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Surgical treatment of trigeminal neuralgia
SURGICAL TREATMENT OF TRIGEMINAL NEURALGIA ADRIAN
S.
TAYLOR,
CLIFTON
M.D.,
SPRINGS,
N.
F.A.C.S. Y.
S
accurate descriptions of trigemina1 URPRISINGLY neuraIgia have been in medica Iiterature for many years, in spite of the fact that the essentia1 nature of Its etioIogy and pathoIogy are the disease is a mystery. unknown, yet it presents a cIear-cut cIinica1 syndrome. The victims of it are usuaIIy past middIe Iife, aIthough it is occasionaIIy seen in the third and even the second decade of Iife. In the experience of the author women are more frequentIy affected than men. Hypertension is common, and every surgeon who attempts to expose the gangIion knows what a Iost, brittIe meningea1 artery means in such cases. The reIationship of high bIood pressure and of arterioscIerosis to the genesis of the pain itseIf deserves further study. Dr. Joseph Hirsh of Birmingham has recentIy reported to the writer a case in which he was treating asthma in a patient who aIso suffered from typica migraine. On four occasions he injected 0.5 C.C. of I :IOOO soIution of epinephrine to contro1 the asthmatic spasms. ImmediateIy typica tic-Iike paroxysms of pain occurred in one supraorbita1 nerve, and morphine was required to reIieve them. BIood pressure determinations were not made at the time. SYMPTOMATOLOGY
Tic douIoureux is a disease of the fifth crania1 nerve, and its onIy symptom is pain in the periphera1 fieIds of this nerve. This pain is typicaIIy paroxysma in character and occurs most frequentIy in the zone of the third division of the nerve, next in the second, and Ieast often in the first. It is often initiated by some irritation in a particuIar spot known as a 699
700
ADRIAN
S. TAYLOR
“trigger zone.” Such stimuIation may be caused by shaving, by food or drink, either hot or coId, or even by speaking. The pain is expIosive, Iightening Iike and shoots upward aIong the Iine of the nerve trunk often to overfIow into an adjacent fIeId. These paroxysms of pain may be accompanied by vasomotor phenomena, the face may be drawn toward the affected side, a curious chewing motion is often seen, and the patient frequentIy hoIds the painfu1 region tightIy in his hand. These paroxysms may recur frequentIy, usuaIIy there is no pain between the attacks, and the paroxysms do not often occur at night. Morphine does not reIieve them and, for this reason, addiction is not the rule in this disease. The pain is excruciating and is probabIy as terribIe as any pain to which human flesh is heir. These typica attacks of pain must be differentiated from other clinica syndromes, chief of which is that form of neuraIgia known as Iower hemicrania1 neuraIgia, or Sluder’s neuraIgia. In Igo SIuderl described “Iower haIf headache,” consisting of pain about the eye, the upper jaw and the teeth, with earache and pain in the mastoid, with a tender point about 5 cm. behind it. The pain aIso extends to the occiput, neck, shouIder, scapuIa, arm, forearm, hand and fingers. Sluder showed that this disease is probabIe often caused by sinus infection and may be reIieved by cocainization of MeckeI’s reIief is to be expected from remova gangIion. Permanent of the IocaI foci. RecentIy VaiI,2 of Cincinnati, has described an anaIogous neuraIgia in which the Vidian nerve is invoIved. There is aIso the fairIy weII-known tic of the gIossopharyngea1 nerve in which the pain is simiIar in type to true tic douIoureux, but is even more terribIe, if that be possibIe. Five recent cases have caIIed attention to the frequency of neuraIgia invoIving the ascending branches of the upper 1 SLUDER, G. The roIe of the sphenopaIatine (Meckel’s) ganglion in nasa1 headache. N. York M. J., 87: 989, 1908. 2 VAIL, H. H. Vidian neuraIgia. Ann. Otol., Rbinol. @ Lwyngol., 41: 837, 1932.
