Touching a raw nerve to relieve the pain

Living with trigeminal neuralgia means the most basic of tasks that stimulate sensation in the face, like brushing your teeth, trigger pain that’s the most excruciating man will know

An elderly lady walked into my consultation room with two girlfriends, chewing gum. Her Gucci shades were stationed over her salt-and-pepper hair and she wore a black dress. Her wrists and ankles were crowded with beaded trinkets.

“Hi!” she said, greeting me with a firm handshake and a brief introduction as I jotted her name. “And your age?”

“Twenty-six!” she blurted, followed by a big smile because it made me look up and stare at her intently.

“Okay, just reverse that,” she reconciled before I could say anything. “Any diabetes, blood pressure?” I proceeded, smiling through the usual questions, still wondering in my head her fancy for playing the fool with me about her age.

“Any heart issues?

“I keep falling in love, doctor!” she said bluntly, as two ladies accompanying her rolled their eyes, gesticulating for her to behave. I shook my head at them, hinting that they let her comfortably continue.

Some patients like to bring on a keen familiarity early on in their meetings with physicians or surgeons. Some may be suffering from a grim diagnosis and might want to appear like they are perfectly fine with it. Others might come with the idea that “since this is someone whose knife I’m going to go under, we might as well be friends first'” For some, it might simply be their personality or disposition. As surgeons, we refrain from judging atypical behaviour unless it helps with the diagnosis.
“What brings you to me?”

“I have this shooting pain in my right jaw. It’s like an electric shock that sometimes goes into my cheek as well. I can’t brush, eat, swallow or chew,” she continued, wincing as she opened her mouth to remove the gum she was chewing with difficulty, wrapping it tidily in a tissue paper. Thinking it was tooth pain, she had visited the dentist but had eventually been told to see a neurosurgeon. The medication she had been prescribed was no longer helping and she had been living with the pain for close to two years. “Sometimes, I feel like jumping off the Bandra-Worli Sea Link.”

I told her friends to ensure that she didn’t take that route on her commute for now.

She was pretty well-informed and knew enough about her condition, trigeminal neuralgia. It occurs when a blood vessel in the brain presses on the trigeminal nerve that supplies sensation to the face. The pain can sometimes be so severe that it pushes patients towards contemplating suicide. Some women patients have told me that it’s infinitely worse than the pain of labour without an epidural. Owing to the location of the pain, most patients visit a dentist first, and when a root canal doesn’t help, they are referred to a neurologist.

“Having a drink at night makes the pain a little better,” she confessed.

“In the good, old days, they used to inject alcohol directly into the nerve to numb it,” I said. She thought I was joking but it’s a fact.

The current options were to inject glycerol or ablate the root of the nerve with some radiofrequency current. The drawback —the pain would be replaced by semi-numbness since it’s a destructive procedure. Or, we could use the Gamma Knife, where a single dose of focused radiation could do the trick. And finally, there was surgery—a little more invasive, but offering the best chance of cure and the least chance of recurrence. I explained that we’d make a small hole in the skull behind the ear and place a pad of Teflon between the vessel and the nerve so that direct contact between the two was eliminated.

After understanding her options, she opted for surgery. “You just want to go back to drinking without pain,” I said in jest.

At surgery, under the magnificence of the microscope, we could see the offending vessel deeply grooving her nerve. When it was lifted gently after meticulously dissecting tiny strands connecting the two, I could see how pale and beat up the nerve looked. I teased the strands of the padding material Teflon and interposed them in the right place, transposing the vessel away to avoid any contact. As we were closing, I told my surgical assistant that this was one of the most gratifying neurosurgical procedures he would ever do. The charming lady woke up completely pain free, and over the next few days, we managed to get her off all painkillers.

Two days after discharge, she sent me this text message: “For the first time in several years, I could brush my teeth and eat breakfast, lunch, and dinner without any pain. What’s still better is that I could have the single malt, pain-free!”

“You are now permitted to use the Sea Link,” I replied.

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