A rare trigger of trigeminal neuralgia
The trigeminal nerve, which supplies feeling and some movement to the face, can deteriorate with age, causing immeasurable suffering. A tumor can press against it, causing indescribable misery. Or, as in Joseph's situation, an unusually large and expanding basilar artery can compress the nerve enough to trigger waves of unspeakable pain.
Joseph, a retired firefighter who has started a new career, was coping with an unexplained source of discomfort on the right side of his face when the true measure of trigeminal neuralgia struck like a bolt of lightning. "It felt like I'd literally walked into an electric, energized cobweb," he recalls. "It almost made me bend over backwards."
Having already been through two unsuccessful courses of antibiotics, Joseph headed to the dentist. When his dentist could find nothing amiss, Joseph headed for the internet. He typed in "electric shock to the face" and got his likely diagnosis: trigeminal neuralgia. He also saw the words Mayfield Brain & Spine.
A physician at a local hospital ordered MRI scans, confirmed the diagnosis, and prescribed an anti-seizure medication and muscle relaxer. But the extraordinary pain continued. "When my face felt that electric jolt, I'd literally wake up out of bed," Joseph says. "It was a pain that would bring me to my knees. I'd be in tears, crying, lying on the floor trying to get the pain to go away. I continued to work, but at night I sometimes slept in a recliner trying to get rid of the pain. I was at my wits' end."
Joseph finally called Mayfield's main number, sent his MRI scans, and received a referral to Yair Gozal, MD, PhD, a neurosurgeon whose specialties include surgical treatment for trigeminal neuralgia. Having surveyed the treatments that Mayfield offered for his condition, Joseph hoped to have a speedy outpatient procedure so that he could go right back to work. But after he completed – unsuccessfully -- a new course of medication, Dr. Gozal told him that an outpatient treatment was not his best option.
"I wanted to do the needle procedure," Joseph said. "But Dr. Gozal told me that wouldn't be my best option. He knows more about this than I do. What I wanted to do would deaden the nerve. He said it might come to that, but there are other options that don't injure the nerve. Also, even if the nerve is deadened, the brain may still have a sensation of that nerve. And if so, there's no way to fix that."
Dr. Gozal was also concerned about the size of the basilar artery that was resting on the trigeminal nerve. While a typical artery is 3 millimeters in diameter, Joseph's had grown to about 8 millimeters and also included a football-shaped fusiform aneurysm.
"The fusiform aneurysm was part of the blood vessel," Dr. Gozal explains. "Sometimes the lining of blood vessels breaks down over time, and weak points form enlarged areas. Joseph's vessel happened to be massive and torturous, and as a result it pushed and compressed his normal anatomy."
Dr. Gozal recommended leaving the aneurysm alone but moving the artery off of the trigeminal nerve. He explained the risks of the procedure to Joseph, but he felt confident that although this would be a challenge, a careful surgery would eliminate Joseph's pain.
"This was truly a rare case of trigeminal neuralgia," Dr. Gozal says.
"His very large (dolichoectatic) basilar artery had literally smashed his trigeminal nerve."
Dr. Gozal made the decision to operate with another Mayfield cranial specialist, Vincent DiNapoli, MD, PhD, at The Jewish Hospital – Mercy Health.
"In complex cases we often work as a team to maximize safety for the patient," Dr. Gozal says. "In Joseph's case, there was significant neurovascular conflict, with the vessel compressing and misshaping the trigeminal nerve. We were able to mobilize the vessel away, and we had to be a little creative about how to keep such a large vessel from returning to its original position."
Says Joseph: "I woke up in the hospital and never had any pain. I thought I'd be sore while I was in the hospital, but I had no issues. I've been pain-free since then."
Dr. Gozal says Joseph's prognosis is excellent. "I don't expect his pain to return. He had a clear compression, and the nerve is now decompressed. Eighty to 90 percent of patients who undergo MVD have prolonged pain relief, and we expect Joseph's long-term outcome to be in line with those statistics."
Says Joseph: "I don't have anything but praise for Dr. Gozal. He did a great job. I was able to go back to work in 3 ½ weeks, and everything was back to normal. I'm off all the medications I was on prior to being diagnosed, and that part of my life is behind me. I think a lot of Dr. Gozal, and I'm glad he was my doctor."
~ Cindy Starr
Hope Story Disclaimer -"Jospeh's story" is about one patient's health-care experience. Please bear in mind that because every patient is unique, individual patients may respond to treatment in different ways. Results are influenced by many factors and may vary from patient to patient.