Neuroscience News Spring 2011 by Clementine Words

Vol. 2, No. 1

Spring 2011

Three options for treating trigeminal neuralgia IN S I D E 2 Diagnosing

Trigeminal Neuralgia

3 Atypical Face Pain 5 Research Briefs :: P hone app speeds up emergency treatment :: S evere ischemic strokes benefit with mechanical intervention

By J. Adair Prall, MD Neurosurgeon, South Denver Neurosurgery About 200,000 Americans suffer from a rare but excruciatingly painful problem called trigeminal neuralgia (TN). This syndrome occurs most often when a blood vessel at the base of the brain presses against the trigeminal nerve and causes a “short circuit,” resulting in severe intermittent facial pain. Medications— including anticonvulsants, muscle relaxants and tricyclic antidepressants—will relieve the pain in about 75% of patients. (Pollock BE et al. 2010) But for the remaining 25% of TN patients, medications either will not sufficiently relieve the pain or they will cause intolerable side effects. Efficacy of medical therapy also generally decreases over time even for patients who find initial relief. One of the most important roles of a primary care physician, dentist and oral surgeon comes in the diagnostic stage. While trigeminal neuralgia can be easily diagnosed in just minutes with a few simple questions, we still see a significant number of patients who have had teeth extracted with no relief. It’s critical for primary care physicians and dentists to recognize this stereotypical description of facial pain. Once a patient has been diagnosed and scanned (see box on page 3), medical therapy is almost always the first line of treatment. However, TN pain may be refractory �� continued on page 2

Exercise caution when making radiosurgery referrals By J. Adair Prall, MD Neurosurgeon, South Denver Neurosurgery Stereotactic radiosurgery is one of the fastest-growing radiation therapies used today. This knifeless surgery using pinpointed beams of radiation is replacing many traditional surgeries associated with significant morbidity and even mortality. In the area of neurosurgery, radiosurgery is now being used commonly to treat acoustic neuromas, meningiomas, and both benign and malignant brain tumors (primary and metastatic). Some of the latest applications are for essential tremor and cluster headaches. As this field has expanded, recent publicity has focused on severe negative outcomes due to radiation overdose or radiation “leakage” beyond the targeted field. The most publicized cases have involved conventional radiation machines that have been adapted �� continued on page 4

Percutaneous procedures damage the trigeminal nerve to block transmission of pain signals.

Trigeminal Neuralgia from page 1 Diagnosing Trigeminal Neuralgia TN is most likely to affect patients over the age of 50 and strikes more women than men. TN is characterized by a sudden, severe, electric shocklike, stabbing pain that is typically felt on one side of the face. Pain rarely occurs on both sides of the face. The attacks of pain, which generally last several seconds and may repeat in quick succession, come and go throughout the day. These episodes can last for days, weeks or months at a time and then disappear for months or years. Significant numbness or weakness does not occur with TN, although in the days before an episode begins, or after many years of ongoing breakthrough pain, some patients may experience a slight tingling or numbing sensation or a somewhat constant and aching pain. The intense flashes of pain can be triggered by vibration or contact with the cheek, teeth brushing, eating, drinking, talking or being exposed to the wind. The bouts of pain rarely occur when the patient is sleeping. TN pain is never constant. Once a diagnosis is made, patients should undergo an MRI scan to rule out a tumor pressing on the nerve, which occurs in about 3–5% of cases. to all medicines or the side effects of the medicines are intolerable. In these cases, the patient should consider surgical options. Patients often rely on their primary care physicians or treating neurologists to help guide them through the decision to seek a surgical solution as well as to choose the surgery that best suits their individual situations. Approximately 8,000 TN patients undergo surgery each year in the United States at an estimated cost of $100 million. At the current time, there are three types of procedures used to treat trigeminal neuralgia. Each surgery has benefits and drawbacks. It is important for primary care physicians and dentists to refer to a neurosurgery practice that has broad experience with TN and with all types of procedures, so that a patient

Neuroscience News | Spring 2011

can choose the most appropriate treatment. The three procedures include:

1. Radiosurgery

(Gamma Knife®/CyberKnife®)

