Advances in Treatment and Understanding of Trigeminal NeuralgiaNeurosurgery Grand Rounds |
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What Is Trigeminal Neuralgia and How Is It Treated?Trigeminal neuralgia is a chronic pain disorder that affects the nerves in your face. It causes a painful electric shock sensation in the jaw or side of the face, and the symptoms can worsen over…
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April 29, 2022 Interviewer: Severe, sudden, and sometimes debilitating face pain is a symptom of a disease called trigeminal neuralgia and some people suffer with the condition and don't even realize that's what they have. Or maybe it was misdiagnosed as something else so they can't get treatment. Dr. Shervin Rahimpour is a neurosurgeon who specializes in the surgical treatment of trigeminal neuralgia, and he's going to help us understand how to come to that diagnosis. So first of all, you tell me it's a poorly diagnosed disease. What exactly do you mean by that? Dr. Rahimpour: Often this pain is distributed around the cheek and jaw area. And so it's natural for patients to think that this is likely a result of their dental health. And so they often seek treatment through a dentist, usually, you know, undergo a tooth extraction or something like that, and that pain persists. So that's often why this is poorly diagnosed is because it overlaps with other common issues like having tooth pain. Interviewer: Yeah. And I think a lot of us think well, the pain is here, this must be the source of the pain. It's in my mouth or my cheek, it must be the source. But that's not the case with this disease. Where does the pain originate from? Dr. Rahimpour: The trigeminal nerve, which is one of the 12 cranial nerves that we have, supplies, amongst other things, the sensation that we feel over our face. So there are two nerves, one for each side. Each nerve supplies the sensation to that half of the face. And the nerve has three divisions associated with it. There's one that kind of overlays the forehead and around the eye. The other division is around the cheek area, and then a third division encompasses the jaw. And so most commonly, the pain is likely to affect those bottom two divisions, which is around the cheek and the jaw area, and that's where this overlap comes with potentially pain coming from your teeth. Interviewer: And somebody goes to the dentist, they have an extraction done and that doesn't solve anything. Do they try to get a diagnosis beyond that, or do most people just give up or do you know? Dr. Rahimpour: Yeah, I should add that sometimes it can be your teeth. So it is worth having that evaluation done by your dentist. But eventually, this pain syndrome is referred either to a pain specialist or even a neurologist. Those are the folks that typically end up diagnosing this as trigeminal neuralgia-type pain. Interviewer: Explain some of the common symptoms that people might experience. Dr. Rahimpour: Yeah, absolutely. So again, this pain used to be . . . this disease used to be known as suicide disease because it was such a horrible pain for patients to experience. And it's often a severe electric type jolt or stabbing pain involving one or more of the divisions of the trigeminal nerve of the face. It's often set off by very relatively innocuous stimuli. What I mean by that is anything as simple as just a gust of wind, or talking or brushing your teeth, or having water hit your face when you're taking a shower. These are kind of the very, very basic and innocuous things that can trigger that type of pain. Interviewer: And what's going on with the nerves that is causing this pain? Dr. Rahimpour: The vast majority of cases are thought to be caused by a vessel sitting on the nerve root as it enters into the brainstem. And so what this vessel causes is damage over a period of time that ends up injuring the insulation around the nerve known as myelin. And then this can result in sort of aberrant firing of the nerve. Interviewer: So it's rubbing against there, damaging the insulation every time your heart beats. Dr. Rahimpour: That's exactly right. Interviewer: It's damaging the . . . Okay. Dr. Rahimpour: So the thought is that if we can remove or transpose this vessel from the nerve root . . . Interviewer: Yeah, get it away from there. Dr. Rahimpour: Get it away from there, that could potentially allow the nerve to heal and prevent some of this aberrant firing. Interviewer: And if a patient has this type of pain, they would go to their primary care physician first likely. What would that workup look like? Dr. Rahimpour: Typically, the patient has these classic types of symptoms or the stabbing electric type pains of the facial region, again, involving either one or more divisions of the trigeminal nerve. And we often ask patients, you know, "How is this pain brought about?" If it's something, again, wind, chewing, talking, anything like that, that's pretty consistent with trigeminal neuralgia. The pain also again persists to seconds to potentially minutes, and so that's another signature or hallmark of the disease. And we often look for patients that, you know, typically we find that this disease occurs more often in the older population. So the incidence kind of climbs as age goes up. But this can also be a result of some other secondary processes. Certainly, it can range anything from facial trauma and include other secondary causes like multiple sclerosis. Interviewer: At what point should a person consider consulting with a physician who specializes in trigeminal neuralgia? Dr. Rahimpour: I think early on it's best to have the medical therapy be optimized. So a lot of the medications we use for this type of pain are actually anticonvulsants used in epilepsy. The reason why is because, similar to epilepsy, the nerve can act on its own and fire. And so the idea is can we stabilize this nerve so