TRIGEMINAL
NEURALGIA
701
cervica1 nerves. In these cases the pain was uniIatera1 and foIIowed the distribution of the occipita1 and posterior auricuIar nerves, and couId at once be relieved by a novocaine barrage extending from the posterior occipita1 protuberance to the mastoid tip. Division of a11 ascending branches between these two points was done for two patients. CompIete reIief was afforded and wiI1 undoubtedIy continue unti1 regeneration of these nerves takes pIace. A hypertrophic cervica1 arthritis is a probabIe cause of this type of pain. TREATMENT
FutiIe attempts to reIieve the pain of true neuraigia are often made by removing foci of infection in mouth, antra and sinuses, so often, in fact, that few patients reach the neurosurgeon with their own teeth or with intact accessory sinuses. The author has seen no patients reIieved by these operations, and has persona1 knowIedge of only one whose pain in the third division was reported to have been cured by the remova of a moIar tooth with a buIbous root impinging upon the nerve in the denta cana1. In a consideration of treatment, it must be remembered that reIief of pain is accompIished at the price of anesthesia. Dandy, however, has reported severa cases in which he was abIe to reIieve pain by partia1 section of the sensory root as it Iay aIongside the pons, with retention of cutaneous sensibiIity. He has perfected his cerebeIIar approach unti1 he is abIe to accompIish the section in a fraction of the time usuaIIy consumed in the transtempora1 operation, and he reports few complications. The cerebeIIar approach, however, is not to be chosen by one unskiIIed in posterior fossa surgery. Permanent or temporary reIief may be offered to patients suffering from tic douIoureux. Permanent relief is possibIe by a highIy perfected operation upon the sensory root of the nerve, or by the sometimes successfu1, even though iII-advised injections of aIcoho1 into the gangIion itseIf. Temporary reIief may be offered with comparative safety by aIcohoIic
702
ADRIAN
S. TAYLOR
injections into the second and third divisions as they emerge from the skuI1, or by periphera1 injections or neurectomies of the termina1 branches of the nerve. AIcohoIic injections into the second and third divisions are usefu1 in affording reIief Iasting often for a year or more, and have the great vaIue of making it possibIe for the patient to evaIuate the resuIting anesthesia, and to choose between his former pain and his present anesthesia. In cases of faIse neuraIgia, the patient is apt to rebe1 over the “wooden face,” whiIe in true neuraIgia, he gratefuIIy accepts permanent Ioss of sensation even over the entire haIf of his face in Iieu of his previous unbearabIe torture. So where the diagnosis is in doubt it may be wise to give the patient the opportunity to choose between pain and anesthesia during the period of nerve regeneration. The injection into the second division is made either under the zygomatic arch into the sphenopaIatine fossa to reach the nerve as it emerges from the foramen rotundurn, or from inside the mouth, according to nerve bIock methods famiIiar to 0raI surgeons. The third division is reached as it emerges from the foramen ovaIe either by a IateraI approach traversing the tempora1 fossa under the zygoma, or from an anterior approach, the needIe cIoseIy hugging the IateraI aspect of the maxiIIa just above the aIveoIar process. These periphera1 injections in skiIIed hands are reIativeIy free from danger, even though tragic injury to eustachian tube and optic nerve has been reported. The writer wishes to warn against any attempt to introduce the needIe into the foramen ovaIe and to inject the gangIion itseIf. SuccessfuI aIcohoIic injections of the gangIion afford permanent reIief, but are accompanied by such risk to the centra1 nervous system and to adjacent structures that they are not to be considered. PeripheraI neurectomy is now confined to the supraorbita1 nerve. The scar of the incision is in the Iine of the eyebrow and is soon covered; the nerve is easiIy exposed, and compIete
TRIGEMINAL
NEURALGIA
703
