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Microvascular Decompression Surgery For Trigeminal Neuralgia

Aaron Cohen-Gadol, M.D.

October 24, 2014

Transcript

- Hello ladies and gentlemen, and thank you for joining us this evening. My name is Aaron Cohen. I'm a neurosurgeon with a special interest in microvascular decompression surgery for trigeminal neuralgia. I would like to take a moment, and thank the Trigeminal Neuralgia Association for putting this event together, and thank all the folks in the office at TNA, who do the ultimate work in order to bring this organization to the level that it is, and help all the patients with their pain. We know how disabling that can be. This evening the focus is going to be on mainly, microvascular decompression surgery. There's many ways to treat trigeminal neuralgia, but we're gonna focus on those classical types that are amenable to surgical therapy. We all know that pain is extremely frustrating. Nobody wants to live with pain, but unfortunately, as a neurosurgeon, we have only a limited set of tools where we can use in order to treat the pain. You want to have the classical trigeminal neuralgia, if you wanna undergo microvascular decompression surgery, and today's presentation hopefully, will provide you in terms of some information, that would make you lead, if you're a reasonable candidate for microvascular decompression surgery. It is important to note that ultimately your individualized meeting with your physician, it's gonna be the most important factor in deciding what is the best mode of therapy to treat your pain. As you can see, there is a set of slides that I would go through, and I will also try to show a video of microvascular decompression surgery, to see what it is that, as a surgeon, we do to treat this pain. Remember, Cindy from Trigeminal Neuralgia Association is gonna be online and is gonna moderate some of your questions. I apologize that I won't be able to answer all of them, expectedly, however she's gonna to try to filter those that are more relevant to everyone who is attending tonight. There are those questions that are gonna be very individualized, very specific to your case, and unfortunately, I will not be able to answer those, because again, I need more information to give you a fair and truthful answer. With that in mind, let's go ahead and start our slide presentation. This is a slide showing really, what patients could potentially go through. You can see sort of this person having all sorts of people poking at him, and trigeminal neuralgia is one of the worst pains humans have been afflicted with. And this is really a pain, that sometimes is worse than giving birth and so we want to find a way to treat it. I mean, as a physician, we all understand how important it is, and we hope that this evening, we will come to some sort of understanding for you, in terms of what is the best way, and would you be a candidate for an MVD, which stands for microvascular decompression surgery. This is actually a picture of a patient of Harvey Cushing, one of the fathers of modern neurosurgery, and you can see again, it depicts that very-much-episodic, disabling pain, that patients often come to the office and complain about. So, what is really trigeminal neuralgia? I think most of you, pretty much know very well that what this disorder is. Most of the trigeminal neuralgia patients are very well-educated. They do their research very well. They know what they're suffering from and they often read about their options before you see them in the office. Well, let's just briefly review, what is trigeminal neuralgia. Trigeminal neuralgia is a pain that is episodic. It is mostly shocking. Although it can have constant character to it, it's mostly episodic. It corresponds to the three divisions of the trigeminal nerve, as you can see here. It's either in the ophthalmic division, around the eye and the forehead. It's either around the cheek, or the maxillary division of the trigeminal nerve, or it's along the mandibular branch of the nerve, and it affects your jaw. It has oral or skin triggers. In other words, if you chew, if you drink, if you try to brush your teeth, you have this jolt of pain that just gets you off your feet. And most patients have a normal neurological exam almost, although that is not always the rule. Occasionally, the patients may have a little bit of sensory loss, that could be detected on a detailed neurological examination. Also, another factor that is characteristic of trigeminal neuralgia, is the fact that it responds to Tegretol, Neurontin, at least temporarily. Although, if you don't respond to those medications, you will not necessarily, you would not exclude the chance of having the good pain freedom, by undergoing microvascular decompression surgery. So if this is classical trigeminal