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Trigeminal Neuralgia
By Hrayr Shahinian, M.D.
K.K. is a 31-year-old Caucasian male who, for the past 5 years, had signs and symptoms of trigeminal neuralgia. These consisted of severe shooting pains in the distributions of VI, V2 and V3 on the left side. Over the past one to two years, his symptoms had progressively become worse. He was treated with Tegretol and Neurontin which initially provided good control of his neuralgia. Subsequently, his neuralgia became refractory to medical therapy, at which point he was referred to the Cedars-Sinai Skull Base Institute for further evaluation.
His past medical history was otherwise unremarkable, and his physical exam showed no additional signs other than pain, when chewing, radiating from his upper lip to the forehead region. His work-up included an MRA study, with gadolinium, with thin cuts, which confirmed the presence of a vascular loop compressing the left trigeminal nerve. He was informed of all the possible options, including expectant therapy, continued medical therapy, radiosurgery and elective microvascular decompression of the trigeminal nerve. It was also emphasized to the patient that, in our opinion, a microvascular decompression of his left trigeminal nerve would be the treatment of choice and would cure him of his disabling neuralgia. After consulting with his wife, he elected to proceed with the microvascular decompression.
He was taken to the operating room approximately six weeks later. Intraoperatively, through a retrosigmoid approach, the origin of the left trigeminal nerve from the brain stem was identified, and a vascular loop was clearly seen compressing it. Using the operating microscope and micro instruments, and with the help of intraoperative facial and trigeminal nerve monitoring, the left trigeminal nerve was decompressed. Two small pledgets of Teflon were used to keep the vessel off of the nerve. These were secured in place using fibrin glue.
Postoperatively, he was neurologically intact except for a mild neuropraxia of his left upper extremity, due to his intraoperative positioning. This resolved spontaneously over the next 36 hours. He was kept in the surgical intensive care unit for one night after which he was sent to the floor, where he stayed another 24 hours. He was discharged home on post-op day 3 and seen in follow-up two weeks later, where all of his staples were removed. He was subsequently seen by his internist and neurologist and has had no facial pain whatsoever.
Microvascular decompression of cranial nerves for trigeminal neuralgia, refractory to medical therapy, and for hemifacial spasm, is associated with excellent results. The cure rate is more than 95 percent if the preoperative work-up includes a specialized MRA which documents the presence of a vascular loop compressing the respective cranial nerve. At the Cedars-Sinai Skull Base Institute, every patient undergoes a detailed workup to prove the existence of the offending vessel.
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