Novel Techniques for Trigeminal Neuralgia Including Trigeminal Neurostimulators

Introduction

Patients with trigeminal neuropathic pain refractory to medical management can be treated with a variety of minimally invasive surgical approaches that either augment or differ from standard microvascular decompression (MVD). For example, endoscopy is increasingly being used to augment traditional microvascular decompressions due to improvements in visualization of the source of vascular or structural compression and ability to intra-operatively confirm an adequate decompression (Artz et al., 2008; C. H. Halpern, S. S. Lang, & J. Y. Lee, 2013; Lang, Chen, & Lee, 2012; Sandell, Ringstad, & Eide, 2014). Other minimally invasive techniques that differ from microvascular decompression include stereotactic radiosurgery surgery (SRS), percutaneous radiofrequency nerve ablation, rhizotomy, balloon compression, and neurostimulation, all of which rely on nerve root lesioning or manipulation to alleviate painful symptoms. Specifically, SRS utilizes radiation, while radiofrequency thermocoagulation and glycerol rhizotomy use percutaneously delivered heat currents and chemicals to achieve nerve root destruction (Hakanson, 1981; Kanpolat, Savas, Bekar, & Berk, 2001; J. K. Lee, Choi, Ko, Choi, & Lim, 2012; William H. Sweet & James G. Wepsic, 1974). Balloon compression similarly utilizes percutaneous placement of an inflatable balloon to cause physical compression of the trigeminal ganglia (Mullan & Lichtor, 1983). Percutaneously delivered neurostimulators can also be used to modulate nerve signals within the trigeminal nerve and distal branches (Holsheimer, 2001). This chapter will discuss the operative nuances of each of these techniques and the published data regarding their comparative efficacy to treat trigeminal nerve pain.