neuralgia, what is non-classical trigeminal neuralgia? The non-classical trigeminal neuralgia is often called neuropathic pain or atypical facial pain. It doesn't fit, is really in the category of a classical trigeminal neuralgia, which I just mentioned on this slide, where patients would be a perfect candidate for microvascular decompression surgery. The atypical facial pain, would be patients who have a lot of burning pain. Their pain could be affecting, maybe part of their temporal scalp. It's really not in the typical distribution that you see on the face. Most of the pain is constant. They have injury to their facial nerve before, and they could have shingles, occasionally MS patients. So please remember, if there is a substantial component of constant pain to your face pain, if there's a lot of numbness and burning pain, that really denotes that you may not be a perfect candidate for microvascular decompression surgery. That doesn't mean you have to live with the pain. I will be the last person to say that. It just means that MVD is not the perfect option for you. And remember, if you don't have classical trigeminal neuralgia, undergoing an MVD or other options that we're gonna talk about momentarily, may potentially, worsen your pain and if not, will not help you. So again, the best way to find out if somebody has classical trigeminal neuralgia, is by detailed clinical history and physical examination. There is no perfect test that will tell you, well, the doctor said I don't have classical trigeminal neuralgia, but I'm really suffering. How can you tell me for sure, black and white, if I have trigeminal neuralgia or not based on a study? Such as study does not exist. Again, it's by clinical exam and more importantly, detailed history taking, by spending time with your physician. So we talked about the classical pain, just momentarily on the slide before. So what is the least common? It's usually the one that affects the pain around the eye. The bouts of pain can happen, but patients can go years without a pain, or months without a pain. So it's pretty episodic, but unfortunately that fear of the pain coming back often affects the lives of the patients tremendously and people seek surgical attention. And remember, some patients may have percutaneous procedures that we will talk about. That is another option besides microvascular decompression, and they have more numbness, because of those procedures in the past. So we wanna know about the initial presenting symptoms of yours, to determine if this is really classical trigeminal neuralgia versus what we call, atypical facial pain. So again, atypical facial pain, constant pain without the cutaneous triggers, burning component, the pain crosses the midline and is not in the typical distribution of the trigeminal nerve pain, the ophthalmic, versus maxillary, versus mandibular division. And again, you gotta have those symptoms in a very relatively classical distribution of the trigeminal nerve that we just briefly talked about. So after you come in and you talk to your physician, and you're diagnosed with typical trigeminal neuralgia, there's options that we're gonna talk about, that would be potentially placing a needle in, around the nerve at the skull base. It's called the gasserian ganglion, and doing various injuries to the nerve to prevent the nerve from causing pain. That's another option to treat the pain besides microvascular decompression. And the last option is radiosurgery and that's providing radiotherapy or radiation beams to the nerve to cause some injury, so the nerve does not cause pain. But if you are let's say younger than 75, have classical features and you're deemed appropriate for trigeminal neuralgia surgery, such as MVD, most of the time I'll say, all surgeons in the country perform an MRI. And as you can see at the MRI here, this is an exaggerated vessel. Again, this is your eyes that you can see on the MRI. This is your nose. This is an axial cross section, like a cross section of a salami. This is your brain right there. This is your brain stem. And you can see this large vessel pushing on the nerve right here, and so that artery presses on the nerve and causes trigeminal neuralgia. And that's one way to know what is causing trigeminal neuralgia. If your MRI is negative, you are not excluded as a candidate to have surgery, but the MRI primarily, wants to rule out a tumor or another etiology, besides a vascular compression on the nerve. So, let's say you have classical trigeminal neuralgia, or you have atypical facial pain. I would say uniformly, the first treatment is medication. That includes Tegretol, Gabapentin or Lyrica. There are other ones. Gabapentin may be called Neurontin, or Tegretol, Carbamazepine, but nonetheless, the first mainstay of therapy for trigeminal neuralgia is