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Trigeminal Neuralgia Trigeminal Neuralgia (TN) is a chronic disorder that usually affects people in middle or late life and is characterized by excruciating pain around the eyes, nose, lips, jaw, forehead or scalp. This pain may be triggered by such simple actions as brushing the teeth, applying makeup or encountering a slight breeze. TN is generally considered to be the most painful of all human afflictions, but it is not fatal. It is highly treatable and can be managed effectively. There is no clear theory on what causes TN. Some experts believe a blood vessel applies pressure to the trigeminal nerve which may lead to the deterioration of the nerve’s protective covering. This deterioration causes the nerve to send abnormal signals to the brain. These signals “tell” the brain that a slight touch or a simple facial movement is painful. Procedure Those for whom medication does not provide relief or those who suffer unacceptable side effects from medication may consider surgery. Depending on the patient, UF Neurosurgeons offer a range of surgical techniques, including microvascular decompression, radiofrequency lesion and radiosurgery. The vascular decompression procedure is the operation recommended for a healthy person who does not want numbness of the face and is willing to accept a major operation entering the skull. It relieves trigeminal neuralgia by placing a small pad between the trigeminal nerve and the blood vessels next to the nerve. The operation requires making an incision in the back of the head, creating a small hole in the skull, and lifting an edge of the brain to expose the trigeminal nerve which is located approximately two inches deep. The incision is made behind the ear on the side of the head where the patient feels pain. The blood vessels that press on the nerve when the nerve leaves the brain are exposed and pushed away from the nerve. A small pad is inserted between the nerve and the vessels. This relieves the pain in most patients. The operation requires a general anesthetic and involves a small risk of complications. These risks include facial numbness, facial weakness, hearing loss, double vision, infection, bleeding, stroke, hydrocephalus, CSF leak, and other neurological deficits. Recurrent pain following the operation occurs in about 15 percent of patients. If the pain recurs another vascular decompression operation or a radiofrequency lesion procedure may be required. The preoperative evaluation is done by the doctor and the Anesthesia Service in the clinic as an outpatient prior to the operation. The patient goes home or stays with their family in a hotel or motel in the area the night before the operation. The patient is admitted to the hospital on the day of surgery. The procedure typically takes about 45 minutes. Most patients spend two nights in the hospital. Intensive care is usually not necessary. The patient should plan on taking approximately two weeks off work after leaving the hospital. A follow-up appointment is scheduled four weeks after leaving the hospital. The other procedure we commonly perform to treat trigeminal neuralgia is called "percutaneous stereotactic radiofrequency destruction of the trigeminal nerve." The term "percutaneous" means the treatment is performed with a needle passed through the skin. The term "stereotactic" refers to the fact the needle is directed by X-ray control. The term "radiofrequency" refers to the radiofrequency heating current which is used to destroy the nerve. Relief of the neuralgia by this method involves making the region of the pain permanently numb. The RFL procedure is performed in the operating room with the patient lying horizontally on his or her back. A needle is passed, under X-ray control, into the cheek on the side of the face where the patient feels pain and through a small, natural opening in the base of the skull into the trigeminal nerve. The patient is put to sleep for a few minutes during the insertion of the needle and during the other painful parts of the operation. This is accomplished with a medication similar to Pentothal called Brevital which results in a very brief period of sleep. After inserting the needle the patient is awakened and a small electric current is passed through the needle causing tingling in the face. When the needle is positioned so the tingling occurs in the area of the tic pain the patient is put to sleep again and a radiofrequency current is passed through the needle to destroy part of the nerve. The patient is awakened a few minutes after completing the nerve lesion and is checked to determine if there is enough numbness in the face to give pain relief. The radiofrequency lesion procedure is repeated with the patient asleep until it has resulted in the desired numbness. In most cases the X-ray portion of the procedure takes approximately 15 minutes. When the procedure is completed the patient goes to the recovery room for about two hours after which they can go home. They are usually able to eat the next meal. The numbness with this procedure usually is permanent. Should the numbness wear off, there is a chance of recurrent tic pain in which case the procedure can be repeated. Several undesirable side effects may follow the procedure. The first is that the numbness may have an unpleasant or painful sensation. Often the numbness has an undesirable quality; similar to the way it feels after a Novocain injection. It is possible to stick a pin into the numbed area without the person feeling it, yet the patient may describe this sensation with words, such as it "tingles", "burns", "draws", "pulls", "crawls", or it is "woody" or "stiff, like cement". Some patients find the numb area seems irritated or aches. One or two percent of the patients will find this sensation more disagreeable than their original tic pain. However, an overwhelming majority feel the numbness is far more preferable than the intense tic pain. The second most common undesirable side effect is a weakness of the chewing muscles on the side of the head where the patient