244 Westchester Avenue, White Plains, NY
Alain C. J. de Lotbinière, MD, CM, FACS, FRCSC


How is Trigeminal Neuralgia treated?

There are several treatment options for Trigeminal Neuralgia (TN) that include medicine and surgery. Anticonvulsant and antidepressant drugs may be prescribed. These might be combined with other therapies such as acupuncture, electrical stimulation of the nerves, or even vitamin therapy to mitigate pain. However, if medication and complementary options fail to bring relief, or if medication causes side effects such as severe fatigue, headaches, nausea, and depression, a neurosurgical intervention may be your best option.

Several neurosurgical procedures are available. Some may be performed on an outpatient basis; others may require hospitalization.

One of the options is Gamma Knife surgery. Gamma rays – not an actual knife – are used to precisely target the trigeminal nerve, a procedure which takes place under local anesthesia and mild sedation. There are about 110 Gamma Knife centers in the United States, one of which is located in Westchester County at Northern Westchester Hospital, where Dr. de Lotbinière performs this procedure.

Gamma Knife

Gamma Knife surgery is also used to shrink tumors or target other brain abnormalities. Its unique design spares normal, healthy tissue because low-dose radiation is delivered via a circle of beams around the head, all of which converge at a specific point to deliver a concentrated blast of radiation to the target. Unhealthy cells slowly die, stabilizing or shrinking the tumor or correcting other conditions.

Gamma Knife surgery is very effective in treating TN. The benefits of Gamma Knife surgery include no risk of general anesthesia, no incision, no hair loss, no hospitalization, immediate return to pre-procedure activities and minimal to no discomfort.

Dr. de Lotbinière is the Director of the Gamma Knife Center at Northern Westchester Hospital in Mount Kisco, the only such treatment center between New York City and Syracuse within the state of New York. For more information, visit www.nwhgammaknifeny.org

Other surgical treatments include microvascular decompression, nerve blocks, and needle procedures. Your best course of action is to turn to a specially trained neurosurgeon, with expertise in treating TN. Please contact us at your earliest convenience.

Trigeminal NerveMicrovascular decompression (MVD), also known as the Janetta operation, is a surgical procedure in which a sponge is inserted between a vessel compressing the trigeminal nerve and the nerve itself. The operation is performed under general anesthesia through a small opening of the skull (less than a size of a quarter) using an operating microscope.

This procedure has the highest long-term success rate of all the neurosurgical interventions for trigeminal neuralgia, with 75% of patients remaining pain-free after 10 years. However it is a procedure that requires a high degree of surgical expertise and should only be performed by a surgeon who is intimately familiar with the microsurgical techniques and anatomy appropriate for this intervention. Complications include hearing loss, strokes, hematomas, spinal fluid leakage, and even death.

Dr. de Lotbiniere has personally performed over 500 microvascular decompressions and has remarkably few complications, well below the published incidence in the literature.

Dr. de Lotbinière inserts a teflon sponge during a MVD operation.

Neuroablative Outpatient Needle Procedures:
These procedures include radiofrequency thermorhizotomy, glycerol rhizolysis, and balloon compression. The aim for each of these procedures is to deliberately injure the trigeminal nerve in a controlled fashion using heat, a chemical, or mechanical compression. Under general anesthesia, a needle is inserted into the cheek and directed via x-rays to a small hole at the base of the skull, with the tip of the needle penetrating the hole.

Trigeminal NerveIn the case of radiofrequency thermorhizotomy, an electrode is passed through the needle and into the trigeminal nerve. Electrical stimulation is then carried out to determine which branch of the nerve is being affected after which the tip of the electrode is heated to a temperature sufficient to injure the nerve using a radiofrequency current. Once the lesioning is finished the electrode and needle are withdrawn and the patient is woken up from the anesthesia.

In the case of glycerol rhizolysis, in place of the electrode, glycerol (a viscous liquid) is injected into the space surrounding the trigeminal nerve, destroying some of the nerve fibers. The patient is then placed in the sitting position for a couple of hours with the head flexed, and subsequently discharged to go home.

Balloon compression is used primarily for attacks of pain involving the upper two divisions of the trigeminal nerve (V1 and V2). A small balloon is inserted into the needle and inflated once the balloon is lodged against the trigeminal ganglion for a brief period (typically a minute) resulting in injury to the pain fibers. The patient is then allowed to awaken from the anesthetic.

Each of these procedures results in a variable degree of facial numbness. However, there is no facial drooping as movement of the face is controlled by a different nerve, the facial nerve. Pain relief is usually immediate and lasts for months to years depending on the amount of numbness generated as a result of the intervention.

Unlike the microvascular decompression (MVD) procedure, the majority of patients will experience a return of their TN symptoms over time given that the trigeminal nerve recovers from the deliberate injury and the underlying cause (a vessel in the majority of patients) remains unchanged. Fortunately, for those patients who choose to undergo a neuroablative procedure, the option of a microvascular decompression remains open as does an additional neuroablative procedure.

Very few neurosurgeons can claim to be equally proficient in all of the above procedures, except for Dr. de Lotbiniere, whose primary focus is the treatment of patients with complex pain disorders, be they cranial or spinal.