Trigeminal Neuralgia Pain Cured Through Rare Surgery

It is commonly described as the most painful human affliction, worse than kidney stones, childbirth without medication, and even traumatic amputation. 

That’s how Baystate Health neurosurgeon Dr. Kamal Kalia describes the symptoms—stabbing, electrical shock-like pain most often involving the lower face and jaw— associated with trigeminal neuralgia (TN).  

The illness is sometimes misdiagnosed as a dental or jaw problem such as temporomandibular disorder (TMJ). Simply talking, eating, experiencing a light touch, or wind hitting the face can trigger an attack which can last for a few seconds to several minutes. Outbreaks can occur over days, weeks or months and if left untreated can worsen progressively.  

A Groundbreaking Procedure

“Renowned neurosurgeon Dr. Peter Jannetta invented a groundbreaking procedure called microvascular decompression (MVD). The surgery soon became known around the world as the Jannetta Procedure and the gold standard for curing trigeminal neuralgia,” Dr. Kalia said. 

Dr. Jannetta was a neurosurgery resident at the University of California, Los Angeles (UCLA) when he proposed the neurovascular compression theory—a novel procedure that moved blood vessels away from the trigeminal nerve alleviating the severe pain of trigeminal neuralgia and away from the facial nerve to relieve spasms in facial muscles. It was while performing cranial nerve microdissections for dental students in 1965 that he made note of the anatomy of the trigeminal nerve, and he began to develop the curative surgery. 

He put his theory to the test performing his first microvascular decompression surgery to relieve hemifacial spasm in 1966. A few months later he performed the first MVD for trigeminal neuralgia. Initial variations of the surgery were conducted at Harbor General Hospital in Torrance, CA, after senior faculty at UCLA forbade him to perform such an untested and risky brain surgery using an operating microscope. 

Skeptics Doubted Jannetta 

Despite the initial success, there were many skeptics about the safety and long-term efficacy of the revolutionary procedure, and of Jannetta’s prowess as a young resident. Instead, neurosurgeons of the day were content to continue with the present treatment which consisted of medical therapy or purposefully cutting the trigeminal nerve, which traded pain in the patient with facial numbness.  

“Dr. Jannetta received relenting pushback from senior leadership in the field of neurosurgery because his theory seemed like such an outlandish idea. However, with continued positive results and studies proving its benefits, as well as lectures to promote the procedure and other neurosurgeons coming to learn from him, those skeptics would go on to become great advocates for the Jannetta Procedure,” Dr. Kalia said. 

When Dr. Jannetta died in 2016, the world lost one of our greatest neurosurgeons, Dr. Kalia noted. 

“I lost a good friend and mentor,” he said. 

Procedure Comes to Springfield, Massachusetts

Dr. Kalia knows plenty about Dr. Jannetta. He trained under him for seven years before bringing his expertise in the delicate microsurgery on the brain to Baystate Medical Center—the only healthcare provider in western Massachusetts to offer the procedure for trigeminal neuralgia. 

“While attending Boston University School of Medicine, I knew that I wanted to be a surgeon, initially thinking about cardiac surgery. Then a classmate gave me a book to read called First Do No Harm about a day in the life of a neurosurgeon. It really grabbed me as the specialty I wanted to pursue,” Dr. Kalia said. 

It was fate and a little luck, noted Dr. Kalia, that led him to the doorstep of Dr. Jannetta. 

Cream of the Crop 

It was Dr. Kalia’s goal to complete his residency at a top-tier neurosurgery program.  

Match Day is held each year in March when graduating medical students across the country learn where they will be spending the next few years in residency. Before Match Day, held the third week in March, students begin submitting their preferred residency program to the National Residency Matching program. An algorithm is used to make the assignments, sending Dr. Kalia to the University of Pittsburgh in 1990. 

“There are five or six hospitals considered the ‘cream of the crop’ with the University of Pittsburgh considered one of them. I was extremely fortunate to get placed there. For a young doctor looking for the best possible training in neurosurgery, Pittsburgh had many advantages over others. They were pioneers in skull-based surgery and were credited as the first Gamma Knife center in North America that one of Dr. Jannetta’s residents brought with him from Sweden. Then there was Dr. Jannetta, who was chair of the department and for whom patients came from all over the world for surgery to cure their trigeminal neuralgia,” Dr. Kalia said.  

A Guilt Trip

“For such a rare and complicated procedure to be considered the training program’s bread and butter and most performed procedure was extremely unique and I was so extremely fortunate to learn the procedure under his tutelage. We were very close; he was close with all his residents, many of whom considered him a father figure and named their children after him. He did offer me a job to stay on with him after my residency. I knew that there was so much more to do in neurosurgery than just the Jannetta Procedure, and that I would always be under his shadow. He understood that and respected my decision, even though he tried to guilt me into staying,” Dr. Kalia laughed. 

A Unique Procedure

So, why are patients from around the country and outside of the United States searching out Dr. Kalia and coming to Baystate Medical Center to undergo the Jannetta Procedure? 

Dr. Kalia noted it is because of the unique skill set required to perform the surgery. 

“In the late seventies and early eighties, few neurosurgeons were using operating microscopes, let alone offering delicate brain surgery to patients. The Jannetta Procedure was unique and still is. There are not that many neurosurgeons that Dr. Jannetta trained who are performing the procedure regularly. Some neurosurgeons may do one every other year, but that is not enough to keep them highly skilled in the procedure. And there is only one neurosurgeon in New England other than me who trained under Dr. Jannetta,” he said. 

More Experience, Better Results

Dr. Kalia has much to be proud of in bringing the Jannetta Procedure to Springfield and providing life-changing brain surgery to those who have few doctors to turn to for help. In fact, 10 years ago, UCLA published five-year data on the enhanced outcomes and recovery offered to those patients undergoing the Jannetta Procedure—noting some 52 surgeries, over 300 minutes operative time and an average length of stay of 3.8 days. Knowing he was doing more surgeries for trigeminal neuralgia in Springfield than at the busy UCLA medical center, Dr. Kalia set out to publish his own data, which he presented in 2014 at the Congress of Neurological Surgery meeting in Boston The five-year data showed he was doing more surgeries than UCLA with a 110 minute operative time and 2.3 day average length of stay.  

Some Other Treatment Options

Today it is reported that 150,000 people are diagnosed with trigeminal neuralgia every year. While the disorder can occur at any age, it is most common in people over the age of 50. The National Institute of Neurological Disorders and Stroke (NINDS) notes that the illness, which usually occurs on only one side of the face, is twice as common in women than in men. 

Treatment for trigeminal neuralgia typically begins with prescription medications such as carbamazepine, a drug originally developed to treat epilepsy but proven to also be effective in treating nerve pain when taken on an ongoing basis. Some patients, however, experience debilitating side effects, while for others their medications stop working, warranting a discussion about surgical treatments such as the Jannetta Procedure. 

According to Dr. Kalia, another procedure, glycerol rhizotomy, is an excellent option for patients who may not tolerate the Jannetta Procedure. It works well, carries an extremely low risk of causing numbness in the face, has a very low complication rate, and patients are discharged within a few hours of surgery. The chance of trigeminal neuralgia returning is, however, higher than with the Jannetta Procedure. Hemifacial spasm—involuntary spasms of the muscles on one side of the face—is also cured in most cases by the Jannetta Procedure. 

“The cure rate for the Jannetta Procedure is 80%, with most patients who come out of surgery touching their face and smiling after feeling not a single jolt of pain. For hemifacial spasms, however, while it can still be instantaneous, some patients will not feel the results for a month or as long as a year and a half.”