TN SURGICAL TREATMENTS
Balloon Compression
Kenneth F. Casey, MD
This procedure is performed in the radiology suite or operating room with fluoroscopy to allow for
excellent visualizations of the foramen ovale. (Foramen ovale—an oval hole/passageway through which
two branches of the cranial nerve V enter the face.) The patient receives a general anesthesia. During
compression, the patient’s heart rate may briefly slow. The patient is fitted with an external pacemaker
to ensure the heart keeps beating at a safe rate. In this procedure, a cannula (a tube used to draw off
fluid) is inserted through a puncture in the cheek and guided to a natural opening in the base of the
skull called a foramen ovale. A soft catheter with a balloon tip is threaded through the cannula. The
balloon is inflated, squeezing the nerve against the edge of the dura and the petrous bone. Balloon
compression works by selectively injuring nerves which mediate light touch. Dr. Casey points out that a
radiopaque substance, (mercury), is used to inflate the balloon. The inflation time is usually 60-90
seconds using 900-1100mm of mercury.Important:
The Cook catheter was designed for the balloon procedure. (The Fogarty catheter was designed to be
inserted into a vein in the leg.)
Being asleep under general anesthesia rather than being sedated.
Glycerol Injection
Thomas Waltz, MDThe glycerol injections take less than one hour to perform and can be done on the
outpatient basis, or an overnight stay when necessary. A thin needle is introduced through the skin next
to the mouth and guided via X-ray flouroscopy through the cheek and up through a natural opening in
the base of the skull called the foramen ovale (see previous article). Just inside the foramen ovale is
the trigeminal cistern, a small cistern of spinal fluid that contains the trigeminal nerve. When spinal fluid
is obtained, a contrast dye is introduced to assure proper needle placement. Glycerol is then injected.
The glycerol bathes the ganglion and affects (damages) the demylinated fibers.
This procedure generally causes less damage to the trigeminal nerve than other precutaneous
procedures. It is highly successful and easily accomplished with low risk of side effects. Compared to
other procedures, it has a higher recurrence rate.
Radiofrequency Rhizotomy
Albert L. Rhoton, Jr. MDRadiofrequency rhizotomy is usually performed on an outpatient basis. A
general anesthetic is used to put the patient to sleep for a few minutes. A needle is then passed
through the cheek directed by X-ray control up through the foramen ovale in the base of the skull. After
inserting the needle, a small electric current is passed through he needle causing tingling in the face.
When the needle is positioned so the tingling occurs in the area of TN pain, the patient is put to sleep
again and the radiofrequency current is passed through the needle to destroy part of the nerve. The
patient is awakened a few minutes after completing the nerve lesion and is checked to determine if
there is enough numbness in the face to give pain relief. The radiofrequency lesion procedure is
repeated with the patient asleep until it has resulted in the desired numbness. In most cases, the X-ray
portion of the procedure takes approximately 30-60 minutes. When the lesion procedure is completed,
the patient goes to the recovery room for about two hours after which they can go home.
Stereotactic Radiosurgery/Gamma Knife
Ronald Brisman, MD / Ronald Young MD
Patients that are good candidates for gamma knife are typically those who cannot manage the pain or
side effects of medications. And, patients need not be in agony before treatment.
At the time of the gamma knife procedure, a thin cut MRI is done, taking about 7 minutes. A helmet,
(collimator), is placed on the patient. The entire procedure takes approximately 25-30 minutes,
sometimes a little longer.
Pain relief after a gamma knife procedure occurs with 1-120 days for about 91% of the classic TN
patients.
Gamma knife procedures can be repeated after 6 months.
Approximately 9% of patients experience facial numbness or a change in facial sensation as a
complication following the procedure.
Microvascular Decompression
John Alksne, MDThis procedure (brain surgery) is done using binocular vision or an endoscope letting
the surgeon use both hands during the operation. The area the surgeon works in is a very small area,
about ‘1’ centimeter in size.The vessel that is causing the problem is very carefully moved away from
the trigeminal nerve. And is packed with Teflon Felt between the artery causing the problem and the
trigeminal nerve. It is possible, but not likely for the teflon to slip within the first few weeks following
surgery. If this should happen, another MVD should be done to correct the problem. Dr. Alksne advised
that the surgeon should not stop after finding the first vessel on the trigeminal nerve because it may not
be the culprit vessel. The neurosurgeon must always examine the nerve re-entry zone during an MVD. If
an MVD is unsuccessful have a thin-cut MRI done before another MVD is performed. To prevent any
inert space within the skull, Dr. Alksne uses bone cement
The success rate of the MVD over the last few years has run in the 91% bracket. A study conducted by
Dr. Jannetta notes that if the patient’s typical trigeminal neuralgia is less than 8 years in duration prior
to the MVD, the success rate is higher.
