate, and when surgery is not advised

A good candidate has typical shock-like pain that responded to carbamazepine at some point, and an MRI that shows a vessel touching the nerve or at least rules out other causes. Microvascular decompression is usually suggested for younger and fitter patients, and for those who want the best chance of staying off medicine. Percutaneous treatment is suggested for patients who are older or less fit, and for anyone who does not want an open operation.

Surgery is not advised when the pain is constant and burning instead of shock-like, because that pattern often does not respond to these operations, or when a dental or jaw problem has not yet been excluded. Pain caused by multiple sclerosis is approached differently. Patients whose pain is still well controlled on a modest dose of medicine, with no side effects, usually do better to continue it. Send your MRI and a list of the medicines you have tried on WhatsApp, and Dr. Salman Falak will tell you whether an operation is worth discussing.

Before surgery: tests and preparation

An MRI of the brain with thin slices through the brainstem is the main test. It looks for a vessel lying against the trigeminal nerve and rules out a growth or another cause. Routine blood tests, an ECG and an anaesthesia review follow, and patients on carbamazepine have their sodium checked because the drug can lower it. Bring the full list of medicines with doses and every previous scan, plus any dental X-rays that were taken while the pain was being investigated. Patients from Faisalabad, Gujranwala, Sialkot or further away can send the scan on WhatsApp before travelling, so that the consultation in Lahore is about the decision and not about repeating tests.

Recovery and follow-up

After microvascular decompression, the patient spends the first night under close observation and a few days in hospital. Headache and some neck stiffness are common for a week or two and settle with simple painkillers. Most patients are back to light activity within a few weeks. Medicine for the neuralgia is reduced gradually after surgery, on the doctor's instruction, and is never stopped suddenly.

After a percutaneous procedure the stay is much shorter, often a day, and the cheek may be sore or slightly numb. Follow-up looks at two things: whether the pain has gone, and whether any numbness or dryness of the eye needs care. Patients from other cities can do the later reviews by video consultation once the wound has been checked, and should message at once if the pain returns.

Where the surgery is done

Dr. Salman Falak sees patients in Lahore at Sharif Medical City Hospital in Jati Umra on Raiwind Road, at Life Hospital in Bahria Town and at Doctor Care Hospital in Al Kabir Town. Operations are done in Lahore, and the hospital is decided with the family at the consultation. Patients from Gujranwala and nearby districts can be seen first at his Friday OPD at Gujranwala Medical Complex on G.T. Road, and patients from the Phool Nagar side on Tuesday. Facial pain is also well suited to a first video consultation, because the history of the pain is most of the diagnosis and the MRI can be sent ahead.

Risks, recurrence and honesty about both

Microvascular decompression is an operation at the base of the skull. It carries the risks of bleeding, infection, leakage of brain fluid, hearing loss on that side, facial numbness or weakness and, rarely, stroke, together with the general risks of anaesthesia. Percutaneous procedures carry a smaller procedural risk but a higher chance of facial numbness, and rarely a troublesome numbness that feels worse than the original pain, or weakness of the chewing muscles.

Recurrence is possible with every option. Pain can come back months or years after a successful procedure, sometimes because a new vessel comes to rest on the nerve, sometimes because the treated nerve recovers its pain signalling. Dr. Salman Falak does not promise a permanent cure. He explains which option gives the best chance of lasting relief in your case and what can be done if the pain returns, which often means repeating a percutaneous procedure or moving on to decompression. Risks are reduced by careful MRI planning, by the microscope, by gentle handling of the nerve and of the hearing nerve beside it, and by close monitoring afterwards.

Related conditions and procedures

The condition itself, with its symptoms and the medicines used, is described on the trigeminal neuralgia page. Other operations on the brain performed by Dr. Salman Falak, including surgery for brain tumours, are listed on the brain surgery page. Patients whose facial pain turns out to come from a tumour pressing on the nerve are treated for the tumour first.