Microvascular Decompression of the Trigeminal Nerve

Microvascular Decompression of the Trigeminal Nerve

Case presentation:

A 63 year-old woman presented with a 10-year history of left sided facial pain. Pain was described as over the left maxilla with radiation to the left eye and over the left side of the head. The severe pain was intermittent and described as sharp, shooting and electrical like in nature. It was aggravated by, brushing her teeth, touching her face, eating, drinking, and cold wind. She had some associated blurred vision. She denied any hearing impairment. There was no numbness of the face. The pain did not cross the midline or affect the right side of the face.

She was neurologically intact on examination. She denied any significant facial trauma. She had multiple dental reviews with no concerns. Current medication included Tegretol and Lyrica. However she still had refractory pain and did not tolerate an increase in medication dosage.

A MRI/MRA head demonstrated a loop of the left superior cerebellar artery abutting the nerve root entry zone of the left trigeminal nerve.

(a) Left image showing distortion of the left trigeminal nerve. (b) Right image showing the left superior cerebellar artery in close proximity to the left trigeminal nerve.

Her facial pain symptoms, examination and radiological findings were consistent with a diagnosis of typical left trigeminal neuralgia. Following detailed discussion on treatment options, decision made to proceed with MRI stealth guided left retrosigmoid craniotomy and microvascular decompression of left trigeminal nerve.

She underwent microvascular decompression of the left trigeminal nerve with no significant intraoperative or postoperative concerns. The loop of the left superior cerebellar artery was indenting the left trigeminal nerve under microscope visualisation. The artery was mobilised and reflected away from the nerve.

(a) Left image shows distortion of the left trigeminal nerve by the left superior cerebellar artery. (b) Right image shows reflection of left superior cerebellar artery away from left trigeminal nerve with no nerve distortion.

There was resolution of left sided facial pain immediate on waking from general anaesthesia. She has had no recurrence of left sided facial pain on subsequent follow-up and therefore has been weaned off medication.


Trigeminal neuralgia (TN) is characterised by paroxysmal excruciating, electric like pain lasting a few seconds to minutes. It is often triggered by sensory stimulus: shaving, talking, eating, drinking, washing, cold wind etc.  As a result this can have significant impact on quality of ADLs such as severe difficulty eating leading to malnutrition and poor dental hygiene. There is no neurological deficits or detectable abnormality of the trigeminal nerve function. Patients can have pain free intervals lasting weeks to months however there is often a considerable fear of the pain returning.

In classic TN, there can be vascular compression of the nerve at the root entry zone most likely by the superior cerebellar artery. An MRI/MRA head is the gold standard investigation to rule out other compressive causes on the trigeminal nerve such as tumour or multiple sclerotic plaques.

The treatment of TN is firstly medical before considering surgical treatment. The decision on which type of surgical approach is based on a variety of factors including patient’s age, medical conditions, and the pain severity. Surgery should be considered in cases of TN refractory to medical management or where significant side effect of medication is encountered. Surgical management includes:

  1. Peripheral nerve branch blocks or ablation
  2. Percutaneous trigeminal neurotomy (Stereotactic):
  3. Microvascular decompression (MVD)
  4. Total or partial transection of nerve
  5. Stereotactic radiosurgery

Microvascular decompression (MVD) has become an accepted surgical technique for the treatment of TN, hemifacial spasm and glossopharyngeal neuralgia. The aim of surgery is to remove the vascular contact with the dorsal root of the trigeminal nerve. A retrosigmoid approach via a posterior fossa craniotomy is performed with the patient either in a park bench or lateral position. A piece of padding (Teflon) is usually placed between the nerve and the vessel. Overall 70-80% of patients can become pain free post procedure.

There are many surgical strategies available that can be effective in managing patient with severe TN. Patients with severe TN require thorough consultation and with appropriate treatment can often lead to successful outcomes with a significant positive impact on their overall quality of life.

– By Dr Norman Ma, Neurosurgeon and Spinal Surgeon 


Patient and staff safety is our highest priority at Briz Brain & Spine.

For patients with appointments, if you are suffering any symptoms such as fever, dry cough, sore throat, tiredness or shortness of breath or have recently travelled interstate, overseas or been in contact with someone who has returned from interstate or overseas, or have been in contact with a confirmed case of COVID-19, please contact our friendly reception team before attending the clinic. A telehealth appointment may be an alternative method of speaking with our surgeons.

Protecting the health of our staff is vital to ensure they can continue to provide great service.  Patients are encouraged to prepay accounts over the phone prior to appointments or via payWave or other contactless payment methods. Patients are also asked to complete the Patient Details Form and sign the Privacy Policy Agreement electronically prior to their appointment. These forms can be found under our Contacts page on the website or by clicking here. Please note, patients are asked to bring only ONE support person to their appointment and maintain appropriate social distances to help reduce the risk of Covid-19 transmission.

During this current outbreak of Covid-19 coronavirus we want to assure all of our patients that we will continue to implement procedures to maintain a hygienic clinical environment. This includes:

-          Disinfecting and wiping down all treatment surfaces

-          Regular cleaning of rooms and shared equipment

-          Thorough cleaning of all communal items including reception chairs, tables, door handles, pens and other shared items

-          All staff have access to infection control procedures and training to implement these as necessary

We are carefully monitoring the directions and advice of Queensland Health, the Australian Government Department of Health and the World Health Organization. In the meantime, it is still business as usual and our doors are open.

Briz Brain & Spine wishes to apologise for the inconvenience caused and thanks you for your cooperation and understanding during this unprecedented situation.