feels the pain. Many people describe the weakness as a change in their bite or as an inability to chew as hard on the side of the lesion. This weakness usually recovers six to eight months after the procedure. The third undesirable side effect in an unwanted spread of the numbness to the adjacent branches of the nerve and to the eye. In some cases we actually are trying to numb the area in and surrounding the eye because the pain is situated there. Numbness of the eye itself is not harmful, but if foreign matter enters the eye the patient would not feel it. Inflammation, scarring of the cornea, and reduction or loss of vision could result. To prevent this we recommend each patient inspects the eye regularly with a mirror and to see an eye doctor if the eye becomes red or appears irritated, even though he or she may not experience pain. A few cases of double vision have been noted after the procedure, but none of these have been permanent. Rarely, meningitis or other neurological problems may occur. Patients are evaluated in the clinic the day before the procedure. Patients are instructed to go to the outpatient surgery desk on the morning of the operation and are taken to the operating room from there. After the procedure the patient remains in the recovery room for about two hours, after which the patient is discharged to their home. The patient returns to work a day or two following the procedure. Radiosurgery is a treatment which involves focusing hundreds of small beams of radiation on the trigeminal nerve. Patients are seen in the preoperative clinic on Monday afternoon for a complete discussion of treatment options. If they elect to proceed, they return on Tuesday morning. The patient is given valium prior to the procedure. The first part of the procedure is head ring application -- a metal ring is attached to the head at four spots after they are numbed with local anesthetic. A CT scan is then performed. CT and MRI images are transferred to a special computer where the radiosurgery plan is developed. The patient is then connected to a special radiation producing machine (called the Trilogy) and the treatment is started. The actual treatment takes about 40 minutes. The head ring is then removed and, after a short period of observation, the patient can return home. Because there is no general anesthesia or surgical incision, the patient can return to completely normal activity the next day. Radiosurgery usually takes 1-2 months to produce pain relief, so patients with more severe pain may be better off with an RFL or MVD. Approximately 50% of patients will eventually be pain free and off medications after radiosurgery. As with other procedures, some patients experience recurrent pain and require additional surgery. A relatively small number of patients experience facial numbness after radiosurgery, which is the only commonly reported side effect. Related
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at UF difference William A. Friedman, M.D. Dr. William Alan Friedman was born in Dayton, Ohio on April 25, 1953. He attended high school in Cincinnati, Ohio. He graduated in 1970 as a National Merit Scholar and attended Oberlin College. There he was elected to Phi Beta Kappa before moving on to the Ohio State University College of Medicine. Before graduating summa cum laude from medical school in 1976, he was elected to the Alpha Omega Alpha honor society and received the Maurice B. Rusoff Award for excellence in medicine. In 1976, Dr. Friedman moved to the University of Florida in Gainesville, Florida. He performed a surgical internship and a neurosurgical residency, from which he graduated in 1982. During residency training he did basic neurophysiology research as an NIH postdoctoral fellow (1 F32 NS0682-02). In 1982, he joined the faculty of the Department of Neurosurgery, as an Assistant Professor. He received an NIH Teacher Investigator Award (NS 00682-02), from July, 1982 - July, 1987, which funded further research into the basic neurophysiology of spinal cord injuries. In addition, this award supported the development of one of the first intraoperative neurophysiology monitoring laboratories, subsequently used to monitor thousands of neurosurgical and orthopedic surgical cases. Dr. Friedman served as Medical Director of the Intraoperative Neurophysiology Service from 1982-1992. Dr. Friedman was promoted to Associate Professor and received tenure in August, 1987. In August, 1991 he was promoted to Professor. In 1999, he became Chairman of the Department of Neurosurgery. He is the author of more than 250 articles and book chapters and has written a book on radiosurgery. He is a member of numerous professional organizations. Most notably, he is a Past- President of the Congress of Neurological Surgeons, Past President of the Florida Neurosurgical Society, and Past President of the International Stereotactic Radiosurgery Society. He is the Past Editor of Neurosurgery On Call, the Internet homepage of organized neurosurgery. He is a member of the Shands Hospital Board of Directors. In 1986, Dr. Friedman began collaborative work with Dr. Frank Bova, which led to the development of the University of Florida radiosurgery system. This system was subsequently patented by the University of Florida and licensed to Philips, then Sofamor-Danek. The commercial version of the system has become one of the most popular radiosurgical systems worldwide. Drs. Friedman and Bova received the 1990 UF College of Medicine Clinical Research Prize in recognition of this accomplishment. Dr. Friedman is the leader of a multidisciplinary radiosurgery team which has treated over 2800 patients, published more than120 papers and chapters, produced many international meetings, and educated hundreds of visiting physicians. Drs. Bova and Friedman recently received NIH R01 funding to support their continuing research efforts. Dr. Friedman is the Director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. He is a Gubernatorial Appointee to the Florida Center for Brain Tumor Research.
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