Our Program

The USC Trigeminal Neuralgia and Hemifacial Spasm Center at Keck Medicine of USC in Los Angeles provides advanced diagnostic, medical and surgical treatments for trigeminal neuralgia, a painful facial condition, and hemifacial spasm, a painless but severe twitching of facial muscles. The center has adopted a number of techniques that are effective in treating or curing either condition, while reducing the possible side effects (including hearing loss) of surgical procedures for either disorder.

Medical treatments for trigeminal neuralgia, also known as “tic douloureux,” include the medication carbamazepine (Tegretol) among others, “nerve blocks”, glycerol or stereotactic radiosurgery. Medical treatments for hemifacial spasm include botulinum toxin (Botox). Surgical treatments for both trigeminal neuralgia and hemifacial spasm include microvascular decompression, a technique that can move abnormally positioned blood vessels thought to cause the spasms or pain behind both disorders.

Our Approach

Our center offers both non-surgical and surgical treatments for either disorder. We collaborate with other specialists in neurology and neurosurgery, including experts in headache and movement disorders. Our team will obtain a complete medical history and conduct a neurological examination in order to carefully differentiate from a multitude of other causes of facial pain.

In addition to standard treatment protocols, the team also uses Gamma Knife® radiosurgery to treat trigeminal neuralgia, particularly for patients who have not responded to conventional medical therapy. Recently, the center reported new surgical techniques that preserved hearing function more than traditional surgeries (hearing loss is a common side effect of trigeminal neuralgia operations).

Our Results

For patients treated between 1994 and 2009 as reported in a recent study:

Number of major complications (including hearing loss): 0
Excellent outcome scores: 81 percent
Good outcome scores: 90 percent
Minor complications: 8 percent
No relief post-surgery: 4 percent

Conditions

The center treats two disorders of the nervous system: trigeminal neuralgia and hemifacial spasm.

Trigeminal neuralgia (TN), or “tic douloureux,” is a neurological condition characterized by episodes of sharp facial pain lasting a few seconds. This pain is usually triggered by chewing, shaving, smiling, touching the side of your face, brushing your teeth, or other sensory stimuli.

The trigeminal, or fifth cranial nerve, is the largest cranial nerve emanating from the brain. It divides into three branches once it reaches the face. They are: V1 (forehead area), V2 (upper lip and cheek) and V3 (jaw region). The pain is usually confined to one or more of these branches on only one side of the face.

Eighty-five percent of cases of TN are caused by a normal artery near the brain stem which is in an abnormal position. This artery has a loop in it which is pressed up against the trigeminal nerve. With each beat of the heart, blood is forced through this artery, causing the artery to bump up against the nerve. With time, this repeat pressure rubs the insulation off the nerve. This causes the nerve to fire abnormal painful electrical-like shocks.

Rarely, TN can be caused by tumors, with less than 0.8 percent incidence, or multiple sclerosis, with about 3 percent incidence.

Hemifacial Spasm (HFS) consists of painless, intermittent, involuntary, spasm-like contractions of the muscles of only one side of the face. These muscles are innervated by the facial, or seventh, cranial nerve. The contractions may involve either the upper or lower half of the face, or may begin with rare spasms of the eyelid muscles and slowly progress to involve the entire half of the face.

Approximately 85 percent of the cases of HFS are caused by a normal artery near the brainstem in an abnormal position. Similar to trigeminal neuralgia, this artery has a loop in it which is pressed up against the facial nerve. With each heartbeat, blood is forced through this artery, causing it to bump up against the nerve and eventually rubbing the insulation off the nerve. This injury to the nerve causes it to fire abnormal impulses, causing the involved facial muscles to contract involuntarily. Rarely, HFS can be caused by other conditions such as tumors, vascular malformations, multiple sclerosis, adhesions or bony skull deformities. One distinguishing feature of HFS is that the involuntary movements persist during sleep.

Treatments and Services

For trigeminal neuralgia, three treatment options are available. They include medical, invasive non-surgical and surgical.