resection of its trunk accompIished. Pain in the infraorbita1 nerve is controIIed by aIcohoIic injection of its foramen, while the inferior denta is injected peripheraIIy through the menta1 foramen or as it enters the inferior denta foramen on the bucca1 surface of the ramus of the mandibIe. These injections have the advantage of being reIativeIy easy and safe; they afford great reIief, and they give the patient choice of anesthesia or pain. Sensation returns in from three months to severa years, and aIong with it pain’. Subsequent injections are usuaIIy Iess satisfactory and afford shorter reIief. The modern radica1 operation for tic douIoureux is a therapeutic triumph and iIIustrates the mastery of physioIogy, anatomy, and of surgica1 technique, which aIone has made intracrania1 surgery possibIe. RemovaI of the gangIion was first proposed by J. Ewing Mears in 1884, and was first successfuIIy accompIished by E. Rose six years Iater. Operations upon the gangIion, and upon its second and third divisions dista1 to the gangIion, were done unti1 SpiIIer in 1899 made the briIIiant suggestion that permanent reIief wouId be afforded by section of the sensory root proxima1 to the gangIion. Frazier was the first to seize upon this suggestion and to utiIize the physioIogic fact that sensory nerve fibers cut between the gangIion and the brain would never regenerate, and it was he who was first to cut the sensory root of the gangIion. To him is due the credit for the saving of the motor root, and the partia1 section of the sensory root which now makes possibIe a seIective anesthesia. In other words, it is now possibIe to divide onIy those fibers of the nerve which transmit pain stimuIi, and to cause the minimum of cutaneous anesthesia. FortunateIy, the first division is seIdom invoIved and it is now no Ionger necessary to cause anesthesia of the cornea, with the Iarge incidence of cornea1 uIcers foIIowing therefrom. The radica1 operation has been so systematized that it has become reIativeIy a simpIe procedure. The author has done the sub-tota section of the sensory root in Birmingham
704
ADRIAN
S. TAYLOR
37 times without a death, and with permanent cure in a11 cases. One patient had a return of pain, and it was necessary to cut additiona fibers eighteen months after the first operation. The re-exposure was easy, no troubIe was experienced from hemorrhage, the uncut fibers were easiIy identified, and permanent reIief foIIowed their section. TECHNIQUE
A basa1 anesthesia with IocaI infiItration is now being used. Avertin, in recent cases, has been very satisfactory. A vertica1 incision as in the cIassic Cushing sub-tempora1 decompression is done, the muscIes are retracted and eIevated with specia1 retractors and an opening is made with perforator and burr just above and in front of the zygomatic root. This is enIarged with rongeurs unti1 an ova1 defect from 3 to 4 cm. in size extending beIow to the ffoor of the middIe fossa is obtained. The dura is now gentIy eIevated and the groove made by the middIe meningea1 artery is sought. This is foIIowed with a seeker toward the foramen spinosum which transmits the artery. The foramen is carefuIIy pIugged with a bit of cotton packed tightIy in with an anguIar denta cavity probe, and the artery divided. It is usuaIIy unnecessary to tie the dista1 end. (DentaI instruments of various shapes and sizes as we11 as cotton sheets and roIIs and pIedgets prepared for the dentists are a11 very usefu1.) The dura is continuousIy eIevated with an eIectric Iighted retractor and the foramen ovaIe is sought mesiaIward and forward from the foramen spinosum. As soon as the fibers of the third division are seen, the nerve trunk is distended with novocaine epinephrine soIution. The gangIion is aIso infiItrated, and an incision is made IongitudinaIIy aIong the IateraI margin of the gangIion, dividing the dura1 sheath. This incision is in Iine with the fibers of the third division, it opens up the dura1 pocket encIosing the gangIion, and aIIows the dura to be stripped back, uncovering the gangIion. As the sensory root comes into view, and is uncovered backward, there is a gush
TRIGEMINAL
NEURALGIA
704
of cerebrospina1 fluid from the posterior fossa. This escape of Auid is heIpfu1, as it decreases the intracrania1 voIume, makes retraction of the tempora1 Iobe easier, and hemorrhage becomes Iess troubIesome. It must be adequateIy controIIed, however, so as to admit of cIear exposure of the gangiion and of the sensory root. BIeeding is perhaps Iess with the patient in an upright position, but the writer is accustomed to operate with the patient Iying upon an incIined tabIe. The motor root runs beneath the sensory root obIiqueIy from above downward and outward; it Iies entireIy free and passes beneath the gangIion to bIend with the third division before it enters the foramen ovaIe. It is possibIe to eIevate the sensory ribbon-Iike root from the underIying smaI1 cord-Iike motor root and to divide as much of the sensory root as is desired without injury to the motor root. The fibers of the third division Iie beIow and IateraJward, those of the second next, and those of the first division highest and mediaIward in