Complications accompanying surgical relief of pain in trigeminal neuralgia

ACCOMPANYING SURGICAL COMPLICATIONS PAIN IN TRIGEMINAL NEURALGIA FRANCISC. PbiladelpAia,

T

HE dingnosis of’ major trigeminal neurnlgi:r in the typical pntient is easy. An elderly patrent presents himself with sudden, intense, lancinating pain in one or the other side of the face. This pain usually affects the upper or louver lip Hnd extends up to, but never across, the midline. The pain is brought on by an) local irritation such BS talking, eating or washing the face. The pnin is definiteI> paroxysmal in charcrcter, coming on in intense, stabbing \vaves with little or no abnormal sensation between attacks in the area involved. As n rule, the patient has had ;I short, initial spasm months or years before the surgeon sees him and, between subsequent attacks, has noted periods of spontaneous remission during which there h:rs been no crbnormal sensation of any kind in the face. The presence of a trigger zone is charcrcteristic. For example, if the upper and lower lips nre involved in the pain, it is frequently noticed that touching either area will cause n spasm of pain to pass from the lower h:\lf of the face into the upper hnlf and the patient soon lenrns to RVoid touching this trigger ;:re:r. Not infrequently, the experienced observer makes the diagnosis of major trigeminal neurnlgin as the patient steps into the office. He will notice thitt part of the face :rbout the upper lip :rnd the nla of the nose is unwashed, dirt! and greasy. This is the trigger zone. An! attempt on the pnrt of the patient to cle:rn up this :rren results, :rt once, in the hrncinnting, stabbing, paroxysmal pain so chsrircteristic of this disease. Fortunately, both sides of the face are but r:rrely involved. In :I series of, roughly, sixteen hundred cases of verified major trigeminal neur:rlgi:r, there hn\-e been but

GRANT,

RELIEF OF

M.D.

PennsJ-lraniu

two in \vhich the pain w;rs noted to be bilaternl at the same time. There hnve been forty-three cases in which, after the p:rin had occurred on one side, this attack ~vas follo\ved a number of years later by similnr pain on the opposite side. The treatment of mnjor trigemimrl neuralgia has become completely stanclnrdized. Section of the sensory- root of the trigeminal nerve is the accepted method for producing permanent relief. Unquestionnbly the relief from the intolerable, lancinating, paroxysmal pnin stabbing, characteristic of this condition IS complete. Nevertheless, the patient is penalized for relief from this pain. Any wide experience with the results of the treatment of major trigeminal neuralgia by root section will soon con\+nce the honest :rnd competent observer that while, for the most part, section of the sensory root gives the patient the freedom from pain that he expects, nevertheless, he p:rys n certain price for complete relief of pain which, in some instances, is mther higher thnn had been trnticipated. The price that the patient p”ys for the complete relief of pain is total anesthesi:r in the Rrens to which the pain ~~3s originnlly referred. This :rnesthesia is produced by section of the sensory root, whether the root be cut at the pons by the occipital :tpproach or just behind the ganglion 6) the temporal route. Dandy’ clnimed ns one of the :rdvantages of the occipitnl ;I]~pro:rch to the sensor\. root that, by this technic, he \vas able to cut just the Interal fibers of the root and thereby bring about ;I selective relief of pain alone, without loss of touch sensation. Our experience has been entirely :rt vnriance with Dandy’s. No mntter where the sensory root is cut, conr-

plete loss of all modalities of sensation ~vas produced if pain sensation F+‘;ISabolished. Occasionally-, hvhen ;I subtotal section of the root ~vas performed, total anesthesia in the third di\Gsion for ail modalities 01 sensation and n partial loss of sensation in the second di\Gion resulted. Howe\-er, in the second division, bvhere sensation was partialI>, preser\.ed, it was al\v:1~3 impossible to determine that pain sensation was lost to ;I greater degree than touch. It is quite true that the operation devised 6). Sjiiq\pist,” the section of the descending root of the trigeminal ner1.e in the medulla, hzs produced se1ectiL.e loss of pain sensation tvithout an equivalent loss in touch sensation. \/\‘c were enthusiastic about the possibilities of the Sjtiq\-ist technic unti1 experience shoLved that, unfortunately, the libers of the third division, which is \reri’ c~omrnonl>. invol\,ed in most se\‘ere cases (if major trigeminal neuralgia, Ia). most centr:lII~ in the medulla. A deep, bold section in the medullar\ area ~vas necessarv to assure section oi these centrally situated third division fibers. The consequences of a deep section in this area was sometimes quite devastating for the patient. A very m:~rkecI ipsolnteral atasia and dyssynergin of :I permanent nature can be produced by too deep a section of the medulla in attempting to cnrr? out the Sjiiqvist technic. Medullar~ tractotom? was carried out in six patients with tvpicnl major tripeminal neuralgia. In fi1.e oLf these six patients, the pain recurred and root section \vas necess:lr>. to relieve the pain permanently. The sixth patient has been entirely comfortable ti)r the past seven years. Very little, if any, loss of touch sensation is demonstrable in this patient although pain has been entirel! lost and his major trigeminnl neuralgia c:ompletel~~ relieI,ed. One important consideration exists when i.he surgical treatment of major trigeminal neuralgia is suggested. It must :~Iways be remembered that facial neuralgiu is not a lethal disease. It may make the patient ~str:rorclin~LriI\, uncomfortable :lnd unI-~app~~ but as f:lr as our records sholv, there

