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Trigeminal Neuralgia: Surgery or No Surgery?
By Dr. Daniel Klauer
Betty (name changed to protect privacy) presented to me for treatment of her Trigeminal Neuralgia on 9/20/17. She was experiencing pain on the left side of her face starting at her ear and extending all the way across her cheek to her midline. She described it as an electric shock, sharp stabbing, and debilitating pain. She claimed she did not even feel alive anymore as her pain was a 9 out of 10. She was praying for help and relief when her physical therapist at the hospital recommend she come see me for an evaluation. She was formally diagnosed with Trigeminal Neuralgia in the Spring of 2017 at The Mayo Clinic in Rochester, MN. She completed a thorough workup with CT, MRI, and Clinical Evaluation. It was recommended that she undergo Microvascular Decompression Surgery to address her Trigeminal Neuralgia.
On 5/19/17, she completed microvascular decompression with a titanium mesh cranioplasty. In review of her surgical notes the following was completed: access was made through the occipital bone (base of skull) entering into the space of the cranial vault. The trigeminal nerve was visualized with compression of the superior and anterior cerebellar artery. Teflon felts were the placed in between the arteries and the nerve to reduce compression on the nerve. The surgery went without complication and a titanium mesh was placed with bone wax through the access point of the cranium.
The goal of this procedure is to relieve the compression of the trigeminal nerve centrally (within the cranial vault) and eliminate the trigeminal pain in the periphery (in the face). Following surgery Betty reported profound relief for 2 weeks. Within two weeks the pain returned just as before. She returned to Mayo Clinic and a second procedure was recommended and completed on 8/18/17. The second procedure was Gamma Knife Radiation (Stereotactic Radiosurgery) directed at the trigeminal nerve. The delivery of radiation to the trigeminal nerve is image guided and completed under sedation. The surgical report stated the procedure went well without complication. Unfortunately, this too did not relieve her pain and thus she presented to us on 9/20/17.
On 9/20/17, Betty’s chief complaints were: Trigeminal Neuralgia, Facial Pain, Pain When Chewing, Limited Ability to Open, and Jaw Pain. We completed a comprehensive exam and imaging with our iCAT FLX. Our exam revealed quite substantial findings. She was suffering from osteoarthritis on both condyles of the mandible, severe dental abscess (tooth #30), and a deviated nasal septum to the left impeding her ability to breathe adequately. She was immediately referred to an Ear Nose Throat Physician and Endodontist. Our evaluation also revealed profound risk indicators for sleep disordered breathing: snoring, fatigue, scalloped tongue, bruxism, narrow airway, nasal blockage and congestion, and frequent awakening. Thus, we diagnosed her with Trigeminal Neuralgia of the maxillary branch.
We also referred her to get a diagnostic sleep study as we felt that was contributing to her chronic pain, inflammation and potentially her sleep bruxism. Although we had the same diagnosis as Mayo Clinic, our treatment plan was quite different. We elected to treat her in the periphery (in the face) rather than centrally as the centrally directed surgeries did not prove to be effective. Our treatment plan consisted of oral appliance therapy with nighttime decompression of the TM joints and reduction of the force of contraction at nighttime. Specifically, a Diamond Dental Sleep Orthotic with an anterior deprogrammer and nasal dilators made to the phonetic bite. Additionally, we planned to utilize photobiomodulation (cold/low level laser) therapy to help create an ideal environment for healing and repair her damaged nerve. As we initiated treatment we referred her to get a diagnostic sleep study and nasal evaluation as well as root canal on tooth #30.
Treatment began on 10/17/17 with delivery of her sleep orthotic and photobiomodulation therapy directed at the trigeminal nerve. At her first follow up visit she reported her pain to be a 4 out of 10 and the following improvements just 2 weeks into treatment:
- Trigeminal Neuralgia 75% reduced
- Facial Pain 75% reduced
- Pain When Chewing 75% reduced
- Limited Ability to Open 60% reduced
Fast forward now to 11/16/17 and she reports her pain level to be a 1 out of 10 and the following improvements:
- Trigeminal Neuralgia 90% reduced
- Facial Pain 80% reduced
- Pain When Chewing 85% reduced
- Limited Ability to Open 80% reduced
Betty now is in treatment with the sleep physician to treat her sleep disordered breathing. The Diamond Dental Sleep Orthotic was addressing this as well as by preventing retrusion of the mandible. Thankfully within a month we were able to resolve her trigeminal neuralgia without the use of medications or surgery. The best part of this whole thing is what Betty said at her last visit, “I feel alive again!”