Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is a neurological disorder characterized by involuntary contractions of the muscles on one side of the face. The spasms typically begin around the eye and can spread to the mouth, jaw, and other facial muscles.

Hemifacial spasm is caused by irritation or compression of the facial nerve as it exits the brainstem. This can be caused by a blood vessel pressing on the nerve, rarely a tumor, or another underlying condition.

Symptoms of hemifacial spasm can vary from mild twitching to severe spasms that affect your ability to speak or close your eye. Treatment options for hemifacial spasm include medications, Botox injections, nerve blocks, and surgery to correct the underlying cause. Hemifacial spasm surgery is the only option that can potentially cure this condition.

The exact treatment for hemifacial spasm depends on the underlying cause and severity of the condition. The goal of treatment is to reduce or eliminate the muscle spasms and improve your quality of life. Many patients ask, “How do I get rid of hemifacial spasms?” Several treatment options can help, but surgery is the only potentially curative method. Non-surgical treatment options for hemifacial spasm include:

• Medications: Anticonvulsant medications, such as carbamazepine and valproic acid, can help reduce or eliminate hemifacial spasm symptoms in some people. However, they may not be effective in many cases, and they can have side effects.
• Botox injections: OnabotulinumtoxinA (Botox, Allergan Aesthetics, Irvine, CA) injections can be used to relax the muscles that are causing the spasms. The injections are typically given every 3 or 4 months to maintain the effect.

The spasms may recur more frequently and earlier as time goes by, and more injections are done. The gradual return of spasms can be bothersome to many patients at the end of each cycle of Botox injection, leading patients to seek more definitive solution via surgery. Moreover, long term Botox injection may lead to permanent facial weakness and cosmetic deformity that is unacceptable to many patients. Therefore, early surgery should be strongly considered.

A neurosurgeon with extensive experience in this surgery can minimize the risks of surgery and provide best results.

• Nerve blocks: A nerve block is an injection of a local anesthetic and a steroid around the facial nerve. This can help reduce inflammation and relieve spasms. Nerve blocks are typically used for short-term relief and are not a long-term solution.

The two options for surgery for hemifacial spasm include microvascular decompression (MVD) and very rarely radiofrequency thermocoagulation (RFTC). Microvascular decompression is typically the method of choice.

The most common surgical procedure used to treat hemifacial spasm is called microvascular decompression. This procedure is performed with general anesthesia and involves making a small incision behind the ear to make a small opening in the skull and access the facial nerve. Once the nerve is located, a small pad or sponge is inserted between the blood vessel and nerve to decompress the nerve.

This procedure has a high success rate with more than 80% of patients experiencing significant improvement or resolution of spasms shortly after surgery. However, up to 10% of patients may experience recurrence and require further treatment. Not all patients will be a good candidate for surgery. Discuss treatment options with your surgeon to determine if microvascular decompression is right for you.

For more information about the technical aspects of the surgery and extensive experience of Dr. Cohen, please refer to the chapter on Microvascular Decompression for Hemifacial Spasm in the Neurosurgical Atlas. 

Another surgical option for treating hemifacial spasm is called radiofrequency thermocoagulation. This procedure is performed with local anesthesia, and a special probe is used to heat and partially injure the nerve fibers that are causing the spasms. Although radiofrequency thermocoagulation is less invasive than microvascular decompression and has a shorter recovery time, it is typically less effective at alleviating symptoms and has a higher recurrence rate. This procedure is reserved for patients who are unable to undergo surgery.

Microvascular decompression is typically preferred over radiofrequency thermocoagulation. Because damage is being intentionally done to the facial nerve, this will cause some degree of permanent facial weakness after the procedure.

As with any surgical procedure, microvascular decompression carries risks and potential complications. Because the procedure involves finding the facial nerve and applying a sponge to decompress the nerve within the confines of a small working space, the potential risks and complications are related to damage to the nerve and its surroundings. These include:

• Hearing loss: Some patients may experience total hearing loss on the operative side. Approximately 5% of patients may have partial hearing loss.
• Facial weakness: Permanent facial weakness on the affected side can occur in up to 6% of patients, although up to 20% of patients may experience temporary facial weakness immediately after the procedure that will go away over time.
• Impaired coordination: Up to 5% of patients may experience imbalance and trouble walking after the procedure.
• Hoarseness or trouble swallowing: Rarely patients may experience a feeling of hoarseness or difficulty swallowing. This is usually minor and temporary.

These risks are significantly less in the hands of experienced surgeons.

Other potential complications of surgery involving the brain include bleeding, infection, and leakage of cerebrospinal fluid.

Hemifacial spasm surgery recovery time can range from two to four weeks. After surgery, you will likely stay in the hospital for 1 or 2 days and will be monitored for the presence of any complications. Most patients experience temporary side effects such as nausea and headaches, though these can be managed with medications. Patients may be given prescription medications or be advised to use over-the-counter pain relievers and other homecare remedies to manage minor side effects. 

After one week from discharge from the hospital, patients are usually scheduled for a follow-up post-op consultation. Your surgeon will check your healing progress and ensure there are no complications. They will also advise you on how to return to your regular routine.

You are likely to be able to return to average daily activities within a week after surgery and return to a desk job within two weeks.

Patients who have undergone microvascular decompression should see an immediate improvement. Rarely, it may take several weeks to determine if the procedure was successful. 

Hemifacial spasm can resemble other movement disorders of the face, such as facial myokymia. Facial myokymia is a condition characterized by spontaneous, fine muscle contractions on one or more areas of the face.

These contractions can appear as twitching or rippling of the skin and can be accompanied by a sensation of tingling or burning.

In some cases, the contractions may be limited to a small area of the face, such as the eyelid or cheek, but in other cases they may involve larger areas of the face, including the mouth, jaw, and even the neck.

The exact cause of facial myokymia is not known, but it is thought to be related to irritation or dysfunction of the nerves that control the facial muscles. Some possible causes of facial myokymia include:

• Inflammation of the facial nerve (Bell’s palsy).
• Injury or trauma to the face.
• Tumors or other growths on or near the facial nerve.
• Multiple sclerosis.
• Toxins or medications.
• Neurological or metabolic disorders.
• Idiopathic, with no underlying cause found.

Facial myokymia treatment focuses on management of the underlying condition or use of medications such as Botox injections or anticonvulsant medications that may alleviate symptoms.

However, facial myokymia typically resolves on its own within weeks to months. Seek medical attention to determine the cause of your facial twitching and begin appropriate treatment.

• Hemifacial spasm is a neurological disorder that causes involuntary contractions of the muscles on one side of the face.
• Microvascular decompression is a surgical procedure that can be used to treat hemifacial spasm by relieving the pressure on the facial nerve.
• More than 85% of patients will experience a lasting cure and relief of spasms after microvascular decompression.
• Risks of microvascular decompression are small and include facial weakness, hearing loss, hoarseness, impaired coordination, infection, and bleeding.

• American Association of Neuromuscular & Electrodiagnostic Medicine
• National Institute of Neurological Disorders and Stroke