This treatment uses focused beams of radiation to damage the trigeminal nerve in order to stop it from sending pain signals to the brain.  Outcomes: 80–85% cure with at least 25% recurrence (Verheul JB et al. 2010. Sheehan J. et al. 2005)  Benefits: Outpatient, noninvasive procedure; no anesthesia; virtually no risk or recovery time, with only a 2% chance of permanent numbness  Drawbacks: Delayed pain relief, up to a month or more, but typically within one week; slightly lower success rate than other surgical therapies  Ideal Candidate: Most patients with TN, in particular, those with relatively good but not great control who are willing to undergo a very low-impact procedure without any recovery time to lessen their pain, side effects or need for medication

2. Percutaneous Rhizotomy

Guided by X-ray, the surgeon inserts a thin needle through the patient’s cheek into the trigeminal nerve to damage it and stop it from transmitting pain signals to the “short circuit” and on to the brain. The surgeon can damage the nerve by injecting glycerol, burning it with radiofrequency energy or crushing it with a balloon. With radiofrequency (PRR), control rates are higher and recurrence rates are lower than with the other needle-based procedures. Although the incidence of numbness is highest, surgeons use this needle method most often because, on balance, it has the most positive effects with the fewest drawbacks.  Outcomes: 90–95% cure with 20–25% recurrence (Taha JM et al. 1995)  Benefits: Outpatient procedure; local anesthesia; immediate relief  Drawbacks: Creates facial numbness, with a 1% chance of severe facial numbness or burning pain called “anesthesia dolorosa”  Ideal Candidate: Patients who have failed other methods; older patients with anesthesia risks who have such severe pain that they are not eating or drinking adequately

During radiosurgery, radiation damages the trigeminal nerve (highlighted area) to stop it from sending pain signals. Sources: Pollock BE et al. Prospective comparison of posterior fossa exploration and stereotactic radiosurgery dorsal root entry zone target as primary surgery for patients with idiopathic trigeminal neuralgia. Neurology. 2010 Sept; 67(3): 633-8. Verheul JB et al. Gamma knife® surgery for trigeminal neuralgia: a review of 450 consecutive cases. Journal of Neurosurgery. 2010 Dec; 113 Suppl: 160-7. Sheehan J et al. Gamma knife® surgery for trigeminal neuralgia: outcomes and prognostic factors. Journal of Neurosurgery. 2005 Mar; 102(3): 434-41.

Taha JM et al. A prospective 15-year follow up of 154 consecutive patients with trigeminal neuralgia treated by percutaneous stereotactice radiofrequency thermal rhizotomy. Journal of Neurosurgery. 1995 Dec; 83(6): 989-93. Pollock BE et al. A prospective costeffectiveness study of trigeminal neuralgia surgery. Clinical Journal of Pain. 2005; Jul-Aug: 21 (4): 317-22. Barker FG 2nd et al. The long-term outcome of microvascular decompression for trigeminal neuralgia. New England Journal of Medicine. 1996 Apr 25; 334(17): 1077-83.

Sekula RF Jr. et al. Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis. Journal of Neurosurgery. 2011 Jan; 114(1): 172-9. Epub 2010 Jul 23. Huang CF et al. Microsurgical outcomes after failed repeated Gamma Knife® surgery for refractory trigeminal neuralgia. Journal of Neurosurgery. 2006 Dec; 105 Suppl: 117-9. Pollack BE et al. Repeat radiosurgery for idiopathic trigeminal neuralgia. International Journal of Radiation Oncology, Biology and Physics. 2005 Jan 1; 61(1): 192-5.

