From the Twitch of an Eye to Hemifacial Spasm Surgery

It started nine years ago with an occasional twitch in Ruby M.’s left eye. As time went on, the twitching became more frequent, severe and painful. Little did she know, she was having hemifacial spasms.

“By the time I started looking for help, it was pulling the left side of my face up to my eye, which would close completely,” the 68-year-old Indio resident recalls. As a result, she couldn’t drive, her sleeping was disturbed, eating was a challenge, and social interaction extremely difficult.

Hemifacial Spasms – a Neurological Disorder

Ruby had a condition called hemifacial spasm (HFS), a neurological disorder in which muscles on one side of the face involuntarily contract, causing sporadic, uncontrollable contortion of the face. It’s usually caused by a blood vessel that compresses the facial nerve where it exits the brainstem. The facial nerve controls the muscles of facial expression.

HFS typically begins in the muscle surrounding the eye and can spread to involve other muscles on the same side of the face. Spasms can worsen over time, leading to nearly constant disfigurement with a grimacing expression. The condition can also worsen in times of stress and fatigue.

Temporary solutions but no relief

“I saw several doctors, but the only treatment they offered me was Botox^®,” Ruby says, referring to botulinum toxin, a bacterial toxin injected into facial muscles; it paralyzes the muscles so they don’t move. However, it is only a temporary solution.

“I had to go back every three months for treatment,” she says, “but the spasms continued to get worse, pulling all the way from my neck to my eye.”

Then, about two years ago, Ruby developed a heart problem requiring a pacemaker to be implanted. This device, which regulates heart rhythm, is placed under the skin near the collarbone on the left side of the chest.

“The spasms then started pulling from there upward, and I was concerned,” she says. “So I saw a neurologist who recommended I see a neurosurgeon who could do surgery for this condition. Other doctors had said there was no surgery for this.”

Neurologist Indermohan Luthra, MD, recommended Board Certified Neurosurgeon Farhad Limonadi, MD, Director, Neurosurgery, Eisenhower Neuroscience Institute. He specializes in brain tumors, minimally invasive spinal surgery, trigeminal neuralgia, facial pain, aneurysms, deep-brain stimulation, and complex spine and chronic pain syndrome.

Surgery – the best option

“Surgery really is the best option for treating the underlying cause of hemifacial spasm,” Dr. Limonadi says. “While Botox may provide some short-term symptom relief, it has side effects such as sagging and weakness of the muscle. And Ruby’s spasms were intensifying in duration and frequency, so this conservative approach had failed.”

Dr. Limonadi performed a retrosigmoid craniotomy with microvascular decompression — a microsurgical intervention performed under a surgical microscope.

“We make a small, quarter-sized entry in the back of the head, on the same side as the spasm, and essentially sneak by the cerebellum and get to the nerve and brainstem,” he explains. “We find the artery that’s pressing on the nerve, separate it from the brainstem and nerve, and place a Teflon™ insulator (a small sponge-like pad) between them.”

It typically takes six months to see meaningful improvement of HFS symptoms after surgery. Ruby’s symptoms began to improve almost immediately. This surgery can be viewed by clicking here.
“Ruby can drive again, and the facial twitching is dramatically reduced,” Dr. Limonadi says. “The improvement is remarkable.”

“He really helped me a lot,” she says. “I can go for days without symptoms now.

“It’s important for people with hemifacial spasm to know there are surgical options which are quite successful,” Dr. Limonadi adds. “People don’t have to live with the facial pain or severe twitching that affects quality of life.” He also credits Dr. Luthra for an appropriate diagnosis and proper management of Ruby.

“A lot of doctors don’t recognize this condition,” Dr. Limonadi says. “But he managed it responsibly and referred responsibly.”