Say Goodbye
To Trigeminal
Neuralgia Pain
With MVD Surgery

Trigeminal Neuralgia pain is primarily caused by pulsatile pressure on the trigeminal nerve, leading to a short-circuiting effect. This occurs when one or more blood vessels compress the Root Entry Zone (REZ) of the nerve, damaging the myelin insulation that normally prevents cross-talk between nerve fibers. The compression and continuous pulsations against the nerve lead to the perception of sudden, severe sharp pain during trigeminal neuralgia attacks. As individuals age, blood vessels can elongate and harden, causing them to indent and bury themselves into the REZ portion of the nerve, exacerbating the disease process. While some patients may experience temporary pain relief known as “pain holidays” when the body attempts to repair the damaged myelin, the attacks generally become more severe and frequent over time. Except for cases related to underlying conditions, such as multiple sclerosis or tumors, the majority of trigeminal neuralgia cases are attributed to blood vessel compression, which can be identified and addressed by a skilled surgeon.

In the initial phase the attacks are short and there is a long gap between them. Progressively the attacks tend to become longer, more severe and more frequent. There may be sudden disappearance of the attacks for a few days or months but gradually these attack ‘holidays’ also become rare and then disappear. In patients who are not treated in time, the attacks become almost continuous and the sufferer is reduced to a miserable creature begging for relief.

Trigeminal neuralgia is basically a clinical diagnosis. What it means is that doctors make the diagnosis by carefully listening to the patient’s history and description of the pain. The typical trigeminal neuralgia has following characteristics:
* it comes suddenly and lasts from seconds to many minutes
* it is in the distribution of the trigeminal nerve, on one side of the face
* it can start from upper or lower gum, teeth, nose, chin, cheek, just in front of the ear, forehead, eye, temple and spread to other parts of the face

The pain experienced in trigeminal neuralgia is very severe and is often described as:
* Sudden electric-current or shock-like pain
* Sudden piercing, sharp knife-like pain in the face
* Pricking of multiple sharp needles
* Sudden blast of hot bomb in the face
* Like somebody putting red-chilli powder on the face.
* Like a lightning striking the face.

Initially, the attack terminates in a few seconds or a few minutes, and then the person is usually pain-free till the next attack. In the advanced stage, the pain remains for a longer time, or become continuous for extended periods of time; and there is continuous low intensity pain between the attacks.

There are a few commonly seen trigger points, which when stimulated start the attack.
* Upper lip
* Ala of the nose
* Forehead just above the eye
* Just in front of the ear
* Upper or lower gum
* Just below the lower eyelid.
Touching one or more of these points, blast of cold, air hitting them, even a gentle breeze against them, brushing teeth (the toothbrush touching the gums), washing face, shaving, jaw movements while talking or chewing etc., can bring on the trigeminal neuralgia attack.

The diagnosis of trigeminal neuralgia is made on the basis of a good medical history. Usually, the description of pain and the patient’s severe agony while talking, typical facial contouring and defensive facial posturing to avoid an attack, immediately give away the diagnosis. However, I always feel that along with the diagnosis of the disease, one has to acquire a fair idea about the severity of the disease.

It is very easy to assume that the patient’s pain is well controlled, if, at the moment of consultation, due to the effect of an anticonvulsant medication the patient appears free of pain. Many patients take their medication sometime before they come to see the doctor, as they rightly expect that they will have to talk a lot during the consultation. I have found time and again, that the apparently normal looking patient giving history of severe, unbearable pain attacks on the very morning.

On probing carefully the spouse, daughter or brother/sister of the patient, describe that pain attacks while the patient starts eating, I have found that the patients learn to tolerate certain amount of pain as they fear that increasing the dose of sedative anti-convulsants will make them non-functional (based on the previous experience).

What they don’t know is that there is a surgical option, having the potential to cure the disease and stop the drugs. That is the reason, why detailed history is a must.

A good quality MRI with trigeminal nerve sequences is the next step, primarily to rule out tumours. A demonstrable vessel-compressing the nerve is helpful but NOT A PREREQUISITE for surgical decision.

This is because severe vascular compression does exist, demonstrable at surgery even when MRI does not show it.

Radio-Frequency Lesioning (RFL) is another option, though I personally keep it reserved only for the occasional patient who does not benefit from MVD surgery, or who is not fit for this surgery or anaesthesia.

This is because, if RFL is done primarily, the chances of the MVD becoming successful is reduced by more than ten percent. RFL, unlike MVD is a destructive procedure. At first, it seems to be an attractive option to MVD, as it seems a very simple procedure. It is one of the weapons in the armamentarium to treat trigeminal neuralgia no doubt, but it is by no means a simple procedure. It destroys a part of the nerve and has complication rates akin to surgery.

Radiofrequency lesioning of the trigeminal nerve is done at the trigeminal ganglion. The Trigeminal ganglion is a small pea-sized nubbin of nerve tissue present in the middle of the skull base from where the three divisions of the trigeminal nerve branch out. These divisions travel forward under the brain in the skull.

To perform the technique of RFL, a thin long needle is inserted through the cheek towards the ganglion through an opening in the base of the skull. This procedure is done under local anaesthesia; and during the actual lesioning, a small dose of general anaesthetic or sedative may be given. A machine that can shoot X –rays continuously (C-arm) is used to direct the needle to its proper position through the ‘foramen ovale’, a small hole at the base of the skull. Once the needle is appropriately positioned, the pain is elicited and confirmed. Then, the needle is connected to the RFL machine. The machine then transmits radiofrequency waves through the needle to its tip. These waves generate heat and destroy the nerve fibers that are responsible for causing the pain.

No. According to Dr. Peter Janetta and his team, who did great work in MVD surgery field in the last century, the efficacy of surgery is higher when done EARLY in the course of the disease. That is, it is prudent not to keep taking medicines numbing the nerve and the entire nervous system for a long time, if you want to increase your chances of being cured. Also, this surgery should be done BEFORE any of the destructive procedures like radiofrequency lesioning (RFL) is attempted. The success rate is also better in the hands of a team that routinely does this surgery. This means that the team which is experienced in this surgery, and does this surgery frequently is likely to give better results.

A common misconception is that this surgery is not for the elderly. On the contrary, to quote Janetta, “this surgery is eminently suitable for the elderly sufferers as the cerebellum is atrophic and the corridor to the nerve wide open for the surgeon.” Our personal experience confirms it emphatically and over half of our patients were elderly.