Trigeminal Neuralgia
Ronald Brisman, M.D.
 

Needle Rhizotomy (Radiofrequency, Glycerol or Balloon) for Trigeminal Neuralgia

Needle Rhizotomy (Radiofrequency Electrocoagulation, Glycerol Injection or Balloon Microcompression) for trigeminal neuralgia

 What is Needle Rhizotomy  (Radiofrequency, Glycerol or Balloon) for trigeminal neuralgia?

This is an out-patient procedure that requires a few hours in the hospital facility and is a little more invasive than the Gamma Knife radiosurgery. During needle rhizotomy, a specially designed needle is inserted through the cheek under x-ray control, and directed towards the trigeminal nerve close to where it enters the brain. The nerve is treated with either heat (Radiofrequency Electrocoagulation), a chemical (glycerol) or balloon microcompression. As balloon microcompression requires a bigger needle and has more complications than Radiofrequency or glycerol, I (Ronald Brisman, M.D.) usually favor needle rhizotomy with  Radiofrequency and/or glycerol. Facial numbness, although not usually bothersome, is more likely after needle rhizotomy than Gamma Knife radiosurgery. Most patients get pain relief from needle rhizotomy. Recurrence may occasionally occur but can be treated by either a repeat needle rhizotomy or another procedure. Rhizotomy refers to the partial damage of a nerve (trigeminal nerve), a maneuver that is well known to relieve the pain of trigeminal neuralgia.  

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 Why do you damage the trigeminal nerve partially? Why don’t you just cut it (or damage it) completely?

Although damaging or cutting the trigeminal nerve completely is more likely to result in long-lasting pain relief, it is also more likely to cause bothersome numbness with a new discomfort often described as a burning, crawling, tightness or itching. Partial damage to the trigeminal nerve is likely to relieve pain without causing unpleasant side effects. If pain returns, it can be treated with either medicines or another neurosurgical procedure.

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 Who is a candidate for Needle Rhizotomy for trigeminal neuralgia?

Patients who are bothered by pain of trigeminal neuralgia or side effects of medicines are candidates for needle rhizotomy. Elderly patients, those with significant medical conditions,  patients with trigeminal neuralgia and multiple sclerosis and those who have failed other procedures are particularly good candidates for needle rhizotomy, but anyone with medically intractable trigeminal neuralgia (not well controlled with medicines) is a good candidate. Needle rhizotomy is a little more invasive than Gamma Knife radiosurgery but is still much less invasive than microvascular decompression. 

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 Is Needle Rhizotomy painless?

Yes. Although there is a possibility of pain during the procedure, Dr. Ronald Brisman has taken special precautions to make the procedure painless. The procedure is done with the patient heavily sedated with intravenous (in the vein) medications that are given by an anesthesiologist under Dr. Brisman’s guidance. The patient is put completely asleep for brief periods but awakens just a few minutes after the procedure is completed. 

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 Can patients who have had a previous procedure for trigeminal neuralgia undergo Needle Rhizotomy?

Yes. Patients who have recurrent trigeminal neuralgia pain after a prior procedure (Gamma Knife radiosurgery, Needle Rhizotomy with Radiofrequency, Glycerol or Balloon, or a Microvascular Decompression) have an excellent chance for pain relief with a subsequent Needle Rhizotomy.  

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 Can patients who are taking anti-coagulating (blood thinning) medicines undergo Needle Rhizotomy for trigeminal neuralgia?

Yes, but they must stop their blood thinning medicines before the Needle Rhizotomy and their physician must be certain that their blood is clotting normally at the time of the Needle Rhizotomy. Aspirin must be stopped at least 7 days before a needle rhizotomy.  Warfarin (Coumadin is the trade name) must be stopped several days before needle rhizotomy and a blood test will confirm that the patient’s blood is no longer affected by the previous Coumadin. Patients who cannot easily stop their blood thinning medicines are better treated with Gamma Knife radiosurgery.  

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 Can patients who are unable to have an MRI (Magnetic Resonance Imaging) because of an implanted pacemaker or defibrillator undergo Needle Rhizotomy for trigeminal neuralgia?

Yes. MRI is not used for Needle Rhizotomy, which is done with the aid of regular x-rays.

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 Explain the different methods (Radiofrequency Electrocoagulation, Glycerol Injection and Balloon Microcompression) for Needle Rhizotomy.