that it prevents it from firing, the same way that we try for epilepsy. Those types of medications are started, they're increased to a therapeutic level and then the patient is evaluated to see if this treats their pain. Again, the vast majority of patients respond to these medications, something upwards of 90%, but half of those patients end up having unwanted drug side effects. And then, of course, there's a 10% that did not respond to the medication at all. Interviewer: Yeah. And this medication, is it kind of a dialing-in process, you've kind of got to figure out the sweet spot for everybody? Dr. Rahimpour: Yeah, I would say that most anticonvulsants are started at a low dose and gradually titrated up. Interviewer: And for the individual that is not responding to medication, or the side effects are just so terrible that it's really impacting the quality of life, and that's where the microvascular decompression procedure comes in. That's what you're doing there. Dr. Rahimpour: That's exactly right. So for patients that aren't responding to the medication, if they've had an MRI scan that shows that potentially there might be a vessel there pushing on the nerve, that's where microvascular decompression can play a role. Interviewer: What about for patients where they have the condition, and it's not pressing against that nerve? That's possible, right? Dr. Rahimpour: Patients where we don't necessarily see a blood vessel pushing on the nerve, or they might not necessarily be a good operative candidate, we can offer other minimally invasive approaches. Those approaches include percutaneous rhizotomies. The premise there is that we with a needle go to the base of this nerve, known as the trigeminal ganglion, and we try to damage that nerve to sort of disrupt the pain signal. The other option is using radiation in the same way that folks use it for tumors to try to focus the radiation and try to damage the nerve again, to stop this pain signaling. Interviewer: Are these other last two procedures, are they an alternative to somebody getting a microvascular decompression? Dr. Rahimpour: They are alternatives, but I should add that they're not as efficacious. So when we do find patients are good candidates for microvascular decompression, we try to advocate for that as it gives us the best chance for pain freedom. Interviewer: After somebody has the microvascular decompression, what is the success rate that that actually takes care of the pain? Dr. Rahimpour: We expect that patients often have immediate pain relief after surgery, especially if we do find a blood vessel that's compressing the nerve. Historically, 70% to 80% of patients are still pain-free at five years. Interviewer: And the other 20%? Dr. Rahimpour: Pain can reoccur. And if that's the case, we can always revisit other possible interventions, including some of the percutaneous and radiosurgery techniques that I mentioned. Interviewer: For the patients who get the microvascular decompression, what's the satisfaction rate among those patients? I hear this could be life-changing for some people. Dr. Rahimpour: Absolutely. So again, this is a very debilitating disease. I mean, you can imagine if it's affecting the way you eat, and the way you conduct yourself throughout your day-to-day in anticipation of a sudden pain strike, being pain-free means everything. And so when patients are pain-free again, where we expect that to be the case in the vast, vast majority of times after microvascular decompression, this is absolutely life-changing.
Trigeminal neuralgia is a chronic pain disorder that affects the nerves in your face. It causes a painful electric shock sensation in the jaw or side of the face, and the symptoms can worsen over time. Learn what causes trigeminal neuralgia and how surgery could provide relief to those suffering from the condition. |
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Focused Ultrasound Treatment for Essential TremorFor patients with essential tremor (ET), the uncontrollable shaking of the hand, head, and voice can interfere with nearly all aspects of life. A new outpatient procedure that uses high-intensity…
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March 23, 2022
Brain and Spine Interviewer: Focused ultrasound to treat essential tremor and how to decide if it's a good option for you. Dr. Shervin Rahimpour is a neurosurgeon who specializes in the treatment of essential tremor. Who is a good candidate to get relief if they have tremor symptoms using this treatment? Let's just start there. Dr. Rahimpour: Essential tremor is the most common movement disorder and affects upwards of 10 million people in the United States. It's characterized by this either postural tremor when you try to maintain a posture with your hands or it can be brought about when you're trying to perform some kind of physical action with your hands. And it doesn't necessarily just affect the hands. It can affect people's voice, their balance, and other extremities. While there are effective medications for essential tremor, some patients don't either respond to these medications or have bad drug side effects, and we have good interventions to try to treat this surgically. Interviewer: And is there somebody in particular, beyond perhaps medications don't work or they'd react badly to them, that would be a good candidate for this particular surgery? Dr. Rahimpour: Yeah, it could be the case that the medications work but just not enough. So you could imagine if your hands are shaking, whether it's affecting your work or just even trying to feed yourself, this can be really debilitating. So if the medications make the tremor a little bit better but not quite to where you need it to be, to be functional, that's where surgical intervention can play a significant role. Interviewer: And if somebody comes into your office, what process do you go through to determine if