Volume 16, Number 3
Surgical Options Hit Facial Pain
Where It Hurts
On Mother's Day last year, Betty Berlin got an unwelcome present-excruciating facial pain, courtesy of trigeminal neuralgia (TN). Home alone, Berlin, 81, danced and screamed for about 15 minutes, she recalls, until the attack subsided.
Classic TN like Berlin's is characterized by unpredictable pain to areas served by the trigeminal nerve-the upper, middle and lower face. Pain keeps to one side during any single attack. Patients liken TN pain to being struck with a 220-volt electrical wire for seconds to minutes at a time, making their previous heart attacks or kidney stones a walk in the park.For Berlin and most patients, antiseizure drugs like carbamazepine, while effective at first, eventually aren't enough. "The peaks [of pain] only get higher, and the valleys aren't as low and don't last as long," says Carol James, P.A., longtime physician assistant with neurosurgeon Benjamin Carson, M.D.
Fortunately, Hopkins has surgical options to give patients with classic TN an excellent chance at durable pain relief. All address the source of the problem, an overstimulated, hyper-reactive trigeminal nerve. Two are minimally invasive-the percutaneous approaches or stereotactic radiosurgery. There's also more traditional open surgery. "The surgical options for treating classic TN are very good," says Richard Clatterbuck, M.D., Ph.D., "and patients should be referred fairly early in the disease, before pain becomes agonizing."
Clatterbuck offers stereotactic radiosurgery using the Leskell gamma knife. The non-invasive approach sends a focused blast of radiation to the nerve, just outside the brain stem, causing damage that reduces its sensitivity. He also performs gold-standard surgery: microvascular decompression (MVD) via craniotomy. MVD addresses a common cause of classic TN by shifting abrasive blood vessels away from the nerve. Carson, in turn, offers MVD and percutaneous approaches. In the latter, a needle gently inserted through the cheek delivers nerve-toxic glycerol to the nerve. Or a small, carefully directed radiofrequency-emitting probe is inserted, generating nerve-damaging heat. Neurosurgeon Richard North, M.D., offers all three.
Each of the procedures, says James, carries different risks, so Hopkins doctors discuss options, helping patients choose the most suitable. "But the terrible pain of this condition is far more deleterious than the risks of the procedure," she emphasizes. The oldest patient, at 100, "did quite well."
A month ago, after Berlin's diagnosis was confirmed, she and Clatterbuck opted for the gamma knife. This Mother's Day found her waiting out the not-unusual period for the procedure to "take."
"There's no reason why patients with classic TN should suffer with pain or take large doses of antiepileptics," says Clatterbuck.
Now on low-dose gabapentin, Berlin has high hopes for that very outcome. --J.D.
For more information, call:
Carol James, 410-614-4449
For Dr. North, 410-955-2438
For Dr. Clatterbuck, 410-287-1260