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what is trigeminal neuralgia


TRIGEMINAL NEURALGIA (SEVERE FACIAL PAIN) AND MICROVASCULAR DECOMPRESSION

What is trigeminal neuralgia?

Sudden, shooting, lancenating, electric current like pain that originates in the cheek, jaw or forehead region is known as trigeminal neuralgia. It can extend into the eyelids, tip of the nose, and gums.

What triggers the neuralgia attack?

Touching certain parts of the face, gums, nose is a common trigger.
Other common triggers include chewing food, brushing teeth, speaking, etc.

Even a wind breeze hitting the face can trigger the attack. Some others may assume that the pain arises due to the dental caries and may visit dentists to have a tooth removed!

The neuralgia attacks can be so severe that some of the patients contemplate suicide.
The very initial treatment is the nerve numbing drugs like carbamazepine and gabapentine. However these medicies cause drowsiness and loss of balance as their dose requirement increases. Furthermore they are just symptomatic therpy and do not address the basic cause of the disease.

 "Suicide disiase"   study of 943 patients 10.10. 2015 
   
 It's a pain that drives you to suicide  
   



Why is there pain?

The trigeminal nerve carries sensation from different parts of the face to the brain through its three divisions. “What is the reason behind these attacks and what therapy can cure it?” was the question tormenting many of the great medical minds for years but without any effect.

A British Neurosurgeon chanced upon an interesting and serendipitous discovery years ago. The area where the trigeminal nerve enters the brain is called the root entry zone. Jeneta discovered that quite often there are one or more blood vessels which lie close to the REZ. These transmit their pulsations to the nerve and the REZ. The transmitted pulsations cause disease in the area of the nerve in contact and this is the real cause of this disease. He thought of  a simple surgical technique of separating these blood vessels from the nerve and keeping them separated by introducing a small pledget of Teflon between the too. Dramatically, the very first patient was totally pain-free after the surgery. Dr Jeneta persevered with this technique and finally it became accepted in the medical community.

These patients experienced joy akin to having a second lease of life!
Even those doctors, who had initially criticized his work, had to appreciate the success of this surgery.

MICROVASCULAR DECOMPRESSION

Many years have passed since this incidence of the serendipitous discovery.
Having performed more than a 100 such surgeries, and interacting with the patients and their relatives and receiving their feedback, I now feel that this surgery as a treatment modality should be offered to these patients, even at early stages before the disease alters personalities and cause psychological problems.

This surgery is performed with the help of a neurosurgical microscope and a small pad of Teflon is interposed between the blood vessel and the nerve (diagram).
Patients are discharged from the hospital in 3 days’ time.It is one of the few operations in Neurosurgery where the results are dramatic and seen early.

Treating pain and restoring the patient’s life to normalcy is one of the primary responsibilities of a surgeon. And this surgery gives me the chance to do the very same!

  
No more facing the pain

Successful neurosurgery



   

Ashwini Ghogardare

   