Multiple Procedures 3. Microvascular Decompression Available since the 1950s, microvascular decompression (MVD)

is also sometimes referred to as posterior fossa exploration surgery. Often considered the “gold standard” in treatment, MVD is thought by many to be the only good surgical option for these patients. It involves making a small incision behind the ear and implanting a small felt pad between the blood vessels and the trigeminal nerve to alleviate the pressure and resulting “short circuit.”  O utcomes: 90–95% cure with 20–25% recurrence (Pollock BE et al. 2010; Barker FG et al. 1996)  B enefits: Immediate relief; less than a 1% chance of serious complications (in the hands of a surgeon with significant experience); minimal risk of numbness  D rawbacks: Inpatient surgery requiring general anesthesia, small surgical risks and a two-day stay in the hospital, with around two weeks of recovery at home

In cases of particularly intractable trigeminal neuralgia, multiple surgical treatments—which can be attempted in any order—may be necessary. Although scarring from radiosurgery was once believed to prevent the use of other surgical techniques, it has since been found this is not the case. MVD is occasionally repeated, especially after long periods of relief; a Mayo Clinic study found that radiosurgery provided adequate pain relief to 80% of patients when it was repeated. (In other words, radiosurgery relieves pain in 80 out of 100 TN patients. If the remaining 20 patients were given a subsequent round of radiosurgery, 16 of those patients—or 80%—would gain relief.) PRR can be utilized multiple times. Occasionally, partial cutting of the nerve (partial sensory rhizotomy, or PSR) is necessary when multiple other attempts have failed. (Huang CF et al. 2006. Pollack BE et al. 2005)

 I deal Candidate: Many patients of all

ages with limited anesthesia risk; MVD for TN is a safe procedure even in the elderly; the risk of serious morbidity or mortality is similar to that in younger patients (Sekula RF et al. 2011) As shown in the descriptions above, there are risks and benefits of each procedure. It is critical that patients and their referring physicians are able to consider all options without bias, based on patient age, medical history and concern about complications associated with different surgical options. MVD surgery uses a pad to relieve pressure on the trigeminal nerve.

Non-TN facial pain More than 1.7 million Americans suffer some sort of facial pain. Up to 25% of these patients have trigeminal neuralgia (TN), with another significant percentage suffering from neuropathic facial pain. These patients have facial pain caused by injury to the trigeminal nerve—sometimes with a known injury, but often unknown. Unlike TN pain, these patients experience pain that is constant, aching and burning. Medical therapy is the first line of treatment for these patients. Until recently, however, few options were available for patients with intractable facial pain. Three new procedures are now being offered with some limited results: ● Peripheral nerve stimulation: Similar to techniques used with spinal cord injuries, an electrode is placed close to the nerve branch and a current is used to create “white noise” to distract or lessen the pain signals to the brain. ● Sphenopalatine ganglion block: Because many patients have pain conduction

through the sympathetic nerves in the face, undergoing this type of block can sometimes eliminate the pain temporarily. ● Gamma Knife® radiosurgery: A study conducted at Cedars Sinai Medical Center found that patients who responded positively to a sphenopalatine ganglion block experienced more durable pain resolution with subsequent Gamma Knife® surgery, resulting in relief for 12 or more months in 75% of patients. South Denver Neurosurgery is actively involved in trying to find more permanent solutions for these patients. In 2009 and 2010, we conducted a study to try to reproduce the results seen at other centers using the Gamma Knife® for neuropathic facial pain. Although we did not see quite the same degree of positive results as in prior studies, we are continuing to evaluate this treatment with stricter selection criteria. In the meantime, we are working to create

Patient resource The Facial Pain Association is a national notfor-profit advocacy organization for patients with facial pain, their families and their health-care providers. The association provides resources for patients and health-care professionals on the various types of facial pain. It also provides one-on-one support through its toll-free telephone lines and helps support more than 65 local support groups throughout North America, Europe and Australia. For more information, go online to www.fpa-support.org. a multidisciplinary program to consult with and treat complex intractable facial pain patients. This approach will include neurology, neurosurgery, pain management and mental health consultants. More information on this program will be available later this year.

