Address for Correspondence
Dr.S.K.Ramachandran Nair
Vyshnavi
Pattoor House.
Vanchiyoor West
Thiruvananthapuram 695035
E-Mail: ramneuro@asianetindia.com

The disease entity of Trigeminal Neuralgia has been known now for centuries. It is probably one of the worst kinds of pains known to man. Interest in the condition is current regarding its patho-physiological mechanisms, various modalities of treatment including drugs, interventional procedures and their relative merits still being widely discussed in scientific circles. Shajahan et al [Link]have produced an interesting paper with illustrative case records where in they have successfully treated 10 cases with micro vascular decompression using Fascia Lata as the material used to interpose between the nerve and the offending vessel. This is a novel procedure as far as the material for interposition is concerned. 

John Locke,(1,2,3) a friend of Sydenham was a great physician and philosopher who gave an early detailed description of Trigeminal Neuralgia associated probably with Hemifacial Spasm. Characteristic of the early Physicians, whose accurate, detailed and careful observations and descriptions of disease have led to the acquisition and progress of knowledge in modern medicine, John Locke gave a description of his visit to the Countess of Northemburland. (4) He found "her in a fit of such violent torment, that though she be a person of extraordinary temper who could endure great pains with patience, it forced her to such cries and shrieks, as you would expect from one upon the rack, which extended itself all over the right side of face and mouth."

"When the fit came, it was as if it were a flash of fire all of a sudden shot in to all those parts, and at every one of those twitches which made her shriek out her mouth was constantly drawn on the right side towards the right ear by repeated convulsive motions which were constantly accompanied by her cries. These violent fits terminated on a sudden and then the Lady seemed perfectly well, excepting only a dull uneasiness on the right side of her tongue which she fancied to be swollen but had not the least alteration in colour, size or sensation on examination."

"Speaking was apt to put her in to these fits, sometimes opening her mouth to take anything or touching her gums, especially in places where she used to find those throbbings, pressing that side of face by lying on it were also apt to put her in to fits".


The Trigeminal Nerve, 5th Cranial Nerve, is one of the biggest cranial nerves and its nuclei extend from midbrain to the cervical spinal cord. It is the sensory nerve of face, greater part of scalp, the teeth, the oral and the nasal cavities , and the motor nerve of muscles of mastication and some others. Also contains proprioceptive fibres from muscles of mastication and probably from extra ocular muscles. (5)

The Trigeminal Nerve was first recognised by Fallopius in 16th century.(4) Vieussens, a French Anatomist in the 17th century identified the Ganglion.Hirsch of Vienna named the Ganglion "Gasserian Ganglion" because Ludwig Gasser was his teacher.

In 1748 Meckel described the dural covering of Trigeminal Ganglion and it is known as Meckel's cave now.

Von Sommering in 1778 introduced the Duodecimal classification of Cranial Nerves and Trigeminal Nerve is identified as the 5th cranial nerve. 

Charles Bell in 1821 in his epoch making contribution "On the nerves, an account of some experiments on their Structure and Function" showed the first real understanding of the motor and sensory aspects of the cranial nerves including Trigeminal Nerve.

The first description of a painful affection of face is found in the writings of ARETEAUS in first century AD.

Krause and others have credited AVICENNA with the first account of Trigeminal neuralgia but his account is more accurate for facial palsy.

First complete case report on Trigeminal Neuralgia was by Wepfer in 1727 

Nicolas Andre' gave the name Tic Douloureux in 1750. (6)

John Fothergill, a London Physician was the first to write a monograph on this condition in 1766 "Of a Painful Affection of the Face". (7)(4) For nearly a century following this the entity was known as Fothergill's disease.(7)

Dandy (8) in 1932 postulated the etiological factor as compression of the nerve in Cerebello pontine angle and in 1934 published the postulate of vascular compression as an aetiological factor. In 66 out of 215 patients the compression of nerve in CP angle was of vascular nature.

Several workers have contributed to the understanding of aetiological factors and pathophysiological mechanisms. Peripheral and central causes have been postulated for the periodicity and severity of pain. (Black, Anderson, Jacob Abraham, King, Alvarez, Wartenberg, Harris, Rowbotham, Kerr, Tarnhoj, Gardner,Malis, Schaltenbrand etal) (12,13,14).