the sensory bundIe. It is possibIe to produce anesthesia and to afford reIief of pain in any of these tieIds by differentia1 section of the fibers in the sensory bundIe. It is of vita1 importance to retain sensation in the cornea, so in a11 cases where the neuraIgia does not invoIve the first division, the upper media1 fibers of the sensory root shouId be conserved. Objection has been made that the neuraIgia might recur in the first division. This actuaIIy happened once in the writer’s experience and a second operation was necessary. Deep venous bIeeding is usuaIIy controIIabIe with pieces of muscIe. Only once has it seemed wise for the writer to Ieave in a drain. The wound is cIosed in Iayers, and the eye Iids sutured temporariIy. In this series of 37 radicaI operations there has been no death. In 2 patients there was a temporary weakness of the externa1 rectus. In one there was a compIete facial paIsy beginning the seventh day after operation, and graduaIIy becoming compIete. The expIanation of this paraIysis of the seventh nerve Iies in the possibiIity of trauma transmitted
ADRIAN
706
S. TAYLOR
from the gasserian gangIion through the great superficia1 petrosa nerve to the gangIion of the knee of the seventh. At this point this nerve Iies in a bony cana1, and sIight trauma might cause sufficient edema of the nerve to cause its interruption in its bony cana1. In this particuIar case, power in the orbicuIaris was Iost, and a coIIeague, Dr. Frank CIements, kindIy did a partia1 tarsorrhaphy to protect the exposed cornea. In this procedure temporary synechiae were formed between the edges of the upper and Iower Iids. FuII power returned within a year, the Iids were separated, and the patient has remained we11without any injury to the eye. TRICHLORETHYLENE
During the war workers in Germany using trichIorethyIene were found to show anesthesia of the fifth nerve. This chemica1 is now being used as treatment by inhaIation. It has a seIective action upon the sensory part of this nerve. Twenty to 30 drops three times a day are inhaIed from a handkerchief by the patient whiIe recIining. ReIief may be afforded in a few days. If it is not experienced in four or five weeks, the treatment is discontinued. SUMMARY
Tic douIoureux is a definite disease of unknown etioIogy without known pathoIogy. 2. It must be differentiated from other neuraIgias which affect the sympathetic nervous system. 3. PaIIiative neurectomies or aIcoho1 injections affording temporary reIief may be wise. 4. RadiaI operation is safer than aIcohoIic injection of the gangIion. 5. The radica1 operation is reIativeIy free from risk, and affords certainty of reIief with IittIe danger of injury to other structures. 6. TrichIorethyIene may prove so usefu1 that operation may become unnecessary in many cases. I.
S.
TAYLOR,
CLIFTON
M.D.,
SPRINGS,
N.
F.A.C.S. Y.
S
accurate descriptions of trigemina1 URPRISINGLY neuraIgia have been in medica Iiterature for many years, in spite of the fact that the essentia1 nature of Its etioIogy and pathoIogy are the disease is a mystery. unknown, yet it presents a cIear-cut cIinica1 syndrome. The victims of it are usuaIIy past middIe Iife, aIthough it is occasionaIIy seen in the third and even the second decade of Iife. In the experience of the author women are more frequentIy affected than men. Hypertension is common, and every surgeon who attempts to expose the gangIion knows what a Iost, brittIe meningea1 artery means in such cases. The reIationship of high bIood pressure and of arterioscIerosis to the genesis of the pain itseIf deserves further study. Dr. Joseph Hirsh of Birmingham has recentIy reported to the writer a case in which he was treating asthma in a patient who aIso suffered from typica migraine. On four occasions he injected 0.5 C.C. of I :IOOO soIution of epinephrine to contro1 the asthmatic spasms. ImmediateIy typica tic-Iike paroxysms of pain occurred in one supraorbita1 nerve, and morphine was required to reIieve them. BIood pressure determinations were not made at the time. SYMPTOMATOLOGY
Tic douIoureux is a disease of the fifth crania1 nerve, and its onIy symptom is pain in the periphera1 fieIds of this nerve. This pain is typicaIIy paroxysma in character and occurs most frequentIy in the zone of the third division of the nerve, next in the second, and Ieast often in the first. It is often initiated by some irritation in a particuIar spot known as a 699
700
ADRIAN
S. TAYLOR
