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Cedars-Sinai skull base surgeon performs world's first fully endoscopic microvascular decompression for relief of trigeminal neuralgia
Skull Base Surgeons at Cedars-Sinai Medical Center have successfully performed what is believed to be the world's first fully endoscopic Microvascular Decompression, bringing immediate relief to a Los Angeles-area retired assistant principal who had suffered with the excruciating facial pain of Trigeminal Neuralgia for nearly 20 years. Using a 2.7 mm endoscope, inserted into a dime-size opening behind the ear, the micro-surgery was performed without the use of retractors, which are typically used in conventional procedures to push the cerebellum behind the brain stem, and lasted about 1.5 hours (compared to 3-5 hours for a conventional procedure).
Trigeminal neuralgia is universally considered to be the most painful affliction known to adult men and women, but it is often misdiagnosed. When diagnosed and treated properly, sufferers usually experience immediate relief from the debilitating pain.
In a 90 minute micro-surgical procedure on Nov. 3, 1999, skull base surgeons at the Skull Base Institute at Cedars-Sinai Medical Center have performed what is believed to be the world's first fully endoscopic microvascular decompression, bringing instantaneous relief to Harriett Rose, a Los Angeles-area retired assistant principal who had suffered with the excruciating facial pain of Trigeminal Neuralgia for nearly 20 years.
Universally acknowledged as the most painful affliction known to adult men and women, Trigeminal Neuralgia (or severe facial pain) affects thousands of Americans every year, many of whom are misdiagnosed or do not yet know that help is available. Indeed, many undergo oral surgeries, tooth extractions and are prescribed a variety of medications, all to no avail. Rose, whose husband is a dentist, was no exception.
"Over the years, I've been to herbalists, chiropractors, nutritionists, a pain clinic, had massages, undergone acpuncture and had a non-invasive massage," she said. "Nothing worked."
"Initially, my dentist thought that my salivary glands were not producing properly, so he gave me lemon drops," she said. When that didn't help, Rose went to an oral surgeon who removed two of her wisdom teeth. Not only did the oral surgery not help, but it resulted in an open sinus that drained pus for about four months. A second oral surgeon admitted her to the hospital to close the sinus, and while he was successful in stopping the drainage, Rose's pain continued unabated, despite heavy doses of the prescription pain killer, Tegretol. Visits to numerous specialists yielded the same results: Nothing.
Over the years, Rose's pain intensified, going from a throbbing type of pain to sharp, stabbing pains, and a relentless dull ache. Eventually, she was unable to put anything into her mouth. "I couldn't brush my teeth or even put a drop of water in my mouth," she said. "When I would experience a flare-up, it would take six months to get it back under control."
Desperate to find some type of remedy, Rose thought that she might be reacting to certain types of foods and began omitting certain items from her diet in an effort to find the culprit. Chocolates, sweets, nuts, aged cheeses, dairy products, and wheat products were just some of the items she avoided, but the pain persisted. "I made lists of the foods I could eat and posted them all over the house," Rose recalled.
Then this Spring, things became markedly worse. "The pain became so bad I couldn't eat or even take my medication," said Rose. "During a six-week period, I dropped from 123 pounds to 108 pounds, and I felt myself growing weaker and weaker."
Then the niece of a friend unwittingly came to the rescue. The niece, who had previously suffered from Trigeminal Neuralgia also, urged Rose to make an appointment with Hrayr Shahinian, M.D., director of the Skull Base Institute at Cedars-Sinai. Rose asked her neurologist for a referral to Dr. Shahinian, and after one visit, knew that he was the surgeon for her. "When I talked to him, I knew right away that he was the man to do the surgery," she said. "He reviewed my previous x-rays, which other doctors had said were normal, was able to show me where the problem was, then explained how the procedure would work. I knew that he knew what he was talking about."
On November 3, when Rose went into the hospital, the pain was so intense that she still could not eat or even talk. When she woke up, however, she was totally pain free. "My daughter came to visit me in the ICU," Rose remembers. "She asked me to squeeze her hand once if I wanted to answer 'yes' to a question, and twice for 'no.' When she asked me if I had any pain, I squeezed twice."
According to Dr. Shahinian, because of the minimal invasiveness of the fully endoscopic procedure, Rose probably could have gone home within 24 hours after the surgery, except that her body had become dependent on the pain medication she had been taking for years.