Medical
The initial treatment of choice for TN is the medication carbamazepine or Tegretol. This drug provides complete or acceptable relief of pain in 69 percent of patients. Tegretol is not a “pain pill.” It is most effective by gradually increasing the dose to a level in the blood which provides maximal relief. Side effects include drowsiness, staggering, dizziness, depressed white blood cell count and liver toxicity. Other medical therapies, which may help with alleviating the painful episodes include baclofen, pimozide, phenytoin, clonazepam, gabapentin and lamotrigine. These medications can be used in conjunction with Tegretol but must be closely regulated by your physician. The benefits of this medical treatment option include avoiding the risks involved with the invasive non-surgical and surgical treatments.

Invasive Non-Surgical

  1. Peripheral Nerve Block
    This procedure provides temporary relief of pain by injecting either phenol or alcohol around the trigeminal nerve branch involved in the neuralgia.
  2. Percutaneous Stereotactic Rhizotomy (PSR)
    The goal of PSR is to injure or destroy the trigeminal nerve via different techniques, which may include radio-frequency thermocoagulation or glycerol injection.

In radio frequency heating, an electrode is inserted through a spinal needle under radiographic guidance, and certain pain fibers of the trigeminal nerve are destroyed by heat. With this technique, there is good pain relief in 80-90 percent of cases. The major complication of this technique is “anesthesia dolorosa,” a painful condition that is difficult to treat. When this occurs, the patient develops a severe constant burning, aching pain which is more disagreeable than the original pain. This occurs approximately 2-4 percent of the time.

With glycerol injection, a rhizotomy or nerve injury is performed by injecting glycerol in this same area instead of using heat. About 85-90 percent of patients have significant relief from TN pain. With this procedure there is a lower incidence of “anesthesia dolorosa.”

The benefit of these invasive non-surgical techniques is that the patient does not have to accept the risks of “major” brain surgery and associated general anesthesia. Another benefit is that recurrences of pain may be treated by repeat procedure, although the results of repeat procedures may be less successful.

Surgical
The surgical procedure performed to treat TN is called a microvascular decompression (MVD). The MVD is recommended for patients who have not responded to medical treatment and are in good health.

With this procedure, the patient is taken to the operating room and a small amount of hair is shaved behind the ear on the affected side. Under general anesthesia, the patient’s skin is opened and a small piece of bone is removed. Working under the microscope, the neurosurgeon is able to identify the blood vessel that is pressing against the nerve. The surgeon will then move it out of the way by tacking it up away from the nerve with an insulating sponge. The bone is then replaced and the skin is closed.

The benefit of the MVD procedure is that the problem itself is treated if in fact the blood vessel is the offending agent. There is an 85-90 percent initial success rate and 70 percent at 10 years after surgery. This is compared to the 20 percent success rate at 12 years post-operatively with the PSR. The incidence of facial numbness is also much less than with PSR, and “anesthesia dolorosa” does not occur.

The mortality for this procedure is less than 1 percent. The most common complications include mild facial numbness (25 percent, and usually temporary), hearing loss on the affected side (3 percent), double vision (usually temporary), spinal fluid leakage (5 percent) and meningitis (less than 5 percent).

Hemifacial Spasm
For hemifacial spasm, two treatment options are available.

Botox
This treatment involves local injections of botulinum toxin (Botox), which is typically performed by a neurologist. The toxin is injected into the affected muscles and works by paralyzing or weakening them. This can decrease or completely eliminate the spasm on a temporary basis. Eventually the toxin will wear off and another injection is required.

The most common complication of this treatment involves severe weakening of the muscles which may present itself as obvious facial weakness with asymmetry at rest, inability to close one’s eye with possible development of a corneal abrasion as a result, difficulty eating with food leaking out the corner of one’s mouth, etc. These symptoms depend on which muscles have been injected.

The patient must understand that if the HFS is caused by the artery pressing on the facial nerve, the Botox is not treating the problem, but rather may be temporarily improving the symptoms. The drawbacks include the need to repeat the injections periodically and the possibility of some permanent weakness after multiple injections.

