Joshua M. Rosenow, MD, FAANS, FACS
Director of Functional Neurosurgery, Northwestern University Feinberg School of Medicine
Trigeminal neuralgia (TN), also known as tic douloureux, sometimes is described as the most excruciating pain known to humanity. The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face.
Neurosurgeons have always been at the forefront of TN treatment. While medical treatments such as diphenylhydantoin came along in the 1940s, followed by the prototypical TN drug carbamazepine in the 1960s, neurosurgeons had already developed multiple surgical procedures aimed at curing this disabling disease.
John M. Carnochan, MD had begun removing the trigeminal ganglion in the 1850s. Other surgeons, such as William Rose, Edmund Andrews and Victor Horsley, adopted this technique as well. The Hartley-Krause approach (named after Frank Hartley, MD and Fedor Krause, popularized in the 1890s, involved approaching and resecting the trigeminal ganglion without opening the cranial dura. William G. Spiller, MD and Charles Frazier, MD refined the procedure by only performing selective resection of the affected divisions of the nerve, with the hope of sparing the unaffected regions. Neurosurgeons adopted this as the standard surgical approach for TN, especially given the absence of any good medical therapy.
At Johns Hopkins in the 1920s, Walter E. Dandy, MD had begun to revolutionize the approach to the trigeminal nerve by opening the skull behind the ear and approaching the nerve at its exit point from the brainstem. This modification is one of the most pivotal in the history of TN treatment. While Dandy used this approach to perform partial cutting of the trigeminal nerve root, he had the opportunity to observe that many of the painful nerves were compressed by arteries. In multiple publications in the late 1920s and 1930s, he speculated about the presence of arterial compression as the cause of TN. His seminal publication in 1934 “Concerning the Cause of Trigeminal Neuralgia,” documented the high frequency of cases with neurovascular compression. This led to the popularization by Peter J. Jannetta, MD several decades later of microvascular decompression. This remarkably safe and effective procedure has become commonplace in the treatment of TN. Moreover, the recognition of vascular compression as playing a role in the etiology of TN has not only provided insights into the genesis of this disease but also into the origins of other disorders such as hemifacial spasm and glossopharyngeal neuralgia.
Neurosurgeons have also pioneered less invasive surgical treatments. Bernard J. Cosman, MS took advantage of the ability for radiofrequency energy passed through an electrode to generate heat and destroy tissue to selectively lesion branches of the trigeminal nerve to relieve pain. Later, neurosurgeon John F. “Sean” Mullan, MD used this same approach in placing a needle at the trigeminal ganglion to develop the balloon compression procedure that can more easily treat a wider distribution of facial pain without requiring the patient to be awake during the procedure.
In Sweden, Lars G. Leksell, MD created the Gamma Knife. This invention created an entirely new class of surgical treatment — stereotactic radiosurgery. Never before had physicians been able to so precisely target radiation without the surrounding tissues also receiving significant radiation exposure. This device now allowed neurosurgeons to deliver high doses of radiation to the trigeminal nerve root while sparing the adjacent, sensitive brain stem from significant radiation. This provided yet another option to patients suffering from TN who could not undergo other procedures or to whom other procedures were less attractive.
Neurosurgeons have continued to innovate over the years in the service of fighting facial pain. In recent years Kim J. Burchiel, MD, FAANS, has redefined how we discuss and diagnose facial pain, allowing neurosurgeons to help ensure that patients receive the correct treatment. For those patients with non-TN facial pain, neurosurgeons in Japan and Europe such as Takashi Tsubokawa, MD, PhD and Yves Keravel, MD have popularized cortical stimulation and Yoshio Hosobuchi, MD, John Adams, MD and Donald E. Richardson, MD in the United States, among others, have played roles in investigating the role of deep brain stimulation.
Neurosurgeons remain committed to providing the highest level of compassionate and timely care for patients suffering from facial pain. We will continue working diligently to bring new technology and scientific discoveries to patients in the hope of relieving them of this burden.
Editor’s note: The content of this post originally appeared on the American Association of Neurological Surgeon’s (AANS) website as part of their 2017 Neurosurgery Awareness Month on trigeminal neuralgia. During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.