Starting from conservative treatment with anticonvulsant medication to peripheral and central interventional procedures, several measures have been tried in the treatment of trigeminal neuralgia with varying success rates. Percutaneous procedures like local alcohol block of peripheral branches of trigeminal nerve, Injection of alcohol, Glycerol (11) etc around Gasserian Ganglion, Temperature controlled Coagulation of Gasserian Ganglion, (12) Micro compression of The Gasserian Ganglion (13), Micro vascular decompression of the root entry zone (10,4) are some of the direct interventional methods tried. Stereotaxic radio surgery and Gamma knife surgery are recent introductions to the therapeutic armamentarium and results are yet to be assessed on a long-term basis.

It has been sometimes argued that the benefit derived from so called microvascular decompression would not be related to the decompressive mechanism but due to the arachnoiditis or scarring from trauma or compression occurring to the nerve at surgery. (15)

From 1960s Gardner, Janetta (9), (10) et al proposed and practiced micro vascular decompression as an effective means of treating trigeminal neuralgia. 

Several types of materials were used to keep the transposed vessels away from the nerve. Muscle, Dacron, Teflon, Gel foam, Poly vinyl foam etc were used with more than fair amount of success (9) (16)

The use of Fascia lata as a material for interposition between the transposed vessel and the nerve is a good idea especially considering the ease of procurement and low cost. Whether in the long run this will lead to scarring and problems like arachnoiditis are to be seen after long term follow up with larger number of cases. If fascia is to be used why not use Temporalis fascia is a question worth considering. 

References

1.John Locke (1632-1704): Physicians and Philosopher. A Medical
Biography. (London, 1963). John D. Mabbott, John Locke, (London, 1973)
URL: http://www.es.rice.edu/ES/humsoc/Galileo/Catalog/Files/locke.html  

2.John Locke:A list of events that influenced Locke's life. 
URL: http://www.oregonstate.edu/instruct/phl302/philosophers/locke.html  

3.Maurice William Cranston  John Locke: A Biography
October 1990 ISBN:0192830449

4. Stookey B. , Ransohoff J. : Trigeminal Neuralgia, its history and treatment .
Springfield ;IL ; Charles C Thomas 1959

5. Gray's Anatomy 36th Edition Page1059 , Williams &Warwick,Churchill Livingstone

6. Veit Braun: University of Ulm, Dept of Neurosurgery; Germany
Trigeminal Neuralgia Neurosurgery 1996 Chapter 167 Page 841.

7. Dr.S.Kalyanaraman ; Trigeminal Neuralgia ;Mediscope, Vol X,NO.VIII ,
November 1967

8. Dandy WE : Concerning the cause of trigeminal neuralgia. Am .J. Surg . 24:447-455 ,1934

9. James Gardner : Concerning the causes of Trigeminal Neuralgia and hemifacial spasm. 
J.Neurosurgery 19:947-958 .1934

10. Janetta PJ Arterial compression of trigeminal nerve at the pons in patients with trigeminal neuralgia. J.Neurosurgery 26: 59-62,1967

11. Hakanson.S Trigeminal Neuralgia Treated by injection of Glycerol in to the trigeminal cistern. Neurosurgery 9:638-46 1981.


12. Gybels JM, Sweet WH Neurosurgical treatment of persistent pain.Physiological and pathological mechanisms of human pain 
Pain and Headache Vol II  1989 Karger Basel,London.

13.Mullan S, Brown A (1996) Trigeminal Neuralgia .
Neurosurgery Quarterly 6(4) 267-288

14.Safe and effective measures for the treatment of trigeminal neuralgia. Adams et al 
URL: www.wfubmc.edu/neurology/newha/tic.htm   

15 .Adams CBT Microvascular compression :an alternative view and hypothesis J.Neurosurgery 70;1-12 1989.

16. Sindou M, Mertens P Microsurgical vascular decompression in Trigeminal Neurlagia A Twenty year Experience . Acta Neurochirurgica (suppl 58);168-170, 1993.

Related Articles in This Issue:

Shajehan S, Fazal Gafoor PA, Krishna Kiran, Usha R
Experience with fascia lata graft for Micro-Vascular Decompression for Trigeminal neuralgia and Hemi-facial spasm
Calicut Medical Journal 2003;1(1):e4
URL: http://www.calicutmedicaljournal.org/2004/2/1/e4/index.html   

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