The benefit of this treatment option is that the patient does not have to accept the risk of “major” brain surgery and associated general anesthesia.

Surgical Treatment
The surgical procedure performed to treat HFS is called a microvascular decompression (MVD), in the same manner as in trigeminal neuralgia (but concentrating on the facial nerve instead of the trigeminal nerve). MVD is recommended for patients who are not happy with the results of the Botox injection and are in good health.

With this procedure, the patient is taken to the operating room and a small amount of hair is shaved behind the ear on the affected side. Under general anesthesia, the patient’s skin is opened and a small piece of bone is removed. Working under the microscope, the neurosurgeon is able to identify the blood vessel that is pressing against the nerve. The surgeon will then move it out of the way by tacking it up away from the nerve with an insulating sponge. The bone is then replaced and the skin is closed.

Patient Information

What to Expect
First, a neurological examination should be performed by a neurologist. The exam is usually normal except for the ability to reproduce the pain by touching the trigger point. Imaging studies, such as an MRI scan with contrast, should be performed prior to any treatment in order to rule out a tumor as the cause of the pain.

Trigeminal Neuralgia
You and your neurologist will manage the pain with medications. The dose and preparation may be modified over time depending on your comfort level. If pain relief is not adequate or the side effects of the medications are unsatisfactory, consultation can he held to discuss alternative procedures.

For invasive non-surgical treatments, peripheral nerve blocks, percutaneous stereotactic rhizotomy and Gamma Knife® radiosurgery can be performed on an outpatient basis. Benefits of these invasive non-surgical techniques are that you will not have to accept the risks of “major” brain surgery and associated general anesthesia. Another benefit is that recurrences of pain may be treated by repeat procedure, although the results of repeat procedures may be less successful.

For invasive surgical procedures, microvascular decompression is recommended for patients who have not responded to medical treatment and are in good health. A special form or MRI called a “fusion scan” available here at Keck, can be performed to visualize the offending vessel contacting the nerve to aid in surgical decision making.

Hemifacial Spasm
For hemifacial spasm, botulinum toxin (Botox) can be injected into the affected muscles to paralyze or weaken them. This can decrease or completely eliminate the spasm on a temporary basis. Eventually the toxin will wear off and another injection will be required. Botox will not treat the problem, but may temporarily improve the symptoms. The drawbacks include the need to repeat the injections periodically and the possibility of some permanent weakness after multiple injections.

Surgical treatment involves microvascular decompression (MVD), similar to the surgical treatment of trigeminal neuralgia. A MVD takes approximately 1-2 hours in experienced hands. Post-operatively there may be episodes of mild HFS, however, they usually begin to diminish 2-3 days following the MVD.

Resources

Trigeminal Neuralgia Patient Support
TNA The Facial Support Group
Fpa-support.org

Living with TNA
livingwithtn.org
Online national support group for patients with trigeminal neuralgia

City of Los Angeles Network of Trigeminal Neuralgia Support
losangeles.networkofcare.org

National Institutes of Health Resources for Trigeminal Neuralgia
ninds.nih.gov/disorders/trigeminal_neuralgia

Hemifacial Spasm Patient Support
National Institutes of Health Resources for Hemifacial Spasm
ninds.nih.gov/disorders/hemifacial_spasm

Benign Essential Blepherospasm Research Support Center
blepharospasm.org

Our Physicians

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Practicing Locations

USC Healthcare Center 2

Specializing In

Cerebrovascular Disease of the Brain and Spinal Cord, Surgical Approaches to the Cranial Base, Stereotactic Radiosurgery, Microvascular Decompression for Bell’s Palsy, Lateral Skull Base Surgery for Facial Nerve Tumors

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Practicing Locations

Keck Hospital of USC
USC Healthcare Center 2
USC Norris Comprehensive Cancer Center and Hospital
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Practicing Locations

Keck Hospital of USC
LAC+USC Medical Center
USC Healthcare Center 2
USC Norris Comprehensive Cancer Center and Hospital

Additional Team Members

Dawn Fishback, PA