ha\,e been onl\. t\vo cases of suicide because of this dreadful facial pain in our series of some sixteen hundred patients. Consequently, when surgery is considered the procedure used for relief of pain must be that whicsh in the surgeon’s hands carries the lowest mortality. As has been stated, there are two routes of approach to the trigeminal afferent tibers; one, through the temporal fossa, either intradurul (:lr estradural, ivith section of the root immediateI> posterior to the gasserinn ganglion; and secondI),, through the posterior foss:~, either cutting the sensory root where it leaves the pons or severing the descending fibers ot the trigeminul nucleus in the medulla. Either of these surgical approaches can be carried out with the patient in the sitting position. It is certain that the transtemporal approach lends itself :I little more readily to the use of n local anesthes,i:\ than does the occipital approach. Dand;;, ’ who originated the occipital approach, carried his procedure through bvith the patient in the prone position. When it is remembered that 85 per cent of the patients who are operated on for major trigeminal neuralgia are o\‘er sixt)- years of age, lvith ~111the possible complications accompanying ndas hypertension, ;I rterio\‘a riced \.ears sclerosis, mvocardial or renal disexw, the disadvantages of the prone position, with the need for endotracheal or rectal anesat once become obGous. The exthesia, posure of the sensory root !,I. the occipital approach is rather more dIftlcult than b> the temporal approach. The root lies more deepI?-. If bleeding occurs, consequen-t upon rupture of the petrosal \.ein Ivhich, runs from the cerebellum to the lateral sinus directly in the line of this approach or if, :IS is not uncommonly the case, ;in ;lrtery :lccompanies the sensory root and is injured at the time the root is sectionead, the control of hemorrhage in this deep field is a matter of considerable diflicultv. Ekctroand the use of Iibrin’ tix~rrt and surger) other congulants have rendered the hazards ;~ccompan~ing hemorrhage much less great. The close proximity of the brain stem and

the facial ner1.e makes the careful and conscientious operator very nervous if he finds himself invol\,ecl in bleeding in this dangerous area. A medullary tractotom> certainly cannot be carried out under local anesthesia. MThen the incision is made into the medulla to section the descending root, the patient suffers intense, Inncinating pain and is quite likely to jump and tbvist. The depth to which the incision into the brain stem should penetrate is a matter of millimeters. Any sudden movement on the part of the patient can \.erv well involve him in serious consequences ‘in spite of the best efforts of the operator. It is our vyy distinct impression that the erect posrtlon is the safest for section of the sensory root, hvhether this be carried out through the temporal or through the occipital approach. Certainly the consecuti\,e series of cases operated on by Frazier” and Gushing:’ wrthout a mortnlrty has never been surpassed. Hwvever, their success was not due necessarily to position because Gushing operated on his patients in the lateral, horizontal position \vhereas Frazier alwa>-s employed the sitting position. Both of these operators used x.er> light, open drop ether, given by nurse anesthetists who were skilled and experienced in carrq’ing these patients through this operati\~e procedure xyith 21minimum of anesthesia. The modern, young, medical anesthetist knov.s how to give n dozen difl‘erent tapes of anesthesia but, in our experience at least, he is deficient in his knowledge of the \~alue of small amounts of open drop ether. In sensor) root section no relaxation is necessary. All the operator asks of the anesthetist is to keep the patient sutliciently under the anesthetic so that he does not mo\.e. As soon as the root is cut the anesthesi;] can, of course, be stopped. We ha\,e seen skilled nurse anesthetists carry elderly patients along for two hours on less than 3 ounces of ether and ha1.e them so lightI>. Llnesthetized throughout the oper:rti\.c procedure th:lt the?. would respond during the closure of the \vound. It is diflicult to persunde the