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Balloon Compression
Kenneth F. Casey, MD
This procedure is performed in the radiology suite or operating room with fluoroscopy to allow for
excellent visualizations of the foramen ovale. (Foramen ovale—an oval hole/passageway through which
two branches of the cranial nerve V enter the face.) The patient receives a general anesthesia. During
compression, the patient’s heart rate may briefly slow. The patient is fitted with an external pacemaker
to ensure the heart keeps beating at a safe rate. In this procedure, a cannula (a tube used to draw off
fluid) is inserted through a puncture in the cheek and guided to a natural opening in the base of the
skull called a foramen ovale. A soft catheter with a balloon tip is threaded through the cannula. The
balloon is inflated, squeezing the nerve against the edge of the dura and the petrous bone. Balloon
compression works by selectively injuring nerves which mediate light touch. Dr. Casey points out that a
radiopaque substance, (mercury), is used to inflate the balloon. The inflation time is usually 60-90
seconds using 900-1100mm of mercury.Important:
The Cook catheter was designed for the balloon procedure. (The Fogarty catheter was designed to be
inserted into a vein in the leg.)
Being asleep under general anesthesia rather than being sedated.
Glycerol Injection
Thomas Waltz, MDThe glycerol injections take less than one hour to perform and can be done on the
outpatient basis, or an overnight stay when necessary. A thin needle is introduced through the skin next
to the mouth and guided via X-ray flouroscopy through the cheek and up through a natural opening in
the base of the skull called the foramen ovale (see previous article). Just inside the foramen ovale is
the trigeminal cistern, a small cistern of spinal fluid that contains the trigeminal nerve. When spinal fluid
is obtained, a contrast dye is introduced to assure proper needle placement. Glycerol is then injected.
The glycerol bathes the ganglion and affects (damages) the demylinated fibers.
This procedure generally causes less damage to the trigeminal nerve than other precutaneous
procedures. It is highly successful and easily accomplished with low risk of side effects. Compared to
other procedures, it has a higher recurrence rate.
Radiofrequency Rhizotomy
Albert L. Rhoton, Jr. MDRadiofrequency rhizotomy is usually performed on an outpatient basis. A
general anesthetic is used to put the patient to sleep for a few minutes. A needle is then passed
through the cheek directed by X-ray control up through the foramen ovale in the base of the skull. After
inserting the needle, a small electric current is passed through he needle causing tingling in the face.
When the needle is positioned so the tingling occurs in the area of TN pain, the patient is put to sleep
again and the radiofrequency current is passed through the needle to destroy part of the nerve. The
patient is awakened a few minutes after completing the nerve lesion and is checked to determine if
there is enough numbness in the face to give pain relief. The radiofrequency lesion procedure is
repeated with the patient asleep until it has resulted in the desired numbness. In most cases, the X-ray
portion of the procedure takes approximately 30-60 minutes. When the lesion procedure is completed,
the patient goes to the recovery room for about two hours after which they can go home.
Stereotactic Radiosurgery/Gamma Knife
Ronald Brisman, MD / Ronald Young MD
Patients that are good candidates for gamma knife are typically those who cannot manage the pain or
side effects of medications. And, patients need not be in agony before treatment.
At the time of the gamma knife procedure, a thin cut MRI is done, taking about 7 minutes. A helmet,
(collimator), is placed on the patient. The entire procedure takes approximately 25-30 minutes,
sometimes a little longer.
Pain relief after a gamma knife procedure occurs with 1-120 days for about 91% of the classic TN
patients.
Gamma knife procedures can be repeated after 6 months.
Approximately 9% of patients experience facial numbness or a change in facial sensation as a
complication following the procedure.
Microvascular Decompression
John Alksne, MDThis procedure (brain surgery) is done using binocular vision or an endoscope letting
the surgeon use both hands during the operation. The area the surgeon works in is a very small area,
about ‘1’ centimeter in size.The vessel that is causing the problem is very carefully moved away from
the trigeminal nerve. And is packed with Teflon Felt between the artery causing the problem and the
trigeminal nerve. It is possible, but not likely for the teflon to slip within the first few weeks following
surgery. If this should happen, another MVD should be done to correct the problem. Dr. Alksne advised
that the surgeon should not stop after finding the first vessel on the trigeminal nerve because it may not
be the culprit vessel. The neurosurgeon must always examine the nerve re-entry zone during an MVD. If
an MVD is unsuccessful have a thin-cut MRI done before another MVD is performed. To prevent any
inert space within the skull, Dr. Alksne uses bone cement
The success rate of the MVD over the last few years has run in the 91% bracket. A study conducted by
Dr. Jannetta notes that if the patient’s typical trigeminal neuralgia is less than 8 years in duration prior
to the MVD, the success rate is higher.
Return to Home Page
Surgical Procedures
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