"The benefits to this type of surgery are indisputable, said Dr. Shahinian, who has also pioneered a fully endoscopic micro-surgery procedure for removing pituitary tumors. Benefits include:
- Minimal scarring -- the point of entry is through a dime-size opening behind the ear.
- Fewer complications.
- No retractors are needed. Because the surgeon can fully visualize (through the endoscope) the blood vessel that is compressing the nerve, there is no need for retractors to be placed on the brain. In conventional microvascular decompression procedures, retractors are typically needed to push the cerebellum back behind the brain stem so the surgeon can see the surgery site. By looking through the endoscope, he can see the problem area without disturbing or re-positioning the brain.
- Shortened surgery time (At present about 1.5 hours compared to 3-5 hours for traditional microvascular decompression surgery. Dr. Shahinian expects that time to shorten even more.)
- Dramatically reduced length of stay in the hospital (At present, about 2 days compared to 5 days for a traditional microvascular decompression procedure. Dr. Shahinian anticipates that within the next two years, this may become a "same-day" surgery.)
- Less discomfort as the brain itself is not disturbed.
- Faster overall recovery, return to work and normal activities.
Today, three weeks after the operation, Rose remains pain free, and two other patients have undergone the state-of-the-art procedure with similar results. "It's a gift," Rose says simply. "This year I'll be able to enjoy the holidays with my family -- pain free."
Oh yes, and all those food lists that she had posted around the house? Rose says she's thrown them all away.
TRIGEMINAL NEURALGIA BACKGROUNDER/SIDEBAR:
Until 1990, relatively little was known about this debilitating disorder, and until recently, treatment options were limited and largely ineffective. Now, however, thanks to a highly specialized type of skull base surgery known as Microvascular Decompression, sufferers can get immediate relief.
According to Hrayr K. Shahinian, M.D., Director of Cedars-Sinai Medical Center's Skull Base Institute, Trigeminal Neuralgia is a disabling disorder of the fifth cranial (trigeminal) nerve. Pressure on this nerve can cause episodes of intense, stabbing, electric shock-like pain in the face. "The pain we are talking about is excruciating - extremely intense, extremely severe," says Dr. Shahinian. "The shock of it can actually cause a sufferer's head to snap back, or it can immobilize the individual. The pain attacks viciously and without warning and left untreated, tends to worsen over time."
This severe facial pain is caused when a blood vessel is in contact with the trigeminal nerve inside the head and is applying pressure to the nerve. Relieving that pressure is a delicate, time-consuming surgical procedure that can take up to five hours using conventional techniques. Using the new, fully-endoscopic approach, that time is usually reduced to approximately 1.5 hours. During the procedure, surgeons meticulously separate the nerve and blood vessel, then insert a Teflon disk between them. Once that pressure has been relieved, patients often report immediate and complete relief from the pain that had become a part of their lives.
"The pain was so severe that sometimes it would cause my head to snap back," says Kurt Kasinoff, a 33-year-old production manager who underwent a traditional type of Microvascular Decompression in Aug., 1997. "It would start as a sharp pain on my left upper lip and would shoot up through my eye, forehead and sometimes the roof of my mouth. There would be no warning, and something as slight as the air from a breeze could start it off. The pain was literally immobilizing - all I could do was sit perfectly still and not move. It was like having a tooth filled without any Novocain," Kasinoff remembers.
Jean Greenebaum, 72, agrees. She also underwent a conventional Microvascular Decompression procedure after suffering with the pain for 10 years. "The pain was sudden, severe and unrelenting," she says. "When it happened, people could tell just by looking at me that something had happened, because I would just freeze -- fearful of making even the slightest movement. I remember once having dinner in a restaurant with my daughter, and the pain came. I didn't make a sound, but tears rolled down my cheeks."
Both Kasinoff and Greenebaum initially thought that the pain was caused by a toothache and went to several dentists. Both also tried various medications without success, and Greenebaum even underwent two root canals and other treatment options before she was finally referred to a neurologist. Initially, he was reluctant to refer her for surgery because of her age. However, after being examined by specialists at the Skull Base Institute, she was deemed a good candidate for the procedure and decided to move forward with it.
After their respective surgeries, both Kasinoff and Greenebaum enjoyed prompt relief from the pain. "It completely eliminated the pain," says Kasinoff.
"I wish I'd known about this surgical procedure years ago," Greenebaum adds. "It was certainly worthwhile, and if I had it to do over again, I wouldn't hesitate to go this route. What is more, I would encourage other people -- even older people -- to consider this treatment, too. When I woke up from the surgery, the pain was gone immediately."
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