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Trigeminal Neuralgia and Community Neurosurgery

Why Local Hospitals May Provide Higher-Quality Care

Recently I gave a lecture in Boston about a surgical procedure that can cure a rare condition called trigeminal neuralgia. People who suffer from this condition have brief attacks in which they experience excruciating pain in the face, mouth or throat.

Many patients describe this pain as similar to an electric shock. Sometimes the condition forces a person to fall to the ground, writhing in pain until the attack subsides. Some people suffering from the condition become so distraught that they consider committing suicide.

Trigeminal neuralgia occurs in 1 in 10,000 people, mostly people over 50 years old. In some cases, it can be managed with medication, but usually surgery is the only permanent cure.

Landmark Discovery

The procedure that solves this problem is called microvascular decompression. It was discovered in 1966 by a legendary neurosurgeon, Dr. Peter Jannetta, while he was a resident physician at UCLA. He made his discovery while doing anatomy research on cats.

Dr. Jannetta observed that the nerve that supplies sensation to a cat’s face and mouth—the trigeminal nerve—is very well-developed. This nerve, which also exists in humans, is vitally important to cats as they use their nose and whiskers to explore their environment.

When Dr. Jannetta noticed that cats have a prominent blood vessel situated very close to the trigeminal nerve, he wondered if the same blood vessel in humans could press against the nerve, causing the severe pain of trigeminal neuralgia.

This impingement on the nerve is similar to a herniated disc that presses against the sciatic nerve in the lower back, causing painful sciatica.

After Dr. Jannetta performed tests to confirm his theory, he developed the microvascular decompression procedure to move the blood vessel away from the nerve and relieve the patient’s pain.

In his excellent book about this landmark discovery, Working in a Very Small Place, author Mark Shelton describes how Dr. Jannetta performs the procedure: “He makes a small opening in the back of the skull … and, with the aid of an operating microscope, inserts tiny bits of shredded felt in between the blood vessel and the nerve, making a pad that relieves—or “decompresses”—the pressure on the nerve. And the symptoms disappear.”1

Surgeons will perform this procedure more frequently in the coming years as more aging baby boomers are afflicted with trigeminal neuralgia and community neurosurgeons will be instrumental in handling the increased patient demand.

Excellent Outcomes at Community Hospitals

A common misconception is that surgeons who perform a high volume of a procedure—and therefore become proficient at that procedure—are found only at university medical centers. Research shows that the opposite is true.

According to a 2012 study published in Neurosurgery, many surgeons who perform a high volume of procedures aren’t associated with academic medical centers, but with rural and small hospitals.2

Another misconception is that overall care is better at university hospitals. A 2010 study by Comparion Medical Analytics made this conclusion: “With the notable exception of cancer care, university hospitals are no more likely to provide the best quality of care than non-university hospitals. While many university hospitals are included in the nation’s top 10% of the best quality hospitals across most clinical categories, the vast majority fall below the national average.”

The study further concluded that patients should consider the quality of care provided by all hospitals in their market area instead of assuming that a university hospital will provide superior care.3

Of course, a primary factor in a positive surgical outcome is the skill of the surgeon. At university hospitals, medical residents—recent graduates from medical school—often perform parts of a surgical procedure. At community hospitals, experienced surgeons typically perform the entire procedure, which can lead to greater efficiency, fewer complications and shorter patient stays.

Technology Is Accessible

These days, neurosurgeons at community hospitals perform highly sophisticated procedures because state-of-the-art surgical equipment is more affordable. Neurosurgery departments at many local hospitals are equipped with image guidance systems, surgical microscopes, a radiosurgery device (“gamma knife”) and a neurology intensive care unit.

I’m gratified that, as a community neurosurgeon, I can use the latest surgical techniques to ensure excellent outcomes for my patients.

The technique I use to perform microvascular decompression is a refined version of the one that I learned years ago from Dr. Jannetta himself. I’m grateful for his teaching and the fact that I can relieve a patient’s suffering with this effective procedure.

In Working in a Very Small Place, Dr. Jannetta describes the wonderful outcome of the surgery:

“What we do is make people whole again, make them normal again. We don’t cut something out or take something away, but rather, we give something back: A normal life.”4


  1. Shelton, Mark L. Working in a Very Small Place: The Making of a Neurosurgeon. New York, NY: Vintage Books; 1989
  2. Dasenbrock H, Clarke M, Witham T, Sciubba D, Gokaslan Z, Bydon A. The Impact of Provider Volume on the Outcomes After Surgery for Lumbar Spinal Stenosis. Neurosurgery, 2012;70(6): 1346-1353.
  3. 2010 CareChex Research Study: An Assessment of the Quality of University Hospital Care in the U.S., Comparion Medical Analytics, p.4
  4. Shelton, Mark L. Working in a Very Small Place: The Making of a Neurosurgeon. New York, NY: Vintage Books; 1989

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