Mr Bhandare

Trigeminal neuralgia has been infamous due to the fairly justified name-tag of "Suicide Disease". 
For ages people have treated it with various methods including application of red chilli powder or Capsacin to the affected part of the face, cutting the
nerves supplying part of the face, numbing themselves with alcohol or drugs etc.
Even in modern times various medical treatments have been tried including ..again.. cutting of the nerves, burning a part of the nerve by the procedure known as Radiofrequency lesion generation (RFL), radiating a part of the brain and nerve etc.
Having used some of these methods in the past (Like RFL) and carrying out over 900 MVD surgeries over the period of the last 10 years, we are more than convinced that this treatment has the best chance of offering a very long term relief or even cure to these unfortunate sufferers...if done fairly early in the course of the disease and by the team performing these surgeries repeatedly. This point was validated long time back by the famous Dr Peter Jennetta who was the pioneer in the field of MVD surgery.
Without getting lost in the medical debates and unnecessary noise of opinions about the treatment of this malady, (which does not help the patients but may reflect war of egos amongst the doctors under the name of statistics), let me summarise by saying that we have an unwavering faith in this surgical treatment, validated by our experience, patient feedbacks and that of many other surgeons before us. 
It is our mission to make available a center of excellence where this surgery is carried out with high frequency and by the same team, with the aim of fighting this terrible pain for sufferers who wish to get rid of this problem. 
I became particularly interested in the treatment of this disease after a unique experience, about 10 years back, in my neurosurgical career. 
Before this incidence, I used to operate on trigeminal neuralgia patients with a surgical procedure called Micro Vascular Decompression (MVD) but not with the frequency and focus with which I have been doing for the past 10 years. 
On a particularly lazy and ordinary afternoon, as I was finishing my neurosurgical clinic, my secretary approached in the door and informed me that there was a rather queer looking gentleman who had come from far away, and it would be better, even though my consulting hours were long over, if I would have a look at him.
A mixture of dismay and astonishment on her face, no doubt brought about by this gentleman's appearance, was quite apparent, and I instantly signalled her to send him in.
I must admit that, though not unfamiliar with the facial agony chronic neuropathies and back problems are apt to bring on in such people, I was taken aback with this man's appearance.
He was a middle aged gentleman, in the late forties or early fifties, his face not shaven for at least two weeks, his walk unsteady and eyelids drooping.
“Are you doctor Jaydev ?” he asked, barely managing to open his mouth. His face was contorted with pain, as he spoke.
There was a shabby looking bag dangling from his right shoulder and his right hand was immersed in it.
As he sat down, he produced a bottle from the bag and placed it on my table.
It was a bottle of insecticide!!...
The scene was unfolding rather unexpectedly for me.
“Well..... please tell me you can cure my pain because, otherwise the alternative is to drink the contents of this bottle and die.........” he said as plainly as possible.
To cut the story short, he was suffering from severe trigeminal neuralgia which had started about six years back. He was having severe stabbing pain on the right side of his face which would be brought about merely by trying to open his mouth. He was not able to talk, eat, shave or even wash his face..... for many days and hence his appearance. He was on very high doses of carbamazepine and gabapentin.... drugs used to control the pain of trigeminal neuralgia.
I was well aware that this disease was called “ Suicide disease” as the sufferers of this painful malady were known to prefer death to continuous suffering of pain. The disease was also infamous due to the expressions like...
“The worst pain known to the mankind” and 
“ The kind of pain one would not wish even for your enemy”.....
But was it not the thing of the past? Do people not know that there is very effective surgery which has the potential to cure this pain..... allowing them to stop the nerve, and indeed the brain, numbing drugs? Why should a sufferer be pushed to this degree of desperation in this modern age?
But right in front of my eyes was sitting a living example and undoubted proof that this disease pushes the sufferers to the extreme even today.
There was no doubt in my mind that he needed surgical treatment for this problem and that too..very quickly.
We did operate on him on the very next day using a very effective technique of micro vascular decompression ( MVD). His right sided trigeminal nerve was severely distorted by a loop of a blood vessel known as 'Superior Cerebeller artery'. The artery was found to have been deeply lodged into the REZ ( Root Entry zone) of this nerve (The part of the nerve at its entrance in the brain).
The continuous pulsation of this artery were incessantly hammering this nerve and this was the root cause of his neuralgia. Under high magnification of Neurosurgical microscope, we dissected and dislodged this artery away from the nerve and separated the two with a Teflon sponge.
As would be expected, his pain vanished immediately after the surgery. 
Though, for me this result was expected, it was nothing short of a miracle for him and for the next two days his happiness knew no bounds. The term 'mad with joy' would have explained his state of mind in the immediate post perative period. 
Before he was discharged, he urged me to focus my energies more on this surgery and repeatedly emphasised the need to inform the patients about this disease and its potential cure.
This incident happened about 10 years back but made a very deep impression on my mind. I was convinced that the patients of trigeminal neuralgia needed to be informed that it can be potentially cured. I was also keenly aware that a focused approach by a team would progressively make this surgery more effective and safe.
With these objectives we set out on a path to educate the public about the symptoms and diagnosis of this disease.
As a result, we were able to create this 'Trigeminal Neuralgia Centre' offering education, counselling, diagnosis and surgical treatment to the patients.
Trigeminal neuralgia can be treated with different methods. But after using some of them, we became convinced that the MVD surgery, which attacks the root cause of this pain and removes it, has the best potential to offer long term cure for these patients (As has been repeatedly highlighted by Dr. Peter Jennetta....the pioneering neurosurgeon in the field of trigeminal neuralgia and the MVD Surgery).
It has been our constant endeavour to take this message to the public at large to wage a war against this terrible and painful condition called trigeminal neuralgia.



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