Ask a Doctor - Neurosurgery

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Q.
I have facial pain extending into the left side of my face, and it has recently moved into my left jaw. I have had it for years, but recently it has gotten worse. The pain is not constant, but is triggered if I brush my teeth, or if cold air hits my face. The pain feels like an ice pick through my cheek. My dentist said it was not a dental issue so I went to my primary physician who said it might be “trigeminal neuralgia” and wants to refer me to a specialist. Is it necessary for me to see a specialist?
A.
Trigeminal neuralgia (TN) is facial pain that originates from the trigeminal nerve. The trigeminal nerve is the nerve that carries pain and sensation from the face to the brain. TN can involve disabling, stabbing, or electric-shock like pain in parts of the face. The condition may occur without warning at any age, but more commonly affects older adults. Several conditions can cause TN, the most common being pressure on the trigeminal nerve from a blood vessel in the brain. The vessel may twist and come in contact with the nerve, and the constant pulsations of the vessel with each heartbeat eventually cause damage to the nerve sheath protecting the trigeminal nerve. Once this nerve sheath is gone, the nerve is exposed and pain can occur. Symptoms usually involve pain on one side of the face, often around the cheek, lower part of face, or around the eye. The pain may be triggered by touch, sounds, temperature changes, or everyday activities like brushing teeth, eating, shaving, etc. Treatment starts with medications designed to help reduce the pain and the frequency of the attacks. Many patients control symptoms with medications, but there are those whom cannot or have intolerable side effects. In these cases, surgical interventions may be indicated.

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Q.
About a month ago, with absolutely no injury to it, my arm started aching and moving it certain directions and I developed a pain and tingling like pins and needles in my right hand. It feels like it is getting worse, not better, no matter how much I try to rest it. I think it may be time to go to the doctor but where do I start?
A.
If you have back pain, neck pain, arm pain and you sit in front of your computer for hours at a time, you need to be aware of the damage you might be doing. Cervical radiculopathy pain travels down the arm in the area of the involved nerve. Pain is usually described as sharp. There can also be a “pins and needles” sensation or even complete numbness. In addition, there may be a feeling of weakness with certain activities. Symptoms can be worsened with certain movements, like extending or straining the neck or turning the head. If pain has persisted or worsened after 4 weeks, it may be time to see a specialist. When symptoms of cervical radiculopathy persist or worsen despite nonsurgical treatments, surgical options may need to be considered. The goals of surgery for cervical radiculopathy are to decompress nerves, to maintain spine stability, and to provide correct alignment of the spine. The procedure that is right for you will depend on many factors, most importantly the type of problem you have. A shared approach between neurosurgeons and otolaryngologists when surgically treating the cervical spine patient offers higher patient satisfaction and may factor in achieving better outcomes.

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Q.
I am a healthy 35 year old working mom – I used to go to the gym weekly and keep pace with my young children until recently when lower back pain stopped me dead in my tracks. My primary care physician has exhausted all conservative measures of treatment for pain in my lower back – steroid injections, physical therapy, chiropractic and antiinfl ammatory pain medications and says it’s time to consider lumbar fusion surgery! Are there minimally invasive options available and what do they entail?
A.
When a patient experiences back pain that does not resolve in a week to ten days, NSAIDS medications, McKenzie-based physical therapy, and/or chiropractic care may be prescribed. Some patients will eventually require and benefi t from steroid injections. When these conservative measures don’t resolve back-related pain, surgery may be necessary. Should surgery be deemed appropriate, there are several minimally invasive fusion techniques available. There is the minimally invasive lateral fusion, or XLIF, where the fusion is done through the side using small incisions, as well as several types of minimally invasive posterior (through the back) fusions. The less-invasive lateral approach is a breakthrough for spine patients, and it is of particular benefi t to patients who want to return to an active lifestyle, or to those who cannot tolerate a larger, open procedure because of the increased risks associated with longer anesthesia time, greater blood loss, increased hospitalization, and prolonged recovery.

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Q.
I have questions concerning spinal cord stimulator (SCS) implants. I’ve had 2 back surgeries in the last 5 years. First a 4 level laminectomy, L2-S1, and a 2 level fusion at the L4-5 and L5-S1 levels. My back has been hurting pretty bad as of late. I saw my primary last week and while he does recommend me having more surgery, he suggested I look into SCS. Could this treatment be an option for me?
A.
Spinal Cord Stimulation (SCS) is an approved method for the treatment of chronic pain in patients for whom physical therapy, medications, prior surgeries or blocks were ineffective. SCS used electrical impulses to relieve chronic pain in the back, arms and legs. These impulses are believed to prevent pain signals from being received by the brain. Success rate is as high as 70% in some chronic pain conditions. The procedure begins with a trial implantation. Trials are minimally invasive offi ce procedures doe under local anesthesia ad are reversible, allowing patients to try it out for three to seven days. If the patient ad physician determine that the pain relief during the trial period is acceptable, the system can be permanently implanted. The implants electrical pulses are programmed with an external control unit. The patient can then use the control unit to turn the system on and off, adjust the stimulation power level and switch between different programs. Ideal candidates for the spinal cord stimulator procedure are those for whom standard spine surgery has failed, those who are still in pain, or those in whom further conventional surgery is not an option. Some patients have extensive scar tissue or pain after surgery where there is no an obvious cause. These patients tend to do best with spinal cord stimulators. However, if there is a structural defect before considering a stimulator, assuming that there isn’t a contraindication to traditional spin surgery such as severe heart disease. Spinal cord stimulators can be very rewarding for both the patient and surgeon alike. It is an amazing thing to have a patient who has been in sever pain for years leave the offi ce after a stimulator trail with markedly decreased pain and a smile.

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