“trigger zone.” Such stimuIation may be caused by shaving, by food or drink, either hot or coId, or even by speaking. The pain is expIosive, Iightening Iike and shoots upward aIong the Iine of the nerve trunk often to overfIow into an adjacent fIeId. These paroxysms of pain may be accompanied by vasomotor phenomena, the face may be drawn toward the affected side, a curious chewing motion is often seen, and the patient frequentIy hoIds the painfu1 region tightIy in his hand. These paroxysms may recur frequentIy, usuaIIy there is no pain between the attacks, and the paroxysms do not often occur at night. Morphine does not reIieve them and, for this reason, addiction is not the rule in this disease. The pain is excruciating and is probabIy as terribIe as any pain to which human flesh is heir. These typica attacks of pain must be differentiated from other clinica syndromes, chief of which is that form of neuraIgia known as Iower hemicrania1 neuraIgia, or Sluder’s neuraIgia. In Igo SIuderl described “Iower haIf headache,” consisting of pain about the eye, the upper jaw and the teeth, with earache and pain in the mastoid, with a tender point about 5 cm. behind it. The pain aIso extends to the occiput, neck, shouIder, scapuIa, arm, forearm, hand and fingers. Sluder showed that this disease is probabIe often caused by sinus infection and may be reIieved by cocainization of MeckeI’s reIief is to be expected from remova gangIion. Permanent of the IocaI foci. RecentIy VaiI,2 of Cincinnati, has described an anaIogous neuraIgia in which the Vidian nerve is invoIved. There is aIso the fairIy weII-known tic of the gIossopharyngea1 nerve in which the pain is simiIar in type to true tic douIoureux, but is even more terribIe, if that be possibIe. Five recent cases have caIIed attention to the frequency of neuraIgia invoIving the ascending branches of the upper 1 SLUDER, G. The roIe of the sphenopaIatine (Meckel’s) ganglion in nasa1 headache. N. York M. J., 87: 989, 1908. 2 VAIL, H. H. Vidian neuraIgia. Ann. Otol., Rbinol. @ Lwyngol., 41: 837, 1932.
TRIGEMINAL
NEURALGIA
701
cervica1 nerves. In these cases the pain was uniIatera1 and foIIowed the distribution of the occipita1 and posterior auricuIar nerves, and couId at once be relieved by a novocaine barrage extending from the posterior occipita1 protuberance to the mastoid tip. Division of a11 ascending branches between these two points was done for two patients. CompIete reIief was afforded and wiI1 undoubtedIy continue unti1 regeneration of these nerves takes pIace. A hypertrophic cervica1 arthritis is a probabIe cause of this type of pain. TREATMENT
FutiIe attempts to reIieve the pain of true neuraigia are often made by removing foci of infection in mouth, antra and sinuses, so often, in fact, that few patients reach the neurosurgeon with their own teeth or with intact accessory sinuses. The author has seen no patients reIieved by these operations, and has persona1 knowIedge of only one whose pain in the third division was reported to have been cured by the remova of a moIar tooth with a buIbous root impinging upon the nerve in the denta cana1. In a consideration of treatment, it must be remembered that reIief of pain is accompIished at the price of anesthesia. Dandy, however, has reported severa cases in which he was abIe to reIieve pain by partia1 section of the sensory root as it Iay aIongside the pons, with retention of cutaneous sensibiIity. He has perfected his cerebeIIar approach unti1 he is abIe to accompIish the section in a fraction of the time usuaIIy consumed in the transtempora1 operation, and he reports few complications. The cerebeIIar approach, however, is not to be chosen by one unskiIIed in posterior fossa surgery. Permanent or temporary reIief may be offered to patients suffering from tic douIoureux. Permanent relief is possibIe by a highIy perfected operation upon the sensory root of the nerve, or by the sometimes successfu1, even though iII-advised injections of aIcoho1 into the gangIion itseIf. Temporary reIief may be offered with comparative safety by aIcohoIic
702
ADRIAN
S. TAYLOR
injections into the second and third divisions as they emerge from the skuI1, or by periphera1 injections or neurectomies of the termina1 branches of the nerve. AIcohoIic injections into the second and third divisions are usefu1 in affording reIief Iasting often for a year or more, and have the great vaIue of making it possibIe for the patient to evaIuate the resuIting anesthesia, and to choose between his former pain and his present anesthesia. In cases of faIse neuraIgia, the patient is apt to rebe1 over the “wooden face,” whiIe in true neuraIgia, he gratefuIIy accepts permanent Ioss of sensation even over the entire haIf of his face in Iieu of his previous unbearabIe torture. So where the diagnosis is in doubt it may be wise to give the patient