medication. These medication may have side effects. People feel dizzy, their memory may not work well. They may have other side effects, and because of that, some patients would desire to have surgical treatment. So if you have classical trigeminal neuralgia, some folks say, "You know what? I took medical therapy. It really helped, but I have side effects and I want to consider surgical therapy." And that's a very reasonable way to proceed with a more aggressive surgical treatment. Let's say you will start ... Or you have allergy to Tegretol. One of our patients, Phyllis, just corrected me and I appreciate that. So Cindy just asked a question, "Is the MVD beneficial if the pain is felt in the eye area?" Yes. We do do microvascular decompression if the pain is primarily in the ophthalmic division of the nerve. That is not absolutely any contraindication to microvascular decompression surgery. I think that's very reasonable to consider. And usually we try not to do aggressive ablative percutaneous procedures, because of the risk of numbness to the eye, and not be able to have the patient protect his or her right eye. So, let's say the medical therapy is failing, or you have side effects to the treatment, and you want to go ahead and try surgical treatment. I think microvascular decompression surgery is very useful and by moving the artery away from the nerve, as you can see in this illustration, we will try to keep the nerve free, so there's no conflict between the artery and the nerve. And that's one way the surgeons in surgery, try to provide the relief for pain. If the artery is not found, that is pushed against the nerve, we usually try to numb the nerve by causing a little bit of injury to the nerve. And you may wake up from surgery having some numbness, but most of the time you'll be pain-free, which is most important. Cindy's asking, "Is there a timeframe from developing trigeminal neuralgia and having an MVD done?" Let me tell you, there is no specific rules to that. I personally feel if you have trigeminal neuralgia, it could be just something that goes away pretty quickly. And so not all the patients who have trigeminal neuralgia, are stuck with it for the rest of their lives. So what I will try, is definitely at least six months of medical therapy, because it could be that you start medical therapy, and eventually the pain goes away, and you don't need any surgery. And trying to be too quick, to have pain and proceed with surgery, may not be a great option, because surgery does have risks, which we'll talk about. And if you had just taken medication in the first place, you would have become pain-free. So what are the surgical treatment options for trigeminal neuralgia? Again, it can be ablative, such as percutaneous stereotactic rhizotomy, where they put a needle in your side of your mouth, they go at the skull base and they cause some numbness. They can send a balloon up there to cause numbness. They can use high temperatures. They can use radio-frequency. Nonetheless, all of those techniques are very similar. They cause some numbness in the nerve that's causing pain in your face. Since the trigeminal nerve is primarily a sensory nerve, you really are not stuck with any weakness. So it's relatively safe, although you don't wanna have too much numbness, because that can be disabling. Let's go ahead, and here's a question from Cindy, and it's a very good one. I'm gonna answer that momentarily. Let's go ahead and review a video of how the surgery is done. As you can see, this is a sort of model, showing how we remove a piece of bone, go around the brain, gently retract the brain, and find the vessel that's sorta pushing around the nerve, mobilize that vessel, and place a Teflon patch between the nerve and the artery. So this is really the fundamentals behind microvascular decompression surgery. Let's look at that in surgery and see how really a surgeon sees it. So this is behind the eye, a piece of bone has been removed as you can see here, and this is the trigeminal nerve right there, and there's a bunch of loops of vessels around the nerve, and what we do is really mobilize the artery, and put a Teflon patch, as you see momentarily, and try to prevent any compression of the vessel on the nerve. Let's go head back to our slideshow and just review some basic ideas about how the surgery's done. Although we talked about those percutaneous procedures, we talked about microvascular decompression surgery, remember radiation rhizotomy is also an option and radiation works by a beam of radiation, burning the nerve to prevent any generation of pain. Usually we reserve that for older patients, who cannot undergo microvascular decompression surgery. It is the lowest risk and it however, has the highest recurrence rate of pain. The question that was a while mentioned by Cindy