Radiosurgery from page 1 for radiosurgical treatments. If these centers did not use a multidisciplinary team, treatment planning may have lacked the input of neurosurgeons with expertise in the involved anatomy and the possible consequences of treatment. In referring patients for radiosurgery for intracranial conditions, I recommend the following:

J. Adair Prall, MD

Neurosurgeon, South Denver Neurosurgery

John Adair Prall, MD, is a board certified neurosurgeon by the American Board of Neurological Surgery. In addition to serving in his private practice at South Denver Neurosurgery, he has served as the medical director for neurosurgery  Know the difference in radiosurgery centers. and neurotrauma at Littleton Adventist Hospital. Many new centers marketed as radiosurgery Dr. Prall specializes in treating centers have appeared in the last few years. trigeminal neuralgia (TN). In the Counsel your patients to be treated at a center past 20 years, he has treated involving both neurosurgeons and radiation more than 1,000 TN patients oncologists to ensure thorough, safe and informed and performed more than 500 ® ® planning. Gamma Knife and CyberKnife TN surgeries. Dr. Prall offers centers always feature multidisciplinary teams. all three commonly used They also will have more experience and TN procedures: radiosurgery knowledge of proper indications and complications (Gamma Knife®/CyberKnife®), to avoid. microvascular decompression (MVD)  Refer to an oncologist who regularly consults and percutaneous radiofrequency rhizotomy with neurosurgeons on these cases. Look for (PRR) procedures. He has performed more oncologists who are affiliated and refer to both radiosurgical and PRR procedures than any traditional radiation therapy facilities as well other neurosurgeon in the region and performs as dedicated radiosurgery centers, such as Gamma Knife® or CyberKnife® facilities. MVDs on a weekly/monthly basis as well. In addition to his work with TN patients,  Refer to a surgeon or practice where surgery, Dr. Prall also focuses on brain tumors, radiosurgery, conventional radiation and other degenerative spine conditions and cerebral therapies are used. There are subtle advantages to different types of radiosurgery. Gamma Knife®, aneurysms. His current research interests for instance, often is used in settings where absolute are in the areas of trigeminal neuralgia accuracy is critical, such as for intracranial targets in and spinal motion preservation. eloquent areas of the brain. This is because a stereotactic Dr. Prall completed his ring is affixed to the skull to allow maximum accuracy. undergraduate work at Princeton CyberKnife®, on the other hand, can be used anywhere University. He attended medical in the body, including the chest and abdomen, where the school at the University of Cincinnati movement of breathing can be tracked and accounted for and completed his neurosurgery when treating tumors in those areas. Treatment with the residency at the University of CyberKnife® also can be performed over more than one Colorado Health Sciences Center. visit, potentially reducing the individual dosage of each Dr. Prall is a member of treatment and lessening the side effects compared to several organizations, including Gamma Knife®, which must be administered in the Congress of Neurological one treatment. Surgeons (current board  Understand the new applications of radiosurgery member), the American and ensure your patients are receiving Association of Neurological information about all options. Referrals Surgeons and the Colorado to surgeons who do not perform If you would Neurosurgical Society (past radiosurgery—or to radiation oncologists like to learn more who do not consider traditional surgery— president). He is married and about radiosurgery, limit the options presented to patients, has four children. He and please call our office sometimes to their great disadvantage. his family live in Littleton, at 303-734-8650 and For example, the vast majority of Colo., where he enjoys I will be happy to acoustic neuromas are now treated with mountaineering, skiing consult with you radiosurgery. The risks associated with and birding. via phone or radiosurgery appear to be fewer than with in person. traditional surgery, with none of the surgical risks of infection, blood loss, etc., and no recovery time. Neuroscience News

research briefs

Mobile phone device allows patients to alert hospital of their arrival Littleton Adventist Hospital is piloting a new mobile phone application that allows patients to inform the hospital’s emergency department of their pending arrival

and fill out paperwork before they reach the hospital. The new application is part of iTriage, a free consumer application developed by Lakewoodbased Healthagen®. When consumers use the iTriage application to locate Littleton Hospital, they will have the option to click “Tell Us You’re Coming” and fill out forms that provide the hospital with specifics, including name, phone number, allergies, symptoms, gender and age.

Mechanical intervention to treat stroke continues to show success

According to the Centers for Disease Control and Prevention, the demand for emergency services in the United States has been on the rise since 1996. With higher patient volume, those needing emergency care are finding overcrowded ERs and longer wait times. By using the “Tell Us You’re Coming” feature, Littleton Hospital is streamlining the intake process for emergency patients and improving ER patient flow.