Radiofrequency Electrocoagulation is the precise delivery of heat (caused by electric current) to the trigeminal nerve. There is some ability (though not complete) to treat selectively those parts (divisions) of the trigeminal nerve that are involved in a patient’s pain. The awake patient’s response to a small current may help localize the position of the needle (electrode for delivering the heat) to a specific part (division) of the trigeminal nerve. There are other methods that Dr. Ronald Brisman uses to identify which part(s) of the trigeminal nerve are being treated. These include the position of the needle as seen on the x-ray and the redness that may develop during heating. By using all three methods, Dr. Ronald Brisman can minimize (and usually avoid) any possible discomfort that the patient may feel during this procedure. Radiofrequency works well for patients who have pain in the third part (lower jaw, lower lip, lower teeth and side of the face) of the trigeminal nerve and also in the second part (mid cheek, upper lip and upper teeth and front of the nose.)

Glycerol injection is the insertion of a chemical ( glycerol) into the space around the trigeminal nerve near the brain where the nerve is bathed in spinal fluid. It is not selective for any particular part (division) of the trigeminal nerve and can treat pain in any of the three divisions.

Balloon microcompression involves blowing up a balloon that treats and partially damages the trigeminal nerve by mechanically squeezing it. It is not selective for any particular part (division) of the trigeminal nerve and can treat pain in any of the three divisions. Because a larger needle is needed and a larger device is placed in the brain (distended balloon) the chance for a complication may be greater than with the other two techniques.

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 What is Radiofrequency and/or Glycerol for treatment of trigeminal neuralgia?

This is the Needle Rhizotomy procedure that Dr. Ronald Brisman favors because it is highly effective and has a very low risk for complications. It maximizes the positive aspects of both Radiofrequency and Glycerol and minimizes their negative features. During this procedure, Dr. Brisman has available both Radiofrequency and Glycerol and uses one or the other or both depending on technical circumstances that develop during the procedure. Some of these circumstances are: the part (division) of the trigeminal nerve that is causing the pain (as Radiofrequency is preferred for third division pain and Glycerol for first division while either can be used for second division); the final position of the needle as determined by x-ray; the patient’s response to a little bit of electrical stimulation; and whether or not spinal fluid emerges from the needle, because spinal fluid return from the needle is favorable for glycerol but only occurs only in about 60 percent of the time.  

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 What equipment is needed for Needle Rhizotomy for trigeminal neuralgia?

High resolution x-rays are required for needle rhizotomy. Radiofrequency electrocoagulation requires an additional sophisticated device that converts electric current to heat. Glycerol and balloons for trigeminal compression are more readily available.       

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 What are the results of Needle Rhizotomy for treatment of trigeminal neuralgia?

Pain relief is often immediate. Occasionally, pain relief may be delayed for a few days.  One month after the procedure, approximately 90 percent of patients are substantially better. Approximately 10 percent of patients will have the procedure repeated within a few months because of persistence or early recurrence of pain. Another 15 to 30 percent will have the procedure repeated within the next five years because of recurrent pain. If the procedure needs to be repeated, it can be done without additional difficulty or risk than originally expected. 

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 What complications may result from Needle Rhizotomy  for treatment of trigeminal neuralgia?

Although Needle Rhizotomy for trigeminal neuralgia can be done safely in the vast majority of patients, there is a small risk for complications, both minor and major. Bothersome numbness does not occur in more than 97 percent of patients treated by Dr. Ronald Brisman. There is a potential for eye problems if the procedure causes numbness to the outer part of the eye (cornea) but a serious eye problem did not occur in more than 99 percent of Dr. Brisman’s patients. Occasionally there can be impairment of the bite, difficulty with chewing or hearing problems. These almost always heal spontaneously although it may take several months. Major complications such as stroke or death are theoretically possible from infection, bleeding or blood vessel injury. No major complications have occurred in the more than 1200 patients that Dr. Ronald Brisman has treated.

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 Can Needle Rhizotomy for treatment of trigeminal neuralgia be repeated?

Yes.

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 Can Needle Rhizotomy be used to treat trigeminal neuralgia if it is being caused by a blood vessel pressing on the trigeminal nerve?

Yes. Needle Rhizotomy is very effective for treating trigeminal neuralgia that is caused by blood vessel compression.

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 Can Needle Rhizotomy be used to treat trigeminal neuralgia that is caused by multiple sclerosis?

Yes. Needle Rhizotomy is very effective for treating the trigeminal neuralgia that is caused by multiple sclerosis.

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 Does an initial Needle Rhizotomy  procedure affect the results of another subsequent procedure such as Gamma Knife radiosurgery or Microvascular Decompression that may be considered for treatment of trigeminal neuralgia that recurs after the initial Needle Rhizotomy?

No. Patients with trigeminal neuralgia who are treated with a needle rhizotomy as their first neurosurgical procedure and then develop recurrent pain have an excellent chance of being relieved by a subsequent procedure whether it is a Gamma Knife radiosurgery, a repeat Needle Rhizotomy or a Microvascular Decompression.

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