is, "Can MVD be repeated?" Yes. We usually reserve that for patients who have very typical trigeminal neuralgia. It does have higher risks to do repeat microvascular decompression surgery, but remember, the experience of the surgeon is very important ultimately, in terms of redoing microvascular decompression surgery. So I see Deborah is asking, "How does the Teflon patch stay in place? What makes it not to be dislodged?" We usually lodge it in between the artery and nerve and there's usually a good amount of space between the two, and when you sandwich it there, there's a crutch in the nerve area, in the axilla, where usually, it keeps the Teflon pretty well. And then ultimately, you gotta position the Teflon very effectively and you'll find out 99% of the time, it sticks in there pretty well. That's one reason why we ask patients not to have too much exertive activity right after surgery, in order not to increase too much pressure in the brain, and potentially dislodge the Teflon. Usually within six weeks to three months, the Teflon scars in and the chance of dislodgment afterwards is relatively very small. So this is the operating room setup. We usually place the patient in a lateral position, as you can see in the operating room in the slides, and we may do a lumbar puncture to drain some CSF. And I'm just gonna go through, sorta show some of the basic positioning techniques in surgery. I'm not gonna dwell on it. I use a curvilinear incision to do the surgery. Many use a linear incision. I think they both work pretty well, and everybody seems to be very happy with it. And really the methods of how we do this, is pretty standard by most neurosurgeons across the country. Before we really rush all the way into questions and just focus on your questions, I wanna say that the most important thing, about trigeminal neuralgia and MVD is correct diagnosis. Patient selection is critical for a good outcome. The surgeon should offer all the procedures, so when you go see him or her, you don't get the same procedure, no matter how old you are, and how many medical comorbidities you have. So seek a surgeon that has everything, not everything, I mean, if he or she only does MVD, that not everything looks like a nail, if MVD is a hammer for them, and they don't know how to do a percutaneous procedure, or do radiotherapy for trigeminal neuralgia. Remember, microvascular decompression is a very durable procedure, however, it does have failures later. Up to 10 to 20% of patients have failure about 8 to 10 years later. And remember, not every face pain is amenable to surgery. I wish it was, but remember, as a surgeon, we can make some pains worse and we definitely wanna avoid that. So with that let's go ahead, and Cindy, if you don't mind typing questions back-to-back for me, and roll your questions. Give it some time for me to finish with one, before we get to the other one. "What about minimally invasive MVD?" I like that question from Marianne, and you know Marianne, minimally invasive surgery is good in the hands of those those who can do it very well, but to be honest with you, in my opinion, I have done it both ways, minimally invasive versus a little bit more invasive, not necessarily very, very invasive, and the minimal craniotomy and the relatively endoscopic versus open with minimal craniotomy, the results are the same. The patients go home the same. Therefore I wouldn't dwell too much on necessarily, an endoscopic procedure versus a mini open procedure. I think they're both the same. Again, it's the experience of the surgeon that is most important and it's most important, what is the surgeon comfortable with, and what are the best results he or she can achieve with that. So, "Is there an MRI that will show compression?" Thank you Cindy. MRI does usually show the compression, but there is a large group of patients whose MRI does not show the compression. That does not exclude you as a patient and a candidate for microvascular decompression surgery. Why? Because the vessel can be very small. And if it's very small, the MRI may not show it because it's missed across two slices of MRI. So what's most important is, that to rule out a tumor, rule out another etiology, besides a vascular compression, and if that is excluded, and the patient has classical trigeminal neuralgia, and they're young, and they don't have medical comorbidities that will prevent general anesthesia, I personally offer them an MVD. "What are the adverse effects of MVD?" Great question from Sheila. You know Sheila, to be honest with you, there is chance of infection, bleeding, meningitis, facial weakness, stroke, numbness. Boy, that sounds like a lot of complications, but the risks are very small in the hands of those who do at least 50 or 100 a year. And so here we do about, more than a hundred a year, and our