they're a candidate? Dr. Rahimpour: First, we make sure that they've actually exhausted their medical options. Obviously, we don't want to perform surgery on someone that could otherwise be treated with medications. The next step is we assess their tremor. Sometimes patients are misdiagnosed, so we want to make sure they actually have essential tremor and not some other kind of movement disorder. Once we've confirmed that, we assess their surgical candidacy. We look at their MRI imaging to look at their brain anatomy. And then we discuss some of the options that are available to them. Currently, we have two different treatment options for essential tremor. Historically, the mainstay of surgical management of essential tremor has been deep brain stimulation, which involves placing electrodes in the sweet spot of the brain called the thalamus where we believe is a critical area for essential tremor. This treatment involves two stages. One is placement of the electrodes in the brain during an awake surgery to make sure that we are providing adequate tremor relief, and then a second stage, which involves connecting those wires to a battery typically in the chest pocket, like you would for a pacemaker. Now, this therapy is not necessarily for everyone. Certainly, for patients who don't want an open surgery, and also those that may not qualify as a good surgical candidate. And that's where I think focused ultrasound can play a significant role. Interviewer: And how does focused ultrasound work then? Dr. Rahimpour: Yeah. So focused ultrasound . . . similar to the way a magnifying glass focuses a beam of light to a point, acoustic lenses can be used to focus sound to a point. And so we use this principle to focus sound energy to that same spot in the brain, the thalamus, to try to disrupt the circuit that's causing a patient to have tremors. Interviewer: This is non-invasive completely? Dr. Rahimpour: Yeah, absolutely. So it involves a couple of things. One is to shave the head entirely, and other than that, there are no incisions, and typically, patients leave the hospital the same day. Interviewer: Wow. And what about relief from the tremors? Does that develop pretty quickly as well? Dr. Rahimpour: Yeah. That, we expect to be immediate. The caveat currently is that we can only treat one side of the brain. So for patients who might, say, be right-handed, treating their left brain for their right hand can mean a significant improvement in their quality of life. Interviewer: And I've heard this procedure could also be used for Parkinson's. Is that true? Dr. Rahimpour: Yeah. So for patients who have a tremor-dominant Parkinson's disease, focused ultrasound can also be an option. And then recently, as of last year, it's also FDA approved for other symptoms of Parkinson's, not just the tremor. Other symptoms include things like bradykinesia or rigidity, so difficulties initiating movement or moving. Interviewer: If somebody is eligible for focused ultrasound, what considerations would a patient go through to determine if that's the treatment that they want to pursue? Dr. Rahimpour: Yeah, so similar to deep brain stimulation, we want to make sure that the patient has the appropriate diagnosis for essential tremor, again, because a lot of things can mimic this disease. So patients have to ask themselves whether or not they are willing to undergo an open surgery, which is deep brain stimulation. And if they're not, then this gives them a nice alternative option. Patients who undergo evaluation for focused ultrasound should also consider potential side effects from this treatment. That includes temporary ones, like having some numbness and tingling sensations on the same side as their tremor, as well as potentially a brief period of time after the procedure of poor balance. As the swelling develops from the treatment over the course of the next several days to weeks after the procedure, sometimes these symptoms can get a little bit worse before getting better. And by three months out to a year of follow-up, we don't expect these symptoms to persist. Interviewer: Are there any long-term type symptoms that a patient should be aware of? Dr. Rahimpour: Very rarely can these paresthesias or the sensation of numbness and tingling persist at a year's time, and the same goes for balance and abnormal gait. One part of our pre-procedural evaluation involves an evaluation by our physical therapist, who assesses patients' gait and balance to ensure that we have a good adequate baseline before undergoing this procedure. Interviewer: For somebody with essential tremor, when you use the focused ultrasound to reduce their tremors, how does that impact their quality of life? Dr. Rahimpour: Treatment with focused ultrasound to reduce tremor can have a very meaningful impact on one's quality of life. It gives them the ability to do some of the hobbies that they enjoy and certainly some basic tasks like feeding themselves. Interviewer: After somebody has had a focused ultrasound to treat tremor and, say, the tremor starts coming back after a period of time, the three years that you mentioned, can they get the focused ultrasound again? Dr. Rahimpour: Absolutely. We can reevaluate them in clinic to see what their options are. Interviewer: And if at that point they've also decided, "Well, maybe I want to try the deep brain stimulation at this point," is that another option? Dr. Rahimpour: Yes, that can also still be on the table as an option.
For patients with essential tremor (ET), the uncontrollable shaking of the hand, head, and voice can interfere with nearly all aspects of life. A new outpatient procedure that uses high-intensity ultrasound has been shown to significantly reduce tremor symptoms for years in most patients. Learn how the procedure works and how effective it can be to help essential tremor patients. |
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