the opportunity to choose between pain and anesthesia during the period of nerve regeneration. The injection into the second division is made either under the zygomatic arch into the sphenopaIatine fossa to reach the nerve as it emerges from the foramen rotundurn, or from inside the mouth, according to nerve bIock methods famiIiar to 0raI surgeons. The third division is reached as it emerges from the foramen ovaIe either by a IateraI approach traversing the tempora1 fossa under the zygoma, or from an anterior approach, the needIe cIoseIy hugging the IateraI aspect of the maxiIIa just above the aIveoIar process. These periphera1 injections in skiIIed hands are reIativeIy free from danger, even though tragic injury to eustachian tube and optic nerve has been reported. The writer wishes to warn against any attempt to introduce the needIe into the foramen ovaIe and to inject the gangIion itseIf. SuccessfuI aIcohoIic injections of the gangIion afford permanent reIief, but are accompanied by such risk to the centra1 nervous system and to adjacent structures that they are not to be considered. PeripheraI neurectomy is now confined to the supraorbita1 nerve. The scar of the incision is in the Iine of the eyebrow and is soon covered; the nerve is easiIy exposed, and compIete
TRIGEMINAL
NEURALGIA
703
resection of its trunk accompIished. Pain in the infraorbita1 nerve is controIIed by aIcohoIic injection of its foramen, while the inferior denta is injected peripheraIIy through the menta1 foramen or as it enters the inferior denta foramen on the bucca1 surface of the ramus of the mandibIe. These injections have the advantage of being reIativeIy easy and safe; they afford great reIief, and they give the patient choice of anesthesia or pain. Sensation returns in from three months to severa years, and aIong with it pain’. Subsequent injections are usuaIIy Iess satisfactory and afford shorter reIief. The modern radica1 operation for tic douIoureux is a therapeutic triumph and iIIustrates the mastery of physioIogy, anatomy, and of surgica1 technique, which aIone has made intracrania1 surgery possibIe. RemovaI of the gangIion was first proposed by J. Ewing Mears in 1884, and was first successfuIIy accompIished by E. Rose six years Iater. Operations upon the gangIion, and upon its second and third divisions dista1 to the gangIion, were done unti1 SpiIIer in 1899 made the briIIiant suggestion that permanent reIief wouId be afforded by section of the sensory root proxima1 to the gangIion. Frazier was the first to seize upon this suggestion and to utiIize the physioIogic fact that sensory nerve fibers cut between the gangIion and the brain would never regenerate, and it was he who was first to cut the sensory root of the gangIion. To him is due the credit for the saving of the motor root, and the partia1 section of the sensory root which now makes possibIe a seIective anesthesia. In other words, it is now possibIe to divide onIy those fibers of the nerve which transmit pain stimuIi, and to cause the minimum of cutaneous anesthesia. FortunateIy, the first division is seIdom invoIved and it is now no Ionger necessary to cause anesthesia of the cornea, with the Iarge incidence of cornea1 uIcers foIIowing therefrom. The radica1 operation has been so systematized that it has become reIativeIy a simpIe procedure. The author has done the sub-tota section of the sensory root in Birmingham
704
ADRIAN
S. TAYLOR
37 times without a death, and with permanent cure in a11 cases. One patient had a return of pain, and it was necessary to cut additiona fibers eighteen months after the first operation. The re-exposure was easy, no troubIe was experienced from hemorrhage, the uncut fibers were easiIy identified, and permanent reIief foIIowed their section. TECHNIQUE
A basa1 anesthesia with IocaI infiItration is now being used. Avertin, in recent cases, has been very satisfactory. A vertica1 incision as in the cIassic Cushing sub-tempora1 decompression is done, the muscIes are retracted and eIevated with specia1 retractors and an opening is made with perforator and burr just above and in front of the zygomatic root. This is enIarged with rongeurs unti1 an ova1 defect from 3 to 4 cm. in size extending beIow to the ffoor of the middIe fossa is obtained. The dura is now gentIy eIevated and the groove made by the middIe meningea1 artery is sought. This is foIIowed with a seeker toward the foramen spinosum which transmits the artery. The foramen is carefuIIy pIugged with a bit of cotton packed tightIy in with an anguIar denta cavity probe, and the artery divided. It is usuaIIy unnecessary to tie the dista1 end. (DentaI instruments