It produces excruciating pain anywhere from the top of the head to the base of the jaw. At an increasing frequency, New York metro area people burdened with trigeminal neuralgia are turning to Dr. Michael Brisman, a neurosurgeon at South Nassau Communities Hospital, for help. His expertise combined with leading-edge medical technology is wiping away their pain and allowing them to walk away with smiles on their faces.Brisman, co-medical director of the Long Island Gamma Knife at South Nassau, has treated more than 200 patients with trigeminal neuralgia, ranking South Nassau among the top hospitals in the Northeast in the treatment of the disorder.Trigeminal neuralgia is a very specific type of facial pain, and a diagnosis is made based on the patient's history. Patients experience sharp, severe pain in the face, usually on the same side and in the same location. "Sufferers often describe trigeminal neuralgia as 'electrical shock' pains," said Brisman. "The pain typically occurs in the lower part of the face, the cheek, jaw, gums, teeth, or nose, but can also occur in the forehead, the temple, the eye or the top of the head. The pains are intermittent, and come on suddenly and disappear suddenly, usually lasting just a few seconds."The pain can radiate back to the ear, or remain localized, and is triggered by mild stimulation on the affected side of the face, such as touch, a light wind, talking, chewing or brushing the teeth. The condition is also characterized by spontaneous remission, as the pains it produces can go away for months or years and then return. In some cases, a patient can experience trigeminal neuralgia on both sides of the face, but rarely at the same time.The disorder is caused in most instances by a small blood vessel pressing on the trigeminal nerve where it exits the brainstem. It is sometimes caused by multiple sclerosis, or by a tumor or other mass pressing on the nerve. MRIs are used to diagnose the cause.About 1 to 2 percent of people with MS will develop trigeminal neuralgia. Patients with MS are more likely to develop the condition at a younger age, usually have atypical features, and are more likely to have bilateral trigeminal neuralgia -- on both sides of the face.After diagnosing the disorder, and verifying a normal MRI of the brain and dental exam, patients are usually treated with medication. Standard pain medicines are often ineffective, and anticonvulsants are frequently used."Many patients will manage just fine with medication," said Brisman. "The medicines do require follow-up blood work, and sometimes can have side effects or fail to fully control the pain. If that is the case, we recommend that the patient consider surgery."Micro vascular decompression (MVD) is the procedure of choice to eradicate trigeminal neuralgia. In this operation, an incision is made behind the ear on the same side as the pain, and a small opening is made in the skull to explore the trigeminal nerve. If a small blood vessel is found pressing against the nerve, as it usually is, the blood vessel is separated from it and a sponge-like material is placed between the blood vessel and nerve. "This is an effective and long-lasting approach that won't cause face numbness and is considered for patients in good health. MVD does, however, have a higher risk of complication than some of the other options," said Brisman. Purposely causing minor damage in the beginning portion of the trigeminal nerve is another effective treatment for the disorder. This can be accomplished by sticking a needle into the cheek, and advancing it under X-ray guidance through the hole in the skull where the nerve emerges (the foramen ovale). The nerve is then damaged slightly by either heating it (radiofrequency), injecting it with an alcohol (glycerol), or inflating a balloon against it. "These techniques for nerve block, or 'rhizotomy,' are minimally invasive and low risk," said Brisman, "but they do carry some risk of bleeding, infection, and face numbness." Another technique that can be used to damage the nerve, which is the most advanced and least invasive employed by Brisman, involves a leading-edge medical technology known as the gamma knife. It is actually not a knife at all, but rather a super-focused brain radiation machine that is the gold standard in brain radiosurgery. Invented by a Swedish neurosurgeon, Dr. Lars Leksell, in the 1950s, it has joined the mainstream in the last 15 years with the advent of the MRI. The highly focused beams of the gamma knife can target the early portion of the trigeminal nerve and relieve the agonizing pain of trigeminal neuralgia. The gamma knife is also used to treat brain tumors and arteriovenous malformations. About 200,000 people worldwide have been treated with the machine.The Long Island Gamma Knife (LIGK) at South Nassau was the first Model C, or automated, gamma knife in the New York area, and can tackle the most complicated brain problems. Nearly 500 patients have been treated with the LIGK thus far. Brisman and Dr. Edward Mullen, the co-medical directors of LIGK, have used the gamma knife to treat more than 150 patients for trigeminal neuralgia. Most patients have experienced relief of pain within days of treatment.Hope for patients with other refractory face pain syndromes can also be found at South Nassau with the use of neurostimulators, pacemakers for the nervous system. Besides Brisman and Mullen, other physicians providing specialty care at South Nassau's Face Pain Center, include Dr. John L. Kefalos (neurology), Dr. Robert Iadevaio (pain management) and Dr. Louis Rosner. South Nassau also offers a monthly trigeminal neuralgia/face pain support group.For more information on trigeminal neuralgia, the Long Island Gamma Knife and South Nassau's Face Pain Center, call (516) 632-3366.