risks have been really less than 1%. I have to knock on wood, and I have to say, within the past four years, none of my patients that we have done microvascular surgery, has not returned to work. So every patient, who has done an MVD, has returned to work, which is really how we evaluate our results. If a patient returns to work, if they are functional as they were before, that's how it should be. As a surgeon, we expect excellent outcomes. Louise asks a excellent question. "Can I lose hearing when I have MVD done?" Yes, and one of the highest risk of MVD is loss of hearing in the same ear, the same side that you had the surgery done. Usually that is very rare. Unfortunately it does happen. And again, if it doesn't return within a year, the chance of it returning afterwards is small. I think Phyllis is asking, "I've been given the option of cutting the nerve instead of padding it." Personally I am against cutting the nerve because if you cut a nerve, there is a risk of delayed anesthesia dolorosa. It is a extremely painful disorder. It's a neuropathic pain. There's no good treatment for it, and I usually consider partial severing of the nerve, or squeezing the nerve, or sorta burning it slightly, so the nerve's still there, because I feel cutting it, really could potentially, place you at a high risk of anesthesia dolorosa, or very burning, delayed pain. Carrie, your surgery damaged the nerve, causing the MVD to be ineffective. I personally don't think so. Some surgeons may say otherwise. I personally feel that radiosurgery does not affect the results of MVD, however, I feel if you have classical trigeminal neuralgia, rather than saying, I'll try the non-surgical options and if the pain doesn't get better, I'll do surgery. I don't like that strategy. If you're a candidate for MVD, I will do the MVD from the beginning, because you don't want to injure the nerve and potentially have side effects related to injury of the nerve from percutaneous procedure or radiotherapy, on top of a microvascular decompression surgery. Somebody, Amy, I'm sorry. Cindy says, "Does insurance cover MVD?" I sure hope so. I don't look at people's insurance when we do take care of them, but I suspect most insurances do, and I suspect you check with your insurance company individually. "Is trigeminal neuralgia hereditary?" Excellent question from Brenda. Yes, it can be hereditary, but extremely rarely. So if you have trigeminal neuralgia, and nobody in your family has trigeminal neuralgia, you probably are not gonna transfer it to your kids or your siblings. You'll be okay. The risk is extremely small. "Do you recommend MVD if the medication is working?", from Andy. I do not. MVD has risks. I personally feel if the medication is working for you Andy, I would stick with it. If you have adverse effects or if you don't have good relief of pain, then you can consider MVD. Sheila is asking, "Are lumbar punctures performed in all MVDs?" Not necessarily. I do it. I like it, but it's not the standard of care. I think it's surgeon's preference. Choice of second Gamma Knife, that really depends on your individual doctor and individual case, so I can't comment on that, unfortunately, Randy. "Are there any concerns about 80-plus years?" You know, it depends how healthy of 80-plus-year-old person you are. I personally feel, if you're 80 years old, it is best to go with a percutaneous procedure, or Gamma Knife, or a CyberKnife, or Novalis. They all stand for radiosurgery. They don't differ much from each other. So radiosurgery means Novalis, Gamma Knife, or CyberKnife. They're all the same, and don't get confused, and I don't believe there's a significant difference between those, but if you're 80 years old or older, I try to be not aggressive with MVD and do a percutaneous procedure. "Well, what about if you have neuropathic pain? What about if you have a lot of burning pain and what we call, atypical trigeminal neuralgia?" Question from Rania. You know Rania, unfortunately that falls in the territory of our pain management colleagues. There are pain management strategies and medication. Also recently, there has been cortical stimulation therapy. I am not the person unfortunately to comment on those. Cindy if you wanna shoot me another question, "Do you recommend MVD for burning in the mouth?" You know, if there is any burning pain, I'll be very careful about MVD. If you have a little bit of burning pain, and most of your pain is that typical electrical shock with cutaneous triggers, well, you can consider MVD, but that has to be discussed based on individual patient and individual discussion with their physician. "If the first MVD did not work, should you consider another one?", a great question from Bryce. I personally feel you should wait for a while. You should try medication. Sometimes patients wake up from