Trigeminal neuralgia (tic doloreaux) is an excruciatingly painful illness in which the afflicted feels sudden pangs of pain in the face. The pains usually last only moments, but are among the most severe pains humans can feel. Pain usually is provoked by touching a "trigger-zone," typically near the nose or mouth.

 

Sometimes even the acts or drinking or eating stimulate the trigger-zone and produce the pain; in these cases, the patients will frequently avoid nourishment, and thereby risk dehydration or starvation. Fortunately, medications such as carbamazepine (tegretol), oxcarbazepine (trileptal), phenytoin (dlantin), pregabalin (lyrica) or gabapentin (neurontin) usually control the pain.

 

In particularly severe cases, or when medication is not entirely effective, surgical treatment may be indicated. A variety of operations have been devised, all of which involve the trigeminal nerve (the cranial nerve which carries sensation from the face to the brain). The current concept of the mechanism of trigeminal neuralgia is that it results from compression ot the trigeminal nerve by a blood vessel where the nerve enters the brain. Some of the procedures involve surgery to decompress this nerve (microvascular decompression or Jannetta procedure). Others involve percutaneous procedures where one inserts a needle into the face, through the foramen ovale (a hole in the base of the skull where part of the trigeminal nerve exits) and, in various ways, partially injures the nerve to stop the abnormal transmission of painful impulses. CyberKnife Radiosurgery has now been used for several years to treat this disorder and has some advantages over the above techniques. Our current treatment preferences are:

 

 

 

Dr. Appley's personal bias favors the above two procedures because of the facial numbness produced by the various percutaneous procedures.

 

 

 

Other combinations of failed treatments exist and must be handled on an individualized basis.