modern, medical anesthetist to give open drop ether in this fashion. Recent experience has shown that elderI> patients who ha\-e been given morphine preoperati\.el> are likely to suffer a serious fall in blood pressure when placed in the erect position. ‘1 here has been at least one recent fat:tIit>. in our clinic which we attributed to the preoperative adminisConsetration of I.~ gr. of morphine. quently, we have recently eliminated morphine as a preoperative medication, substituting a small dose of phenobarbital plus atropine. Our overall mortality in major trigeminal neuralgia, using the erect position and the transtemporai extradurnl approach, is 1.85 per cent. We would repeat that since major trigeminal neuralgia is not a lethal disease, if an operative death occurs in an attempt to relieve it, the surgeon has unquestionably predeceased the patient unnecessaril),. It is for this reason that we insist that every precaution should be taken to protect these elder]\ patients who have major trigeminal neuralgia from any operati\;e accident, whether that accident be due to the surgical technic used or to the anesthesia employed. A second complication, which can mar the results of section of the posterior root for relief of the stabbing, Iancinating pain produced by major trigeminnl neuralgia, is a paresthesia of the face in the anesthetic area. In our series, 62 per cent of the patients were completeI\and entirely satisfied with the operative results. Thirty per cent Lvere \:ery glad that they had had the operation and had been reliex,ed ot their pain but stated that they were conscious of the numbness of the face. The? accepted this numbness quite philosophically as the price thev had to pav for relief of‘ pain. The remaining 8 per cent corn-plained of the numbness in their face; about one-half of these, or 5 per cent of the tot:tJ, complained with \‘ery considerable bitterness. The face burns, it has ;I creepy, crn\vling sensation in the numb ;\rea; the tongue and Iip feel ;IS though t.hey had been

.l‘hesc

patients

insist

that

opcratiotl,

the

Iicl‘ 01‘ piti.

while not ;I complete failure, has not I~\ any means li\.ed up to their espcctations as far :IS relief from pain is concerned. An oc’c.asionaI patient will state that he is more uncoml’ortable after operation than hc \v:\s before because this burning sensation in the face is present for t\venty-four hours :I da,\ and keeps him a\vnke :tt night, ivherexs the Ia ncinating pain was only- intermittent, rnrel!

occurred

tacks,

which

nt night,

and

he could :t\wid

to Lvhich he had become

bctbvcen at-

b! precautions

accustonied,

there

change in facial sensation. The lxasibilitj of paresthesia in the anesthetic area is the principal objection to sensor\ \vas

no

root

section.

pait1

ing for conlplctc that

hc c;tn

lvithout

complete

anesthesia.

:tncsthcsi:t,

he

rn:~~-

be

told

relie\ed

b)

then

perrn:lnentl~~

\vill recur.

Hmvever,

nothing

cut,

the

once the sensor\ anesthesia

be done

It is for this

that

he will

alcohol

prepar:ttor>

objects

to impro\‘e

reason

that

the situ-

iniection,

has a \-et-v

plncc in the treatment

of major

those

patients

plainrcl of paresthesia

block

of one or the other

ner\.c

are much less likeI\.

and Ii\re had c\,entual

pain. It is our firm opinion that the best method for pre\.enting p:lresthcsi:1 in the face following root section is by preliminary relief of’ the neuralgic pain b!. alcohol injection of the appropriate branch, or branches, of the nerve invol\-ed. \Ye appreciate full! that preoperati\,e blocli of the second or third division with alcohol is ;I painful ordeal for the patient. ‘I-he net-1 e cannot in ex.er? instance be accurateI! inof the trigeminal

and iected permanent. ful

block,

the

relief

pr( duc,ed

H 0~ e\ er, follmving the

patient

can

:I

is

not ot

pain for :I year to eighteen months and :I second block \vill keep him pain-fret for another

Jear.