MVD and they still have pain and the pain goes away in a delayed fashion. So if you wake up from your surgery, don't get alarmed if you still have pain. The nerve may be very much irritated and it requires more time to heal. If your pain remains there for another three months after surgery, it really depends what your surgeon found in surgery to consider another one. That really has to be individualized and therefore, I cannot comment on it based on this short discussion. "Does stress trigger TN?" Absolutely. Stress is one of the most common trigger factors for TN. So if you have TN and you're barely under control with medication, avoid stress. It would help you. I think anything that would put your nervous system at a stressful level, would cause a worsening in your pain. "Does TN cause blurred vision?", a question by Brenda. I don't believe so. Again, that has to be individualized. If you have any other symptoms, besides facial pain, I think a detailed evaluation by a neurologist or neurosurgeon and an MRI would be very much in order, in order to prevent missing another potential lesion, that could be causing your symptoms. "What to expect after surgery? How long for surgery to heal?" Excellent question from Dana. You know, Dana, usually after surgery, you spend the first night in the ICU, you feel nauseous, often you have headaches, you feel horrible. You're like, what the heck did just happen to me? I just got, you know, hit by a truck. That is normal after surgery, because of the surgery in the part of the brain in the back of the head. You feel nauseous. You vomit. You have headaches. That, usually, is temporary. It goes away within two or three days. Most patients stay in the ICU one night and they go to the floor. They are discharged two or three days later, and you need to avoid heavy lifting for up to six weeks after surgery. And then if you have office work, you may return to office work in a month later, after your surgery. Cindy is asking, "Does the Teflon pad or felt used to decompress, can it cause scarring?" Yes, but that is extremely rare. Very occasionally, if you put too much padding, you may have a recurrence of trigeminal neuralgia. It's called Teflon granuloma. But again, that's rare, and the case has to be carefully discussed, before a repeat microvascular decompression or a second procedure discussed. "Can I fly right after surgery, to return to home?" I would say, I would stay around in a hotel, at least a few days after surgery. Make sure you feel all right. There's no CSF leak. There's no brain fluid leaking anywhere. Your nausea is under control. And maybe after a few days, may be prudent to fly. I personally feel it would be nice not to fly at least for a week after surgery, but if you have to, I would wait a few days, just to get your strength together, and get the air out of the head, when you have surgery, that can occur, before entering the plane, where the atmospheric pressure could change. So Fred is asking, he had suffered from terminal neuralgia, he had Gamma Knife, pain-free for five years, pain is back, "Will the length of time when you have trigeminal neuralgia affect the success rate?" We don't know. We don't know if the length of time you suffer from TN will affect the final outcome of your surgery. That study never has been done prospectively and the retrospective studies have their shortcomings, therefore nobody can, for sure, tell you if the length of your suffering correlates with the outcome of your MVD. "Does CSF leakage, is it a major problem?" It is not a major problem. That's when you have surgery, and fluid leaks out of your nose or your ear. It's not a major problem, but you need to see your surgeon right away, because usually that means there is a connection with the surgical site and your nose or your ear through the sinuses, and the surgeon has to fix it, either by putting a drain in your back, or going back for a short surgery to plug up the areas that are leaking through your sinuses. If you have CSF, it can brain fluid leak and you don't fix it, you can have meningitis, and that can be life-threatening, so that has to be fixed right away. So, you know, some of the folks are asking one of our colleagues, Julie, "My doctor prescribed antidepressant that would calm me down, and would that be helpful?" That has to be really individualized. I cannot comment for you guys unfortunately, what is the right medication for you, because that really requires individualized care with your physician. So, "Will the pain travel to the different areas of the face?" Usually it depends where the pain is, but usually, the most commonly, if you have the pain around the eye, starts around the eye right here, and then shoots up towards your forehead. If you have the pain here or here, it sort of shoots up, to this portion of your