Trigeminal neuralgia type 2, also known as atypical trigeminal neuralgia, is an extremely rare disorder. Fewer than five people per 100,000 are diagnosed annually with trigeminal neuralgia, and atypical trigeminal neuralgia represents only a small portion of that already tiny population. Diagnosing and treating trigeminal neuralgia type 2 is further complicated because some patients experience both types of this debilitating disorder.
In trigeminal neuralgia type 1, patients feel extremely sharp pain radiating in the cheek area roughly running diagonally from the side of your forehead or your ear to the chin. These episodes of pain are commonly short – between just a few seconds and a couple minutes in length – but are characterized by some of the most excruciating pain a patient can experience. For patients with trigeminal neuralgia type 2, the intensity of the pain might be somewhat lower, but lasts far longer. In fact, people with atypical trigeminal neuralgia may experience nearly constant burning sensations.
While medical management is the ideal response to both forms of trigeminal neuralgia, medication does not always provide the best outcome. For some patients, the side effects of medications commonly used for trigeminal neuralgia can cause side effects that are disabling or induce neurological issues like overwhelming fatigue or mental confusion. And for other patients, pain continues despite working up to the highest allowable doses of these medications. When medical management fails, neurosurgeons can respond in several different ways to help bring relief from the pain of trigeminal neuralgia.
Microvascular Decompression (MVD)
One factor that can lead to trigeminal neuralgia is the compression of the trigeminal nerve. In cases where medications fail to improve a patient’s pain and quality of life, and an MRI shows compression of the nerve by an artery or a vein, microvascular decompression (MVD) surgery should be considered.
How appropriate MVD surgery may be to your particular case of atypical trigeminal neuralgia will also depend on your health history. Microvascular decompression is considered invasive brain surgery, and so your overall health must be a factor in choosing to pursue this type of treatment.
Microvascular decompression begins with the administration of general anesthesia. Once you are fully sedated, your neurosurgeon will create a small opening in the back of your head, behind your ear on the side where you’ve experienced trigeminal nerve pain. Once the surgeon has direct access to your trigeminal nerve, the point of impingement or compression is identified. Blood vessels are the most common culprit in trigeminal nerve impingement. Your surgeon will then insert a small Teflon sponge between the nerve and whatever is pressing against it.
If your health allows, microvascular decompression is a preferred surgical treatment for trigeminal neuralgia because it offers the highest rates of success in pain elimination. If radiological imaging does not give a clear indication of compression, or if your health will not allow the use of general anesthesia, other options are still available once medical management is no longer a viable option.
Gamma Knife Radiosurgery
Neurosurgeons can successfully use Gamma Knife Radiosurgery to treat trigeminal neuralgia type 1 and type 2. With this procedure, your head will be placed within a head frame in order to ensure that movement does not interrupt or impair the procedure. Then, imaging is used to determine the location of where the trigeminal nerve meets the brainstem. Next, multiple beams of focused radiation are focused on this area. That radiation interrupts pain signals along the trigeminal nerve before they can reach the brainstem.
If you undergo Gamma Knife Radiosurgery, you won’t spend a long time in the hospital – patients leave on the same day of treatment. However, this procedure isn’t an immediate pain reliever. Rather, it may take several weeks before you experience results. After that time has passed, you may find that your pain is either greatly diminished or has gone away entirely.
Percutaneous Rhizotomy
Percutaneous rhizotomy for trigeminal neuralgia type 2 is typically an outpatient procedure. When you and your neurosurgeon elect this option, imaging is used to thread a specialized needle through your cheek to the base of the trigeminal nerve near the brainstem.
Then, heat is conducted through this needle and applied directly to the nerve. This heat is able to disrupt how the sensation of pain flows across the trigeminal nerve. While percutaneous rhizotomy may result in some sensation loss or numbness, that’s often preferable to the pain of trigeminal neuralgia. Additionally, this procedure is customized to your specific pain, meaning that your neurosurgeon can directly address the specific area where your pain occurs, as well as the intensity of that pain. Percutaneous rhizotomy can also be repeated as needed to achieve the highest possible amount of pain cessation.
Pain Stimulator Implant
The last considered surgical response to trigeminal neuralgia type 2 is implanting a pain stimulator within your head. This treatment is typically only considered after other types of surgical responses have already been tried. This is a moderately non-invasive treatment option. However, it is typically a two-part surgery to determine whether a temporary stimulator can lead to pain relief before a permanent one is implanted. Pain stimulators are specifically placed on the places experiencing the highest degree of pain, using a CT scan to ensure proper placement. Then, a signal is passed through the stimulator that confuses your trigeminal nerve and prevents the transmission of pain as a result.
You and your neurosurgeon can determine the best road map to pain cessation by considering the nature and placement of that pain, other factors that may play a role in your overall health, whether impingement is detected and what other modalities have already been tried. You can play an active role in determining which treatment to pursue by openly sharing all aspects of your health history with your neurosurgeon. You should also be sure to ask any questions you may have along the way.