of various shapes and sizes as we11 as cotton sheets and roIIs and pIedgets prepared for the dentists are a11 very usefu1.) The dura is continuousIy eIevated with an eIectric Iighted retractor and the foramen ovaIe is sought mesiaIward and forward from the foramen spinosum. As soon as the fibers of the third division are seen, the nerve trunk is distended with novocaine epinephrine soIution. The gangIion is aIso infiItrated, and an incision is made IongitudinaIIy aIong the IateraI margin of the gangIion, dividing the dura1 sheath. This incision is in Iine with the fibers of the third division, it opens up the dura1 pocket encIosing the gangIion, and aIIows the dura to be stripped back, uncovering the gangIion. As the sensory root comes into view, and is uncovered backward, there is a gush
TRIGEMINAL
NEURALGIA
704
of cerebrospina1 fluid from the posterior fossa. This escape of Auid is heIpfu1, as it decreases the intracrania1 voIume, makes retraction of the tempora1 Iobe easier, and hemorrhage becomes Iess troubIesome. It must be adequateIy controIIed, however, so as to admit of cIear exposure of the gangiion and of the sensory root. BIeeding is perhaps Iess with the patient in an upright position, but the writer is accustomed to operate with the patient Iying upon an incIined tabIe. The motor root runs beneath the sensory root obIiqueIy from above downward and outward; it Iies entireIy free and passes beneath the gangIion to bIend with the third division before it enters the foramen ovaIe. It is possibIe to eIevate the sensory ribbon-Iike root from the underIying smaI1 cord-Iike motor root and to divide as much of the sensory root as is desired without injury to the motor root. The fibers of the third division Iie beIow and IateraJward, those of the second next, and those of the first division highest and mediaIward in the sensory bundIe. It is possibIe to produce anesthesia and to afford reIief of pain in any of these tieIds by differentia1 section of the fibers in the sensory bundIe. It is of vita1 importance to retain sensation in the cornea, so in a11 cases where the neuraIgia does not invoIve the first division, the upper media1 fibers of the sensory root shouId be conserved. Objection has been made that the neuraIgia might recur in the first division. This actuaIIy happened once in the writer’s experience and a second operation was necessary. Deep venous bIeeding is usuaIIy controIIabIe with pieces of muscIe. Only once has it seemed wise for the writer to Ieave in a drain. The wound is cIosed in Iayers, and the eye Iids sutured temporariIy. In this series of 37 radicaI operations there has been no death. In 2 patients there was a temporary weakness of the externa1 rectus. In one there was a compIete facial paIsy beginning the seventh day after operation, and graduaIIy becoming compIete. The expIanation of this paraIysis of the seventh nerve Iies in the possibiIity of trauma transmitted
ADRIAN
706
S. TAYLOR
from the gasserian gangIion through the great superficia1 petrosa nerve to the gangIion of the knee of the seventh. At this point this nerve Iies in a bony cana1, and sIight trauma might cause sufficient edema of the nerve to cause its interruption in its bony cana1. In this particuIar case, power in the orbicuIaris was Iost, and a coIIeague, Dr. Frank CIements, kindIy did a partia1 tarsorrhaphy to protect the exposed cornea. In this procedure temporary synechiae were formed between the edges of the upper and Iower Iids. FuII power returned within a year, the Iids were separated, and the patient has remained we11without any injury to the eye. TRICHLORETHYLENE
During the war workers in Germany using trichIorethyIene were found to show anesthesia of the fifth nerve. This chemica1 is now being used as treatment by inhaIation. It has a seIective action upon the sensory part of this nerve. Twenty to 30 drops three times a day are inhaIed from a handkerchief by the patient whiIe recIining. ReIief may be afforded in a few days. If it is not experienced in four or five weeks, the treatment is discontinued. SUMMARY
Tic douIoureux is a definite disease of unknown etioIogy without known pathoIogy. 2. It must be differentiated from other neuraIgias which affect the sympathetic nervous system. 3. PaIIiative neurectomies or aIcoho1 injections affording temporary reIief may be wise. 4. RadiaI operation is safer than aIcohoIic injection of the gangIion. 5. The radica1 operation is reIativeIy free from risk, and affords certainty of reIief with IittIe danger of injury to other structures. 6. TrichIorethyIene may prove so usefu1 that operation may become unnecessary in many cases. I.