nose, or may shoot down to your jaw. The shooting and the traveling of the pain, as long as it's kept within the distribution of the nerve, that we talked about, that is okay, but you can't have pain shooting on the other side. You can't have really pain shooting in your ear, because that could be potentially another disorder called glossopharyngeal neuralgia, and that's when you swallow, the pain shoots in your ear. That's a different disorder. So, "Does TN affect the neck at all?" Not usually. That will be very unusual and it will be more in the realm of atypical facial pain. Yes, Phyllis, the cold, the flu does set off your pain. You're very right. Anything that stresses your system, will set your pain off. Barbara is asking, "Will acupuncture, chiropractic care, help the pain?" You know, personally, I believe evaluation with a physician is the best approach. As long as the chiropractic treatment has no risk to you, I have no problem if it's helping you. "Does the TNA keep a list of neurosurgeon who perform MVD?" Absolutely, I believe so, and if you have a question, please email Cindy Etsell, as Cindy is spectacular in terms of helping you guys, from TNA. She will leave her contact number, that you can email your questions to the TNA, that does a spectacular job, and I'm sure, that can provide you guys with some feedback. So, "What is genicular neuralgia?" That's a very rare disorder. That pain is really disabling pain in the ear. Not much pain in the face, very little pain in the face, that when a breeze of air, when you take a shower, when you touch your ear, you have this extreme, excruciating pain within the ear. That's called genicular neuralgia. That's different from trigeminal neuralgia. And remember, we don't want to mix that up with trigeminal neuralgia. Trigeminal neuralgia is in the face. If you have ear pain with your face pain, be aware you could be suffering from atypical facial pain. So Patricia asked if I can repeat about pain upon swallowing. Glossopharyngeal neuralgia is different than trigeminal neuralgia. If you swallow, the pain shoots in your ear, and the trigger factor is swallowing. You don't have much pain at all, in the face. That's called glossopharyngeal neuralgia. So that is different. If you have pain shooting in your ear when you swallow, not necessarily when you brush your teeth, or chew, or any other activities in the face, that's glossopharyngeal neuralgia, extremely rare, often misdiagnosis. Be aware of it, but again, it's swallowing, pain shooting in the ear. That's glossopharyngeal neuralgia. "Does a rise in blood pressure trigger the pain?" That's controversial. Usually increase in blood pressure is associated with a stressful event, and therefore I have to say, probably does, not necessarily because of blood pressure, because of associated stress. That is a difficult sorta relationship, if the rise in blood pressure causes worsening of your TN. I don't believe heart rate affects TN, but again, those factors have not been best studied, Brenda. "Is there a timeframe where the injury moves from fixable to permanently damaged?" Andy, unfortunately, I can't answer that question. That's a very specific question. Renee Cohen has the same last name as mine. "I have been told that the pain actually raise your blood pressure." Correct. If the pain is so disabling in TN, that does raise your blood pressure. Correct. Any stress does raise blood pressure, let alone TN. The diet, the sodium in the diet, that's very difficult for me to answer, if that really affects much in terms of TN. "Does cold triggering stop after the MVD?" Yes, after your MVD, you are supposed to be pain-free no matter what you do to your face. So if your MVD is done and you have a good result, we expect a very happy patient, nothing else. But again, it all depends on a good patient selection. "Can TN cause blackouts?", by Brenda. I don't believe so. That's extremely rare if it does, If you have a blackout by your TN, I would see a neurologist to also assess your heart and make sure there's other etiologies. I mean, occasionally, I guess you could say that, you know, trigeminal nerve has association with the cardiogenic reflexes, but again, those symptoms are extremely rare. A question from Abby Williams. Abby's asking, "If you're on medication, is it difficult to differentiate atypical facial pain from trigeminal neuralgia?" Not usually. I think every patient should be very honest with their surgeon about what is their symptoms, and what it was before, and the surgeon should be able to make a accurate diagnosis based on the history. "Is the skull bone here replaced after the surgery is done?" Yes, sometimes we replace it, sometimes we put medical cement. For you, as a patient, it should feel the same. It doesn't make a difference. It's a surgeon preference. I believe replacement