Indications for surgery:
Typical trigeminal neuralgia, refractory to medical therapy or with intolerable medication side effects.
Benefits of surgery: For patients with typical trigeminal neuralgia this is the most effective, most durable treatment option. Initial relief of trigeminal neuralgia is present in approximately 90-95% of patients with sustained relief in approximately 70-80% of patients 10 years after the procedure. For patients with atypical symptoms the benefits of surgery tend to be less pronounced but in some cases are still significant.
Evidence of surgery: Multiple large case series demonstrate effectiveness and durability of treatment. In elderly patients with trigeminal neuralgia the operation remains very effective though the risks of surgery are increased.
Risks of surgery:
Serious risks: include major complications including death, stroke or major neurological disability. These risks are low in this procedure amounting to ~2%
More common risks: Ongoing pain following surgery in 5-10% of patients and recurrence of pain in the longer term in ~30% of patients. The risk of recurrence is higher if no compression or venous compression is identified during surgery. Risks of CSF leakage, infection, hearing loss or deafness, facial numbness or weakness, speech or swallowing problems, can occur. These are rare but significant if they do occur and may occasionally require further surgery. Patients may also experience scalp pain or numbness or headache after the surgery. The surgery like all operations carries risks relating to anaesthesia and post-operative medical problems such as blood clots and chest or urinary tract infections.
Brief description of surgery: Under general anaesthesia hair behind the ear of the affected side is shaved and the area prepared. A cut is made and bone under the cut is removed to allow exposure of the membrane lining of the cerebellum. Brain and spine fluid is drained and the cerebellum relaxes allowing, using the operating microscope, the surgeon to identify the nerves and blood vessels in the tiny space between the brainstem and the skull. The fifth nerve is exposed and blood vessels compressing it are freed and moved away from the nerve. Teflon packing is placed between the nerve and vessel and then stuck in place using tissue glue. The membrane linings of the brain are then closed and the bone returned in place followed by closure of the muscles and scalp.
After the surgery: Patients are returned to a high dependency neurosurgery ward where very close monitoring is performed by expert nursing and medical staff. Blood pressure and neurological function is regularly tested. Patients after surgery will usually experience a headache and pain where the surgery was performed which is treated with analgesia. The neck is usually sore and stiff after the surgery. After 24 hours of monitoring patients are usually moved to the main neurosurgery ward. Patients are usually allowed out of bed and are allowed to mobilize with assistance from physiotherapy and nursing staff until deemed ‘safe’, which is usually the day after surgery. A typical ward stay is 2-3 days after this operation.
Wound care: Dissolvable stitches are usually placed in the wound. The wound stays clean and dry for 10 days after the surgery, after which your local GP or practice nurse should check the wound is clean and dry. During this time you should avoid getting your dressings wet and if you do so they should be replaced.
Following surgery when you return home you will have activities restricted. You should plan to take a lot of rest as you will be much more tired than normal. Each day you should do a little bit more light activity like walking. You should not go to work or play sport during this period of time and over the 6 six following the surgery will start to feel more capable and stronger. You should not drive or operate machinery during this period of time.
I will see you 6 weeks after the surgery in my clinic. At this time if you are well I will plan with you a return to normal activities including work. This is in a graduated but after about 3 months following the surgery you will feel stronger and hopefully back to normal with minimal pain.
Medications: If you are free from trigeminal neuralgia following the surgery you can start to reduce you trigeminal neuralgia medications slowly. These medications can be dangerous to stop suddenly and so I would usually recommend gradually withdrawing the medications over a few months
Or weeks depending on the dosage you are taking.