More

important,

the

ant’+

resulting from the :~I~ohol block\ is preciseI\, similar to that \vhich \vilI be produced b,v section of the sensor\ root. If, therefore , a patient has had his pain rcthcsia

lieved

b,y alcohol

block,

he know

face \vill feel and appreciates

price that

he must

\‘ct-!

ho\\- his

full!- the

1x1! for pcrmancnt

iiet7.e

rc-

who

of the

agreeable

had

trigeminal been

that

preliniinnr~

branches

of the

to complain

sensor> are

paresthesia

sensations

in spite definite

a’nesthesia

consequently

burning

has

ha\-e

total

scc$on and

de\,elop

of

\vhich

root

of the

less IiLel!, and other

in the anesthetic

to dis-

area.

far- ;IS the first and second [Ii\-isions

As are

experience

pcrm:lnent,

folIo\vs

other

concerned,

por:ir>

relief’

of

pain

methods are

for

ten)-

:t\~~~ilablv than

simple ;tIcohol inicction. A\.uIsion of the supr;~orbit~tl ncr\.c through an incision in the eyebro\j, is ;I simple, safe pt-occdu t-c‘and \vill

success-

be relie\.ed

the

Our

is

to it

\\T I)elie\ c

of its disacl\~:tntnges, neuralgi:t.

root

produced

and if the patient can

ation.

that

Ho\ve~~cr, WC have become completely. dissatis!ied \vith the Sjiiq\rist procedure because, in our experience I?-ith six patients with nin jor trigeminal neuralgia, t\vo c‘onlrecurrence

~‘OIISC-

~IM.:I;\s ha\-e the anesthesia. If, during temporar~~ relict 1,~. bloc>l\, the anesthesia has not been ;tn :tnnoy;lncc to him, hc is quite Lvilling to ha1.c the sensor> root cut and thr anesthesia made permanent. If, after an alcohol injection, he objects to the numtbnc~s of his face, hc c’:ln be told that ii’hc \\ ill bc patient for a scar that numbness \vill disappear, sens;itton \vill return to normil ;I nd his pin

perm;\ncnt

:tn;tlgesi:i

relief,

lx but

has been

so

the

root w&on

much hopefulness the reports of medullary tractotom> described b! Sjiiqvist, hvith its production of selecti\-c \vith

After

upon alcohol blocI\, wxt-s ;IV::IJ., the recurs. \C:hen the patient rctrtrns asli-

VT

hailed

It ~vas for this reason that

quent

t-elie\,e

the

suptxorbital

four or Ii1.e fears. mucous

mt’mbrane

cspe

the

An incision under

second

neuralgia

for

through

the

the upper

cfi\-ision

\.er!’

lip jvill rc:tdil>,.

On~c the inftxorbital fornmcn \vith the enierging ncr\e is \.isible, it is ;I siniplr matter- to introduce ;I \\ ire for 2 or ; (‘111. itltc) the inl‘t-aorbital canal :tntl congulate the

net-\ c’ kvith

;tncsthctic

ncur:tlgi:i,

the

elcctrc!surgic;tl

unit.

patient \vho insists upotl at1 for relief 01‘ scc~ontl mrii\~ision this procedure has sonlt’ :td-

In :1 ner\.ous

v~~ntagc ov’cr direct alcohol injection. As far as the third cliv~ision is concernccl, if the lower lip and teeth alone are involv~ecl, the nerve can be blocked with a drop or two of alcohol M-here it descends around the rnmus of the mandible. If the tongue is in\.ol\red, however, the lingual branch of the third division usually leaves the main trunk above this point. Consequently, alcohol injection through the cheek, picking up the whole nerve where it leaves the skull is necessary when the paroxysms of pain involve the tongue. The third complication of section of the sensory root, particularly when it is completely sectioned, is keratitis and ulceration of the cornea in the ipsolateral eye. Subtotal avulsion of the sensory root, as suggested by Frazier:’ in 1923, sparing that part of the root that runs to the first division and thus not completely desensitizing the cornea, has well nigh eliminated this particular complication. The problem always arises, of course, in those patients who have major trigeminal neuralgia in all three divisions, as to whether a subtotal avulsion is appropriate. It is our definite experience that it should be done unless the supraorbital area is the trigger zone. Fortunately, this is the exception rather than the rule. In those instances when the trigger zone lies in the second and third division and when irritation of this trigger zone results in pain in the first division, it is entirely safe to carry through a subtotal avulsion. Desensitization of the trigger zone will eliminate the spread of pain into the first division. However, in certain cases when a subtotal avulsion has been done, there is, later on, a spread into the supraorbital area. If this occurs, it is a simple matter to avulse the supraorbital nervre at its foramen. It is, in our opinion, always much better to preserve the fibers in the root running to the first division than to do a total section. As vve have said, if pain spreads later on into the first div.ision, it can be relieved for four or fi1.e years 63 avulsion of the supraorbital nerve. iLlan> of these patients are elderly ancl much can