of something, either the cement or the bone, is appropriate. "Is the neuropathic form of the pain, or atypical facial pain, hereditary?" Extremely rarely, Lesley. Patricia, "Is pain in the face, not in the ear, after swallowing of TN?" It could potentially, but that's extremely rare. You've gotta have some cutaneous features on the face, such as chewing, or touching, or other symptoms we just talked about. Karen is asking, "I started with burning pain for three years, now I have only the pain in the past three years. Why would that change?" Well, that's really individual, Karen. I wish I could answer your question. That's something unusual and I would say personally visiting with a neurologist with expertise in TN care would be appropriate. Robin is asking, "If you have reached the limit of your Gabapentin, is there another medication?" I think you potentially can have Tegretol, but usually, if the medication is not working for one, if the pain is not working with one medication, it's not going away, usually it may be time to try surgery, something more aggressive, or try Tegretol. I think that will be reasonable. If you're allergic to Tegretol, maybe try Lyrica. I think that may be a good choice for you. Kristen had MVD in 2004, pain-free, some occasional aching now, "Is this a sign that the surgery is failing?" No, Kirsten, and for all our patients, please remember, patients who have had MVD may have these unusual pains, twitches, sorta unusual feelings. That does not mean your pain is coming back. Live your life happy. We are here to help you. We all need some life without stress. And most of the time, those little twitches don't go anywhere. Gary is asking, oh, I'm sorry, "When TN comes back five years after TN, what usually is the cause of return?" That's multifactorial. Sometimes it can be that the nerve sorta had this inert dysfunction and it wasn't working well, so after a while it became another generator for the pain. It could be that the Teflon patch was moved. It could be that the vessels has moved, also because the Teflon patch moved. But most of the time, I think TN is something that's not 100% curable, and the nerve itself is so injured from the initial etiology of the pain, before the surgery was done, that it somehow learns to recreate the pain. And again, you have to personally discuss it with your physician before considering other options, if you have had MVD in the past. Let's go ahead and ask a couple of last questions. I think it's about 8:50. We want you guys to also return to your families. Robin is asking, "Are there good results with medical acupuncture?" Unfortunately, I do not have experience with that and I leave it in the good hands of you guys as patients, to recommend that to your colleague patients. Excellent question by Sheila, "What are your ideas about weaning medication before surgery?" I don't do that. I keep all patients on pain meds through the surgery and if they're pain-free for two weeks afterwards, one or two weeks afterwards, I slowly ask them to wean themselves off. Take one pill off every few days and slowly get rid of the medication. From Barb is asking, "The Tegretol worked for a year and a half, and then the pain came back. Have increased the meds with some relief. How often do the episodes occur?" That's very hard to know, and that's very individualized based on the patient. A FIESTA MRI for Roberto showed vascular compression of TN, "but I also have some burning and atypical pain. Would you still advise MVD?" That is very difficult to answer, Roberto. I'm sorry. I wish I could. That really requires a detailed history taking and nobody can diagnose TN by just one or two questions, so I recommend an evaluation by your physician. Well, I wanna thank all of you 90-some patients who joined us this evening. Folks, we had almost 100 patients this evening, and I have really enjoyed taking care of trigeminal neuralgia. It has been the most satisfying part of my career as a neurosurgeon. The happiest patients I have, the most number of Christmas cards I get, are from my trigeminal neuralgia patients, who have been cured. So, it's been an honor for me to service all of you guys. I wanna thank all of you this evening for joining me. I would also thank the TNA for putting this together. We wish to hopefully put something like this together for you guys in the near future, have other guests who can answer questions, and hopefully this web conference will provide a milieu and environment for you guys to further answer questions. And as we always say, "For patients, knowledge is power." You know more, you're gonna treat yourself better. And that's what we are here for, in conjunction with TNA. From all of us and TNA, I wish you all the best and from Indianapolis, good night.

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