Neuroscience News | Spring 2011

• Save time by filling out the intake information on their way into the hospital, which facilitates the registration process • Notify emergency staff if an extended-size wheelchair will be needed for patient unloading • Inform staff if the incoming patient has allergies or other special medical needs

The Merci Retrieval System is used to remove clots.

A clinical registry trial released at the 2011 International Stroke Conference in late February found that the use of mechanical intervention to restore blood flow in ischemic stroke patients in community hospitals parallels success rates demonstrated in randomized clinical trials. Data tracking 1,000 stroke patients who received the Merci Retrieval System in 30 stroke centers throughout the United States found that outcomes were consistent with previous randomized clinical trials. The Merci Retrieval System is a minimally invasive catheter-based system designed to retrieve and remove clots in patients. It is used as an alternative for patients who are ineligible for IV tPA or as an adjunct to recanalization therapy in patients who have persistent artery occlusions despite treatment with IV tPA. The use of endovascular devices is particularly beneficial to patients with large vessel ischemic strokes, Nichols says. These patients have very high 90-day mortality rates, generally above 30%, and only one-third of those who survive have a “good” outcome, defined as 0–2 on the Modified Rankin Scale (MRS). Littleton Hospital, which provides 24/7 neuro-interventional treatment to handle these severe cases, offers the Merci Retrieval System as well as other trans-catheter–based devices for treatment of acute stroke.

“Tell Us You’re Coming” phone app lets patients:

Use of any device outside the setting of the original clinical trial that then shows similar outcomes is an important finding. In short, it shows that, in the real world, we’re using the device correctly as a group of neurointerventional specialists.” – Christoper Nichols, MD Stroke and Vascular Neurologist Littleton Adventist Hospital

About Us South Denver Neurosurgery provides state-ofthe-art diagnostic and treatment programs for a wide range of brain and spinal disorders. We partner with our patients and their physician teams to make individualized decisions and treatment plans. Our physicians are some of the most experienced in the Rocky Mountain region, offering the latest, most up-to-date procedures and treatment options to patients.

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Physicians desiring a consult, please call: 303.734.8650 Locations: Littleton Adventist Hospital Campus Arapahoe Medical Plaza III 7780 S. Broadway, Suite 350 Littleton, CO 80122 Porter Adventist Hospital Campus Harvard Park Medical Plaza 950 E. Harvard Ave., Suite 620 Denver, CO 80210 Castle Rock Adventist Health Campus 1189 S. Perry St., Suite 230 Castle Rock, CO 80104 South Denver Neurosurgery 303.734.8650 (phone) 303.734.8653 (fax) www.SouthDenverNeurosurgery.org

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Meet Our Physicians

Ben Guiot, MD Neurosurgeon, boardcertified by the American Board of Neurological Surgeons and the Royal College of Physicians and Surgeons of Canada. Specializing in all aspects of spine care including: :: Minimally invasive spine surgery :: Spinal deformity correction :: Reconstruction of complex spinal disorders

Christopher Nichols, MD Neurologist, specializing in stroke and vascular neurology and endovascular neurosurgery, including evaluation and treatment of: :: Brain aneurysms :: Arteriovenous malformations :: Dural arteriovenous fistulas :: Acute stroke and intracerebral hemorrhage :: Cervical and intracranial arterial disease :: Cerebral vasculopathy :: Cerebral venous thrombosis

J. Adair Prall, MD Neurosurgeon, specializing in: :: T rigeminal neuralgia :: S pinal disorders :: Neuro-oncology :: Minimally invasive and motion preserving spine surgery :: Stereotactic radiosurgery (Gamma Knife® and CyberKnife®)

David VanSickle, MD, PhD Neurosurgeon, PhD in bioengineering, specializing in: :: D eep brain stimulation (DBS) for Parkinson’s and Essential Tremor :: Epilepsy surgery :: Neuro-oncology :: Spinal cord stimulator implantation for pain :: Transphenoidal surgery (pituitary surgery) :: Minimally invasive and motion preserving spine surgery :: S tereotactic radiosurgery (Gamma Knife® and CyberKnife®)