1II our scrics t hcrts and IO per cent of rccurrcnccs in the lirst di\,ision, usually after six or sev’en Iears have passed. It is much better, in our opinion, to accept the risk of recurrence in the first division consequent upon sparing the inner fibers of the sensor> root than it is to avulse completelv the sensory root and risk the possibility of complications in the cornea. Prior to 1925, vvhen total avulsion of the sensory root was the routine procedure, the incidence of some degree of keratitis vvas 15 per cent. In about one-half of these patients, closure of the lid was necessary to control the keratitis and in between 1 and 5 per cent of the total patients the eye on that side vvas lost. This calamity usualI\ followed neglect of the eye on the part of the patient and attending physician. The keratitis spread, burrowed in to invrolve the anterior chamber, produced an anterior hypop>on and enucleation of the eye was necessary. At the present time most competent ophthalmologists recognize this situation promptI! and close the eyelid. Closure of the eyelid vvill result in healing of the kerntitis within ninety-six hours. Tarsorrhaphy is the only proper treatment for this complication. The final complication which ma!; accompany operation on the sensory root b). either the temporal or occipital approach is facial paralysis. In the last five hundred patients operated on through the temporal approach, this complication has appeared in, roughly, 6 per cent of patients. Fortunately, in none of these patients has the paralysis been of a permanent nature. In every instance it has disappeared within six months. When the sensory root has been completely avulsed, the appearance of a facial weakness creates a very aukward situation. Inability to close the ipsolateral e>.e following complete section of the root, with total cornea1 anesthesia, will certainly result in drying of the cornea a n d consequent ulceration. Closure of the lid is therefore necessary in all these patients. The lid should be kept closed until happen

hnvc

in 1iv.c scars.

Ixc~ll IxhxTll

5

I hm

ha5

Iwcm

~~ltfl~icl-li

Ic~L\lr-ll IIf lJO\V(‘I ill

the facGl ncr\.c to assure closure of the c’\‘clid. If subtotal :l\.ulsion has been done :;ntl if cx)rne:ll sensiti\.it), is retnincd, tarsorrhaphy is not necessar>-. Howe\.er, \er\ close \\:\tch should be kept on the eve anti if there is any slightest e\.idencc ~ji kerntitis. lid closure is imperati\.e. The cause for facial paralysis or bvealiness following approach to the sensor>’ root b,v the temporal eutradurnl route is injury to the supcrlicinl petrosal \,ein or theiridian ner\.e. This nerve and \.ein run from the facial cunal along the anterior face of the petrous ridge and under the ganglion. For this reason during the separation of the dura from the ganglion sheath, it is necessar? to take care that the dura is not stripped from the anterior surface of the The dissection should be petrous ridge. made in such n fashion that the root can be exposed without elevating the dura in this area. If the dura covering this nerve and \ein is not disturbed, facial paralysis is much less likely to result. The a\.oldance of facial paral~.sis during an approach to the sensor\. root through the temporal fossa is one of the claims made for the intrndural approach. Fncial paralysis or weakness can also follow the occipital :q~pro:~ch to the sensor!. root. However, during this approach it is rather more likeI? that the t’;tcinI nerve is seriousI>, injured bvith :I treater probabilitv of pernx~nent and lasting facial w.enkness.

I I1 ~llllllllar~, it c‘:tl~ bt~ xjitl that whilt~ scc*tion of the sensory root lvill rylie\ e pcrniarientl~~ and cvmpletel\ the :a \‘ag:(‘, paros\sm;II pain of major trI,ueniinaI neuralgia, ne\.ertheless, both surgeon and patient must realize that for relief l:)f pain the patient pans :I definite price. The basic, inescapnblc price that he pa~‘s is complete anesthesia of the face. The surgeon’s skill in selecting patients for operati\.e procedure and his deftness in c.arr,ving out the surgic:Il technic can eliminate all of the other complications herein enumerated. It is important, however, for both surgeon and patient to realize that, hvhile the operative procedure for the relief of major trigeminal neuralgia can and \vilI relie1.e the parox! smnl pain, nevertheless, the path\va>. to complete satisfaction v,ith the operative procedure on the part of the patient is strev,n with wrtain definite hazards.

I