The treatment of facial pain: Neurosurgical techniques

Among the chronic facial pain syndromes, Tipical Trigeminal Neuralgia is the main indication for a neurosurgical treatment. It is recognized that the most common ethiological factor is a neurovascular conflict, involving the trigeminal root at his entry in the pons. In this case microvascular decompression of the root is the first option that should be offered, at least in patients in good general and neurological conditions. The operation is aimed to remove the offending vessel and to allow a natural repair of the damaged trigeminal fibers. The clinical results in thousand of cases operated on in the last 20 years support this view. Microvascular decompression gives the best short and long term results on the painful attacks, leaving the trigeminal root intact and with very low risk of morbidity and mortality, at least in experienced hands. In patients having high risk for a major surgical procedure, multiple sclerosis or inoperable tumors, a percutaneous procedure are the first option. Nowadays radiofrequency thermocoagulation, glycerolysis, and balloon compression of the retrogasserian trigeminal root are the most accepted techniques. They allow a high rate of success with a relatively low incidence of trigeminal deficits and dysesthesias. Anesthesia dolorosa and keratitis are rare. That is why the neurosurgical treatment should be offered early in invalidating tipical trigeminal neuralgia.