Compression rather than decompression for trigeminal neuralgia

C ONSIDERABLE progress has been made during the past 4 years in the surgical management of major trigeminal neuralgia. However, very little has been added to our meager knowledge concerning the etiology of the pain. Woltman in 1951 suggested to us the possibility of controlling facial neuralgia by decompression of the peripheral branches of the trigeminal nerve at their points of exit from the skull. This suggestion was based upon the experience of Woltman and Williams 2 in treating facial tic by decompression of the seventh nerve. During the period from 1951 to 1953, 10 patients were surgically treated for trigeminal neuralgia by decompression of the peripheral branches of the trigeminal nerve at the foramen ovale and foramen rotundum. The surgical procedure consisted of temporal craniotomy, exposure of the foramen ovale and/or foramen rotundum, enlargement of the foramen by means of a motor-driven high-speed dental drill, neurolysis of peripheral branch or branches with saline followed by multiple linear incisions in the sheath of the nerve (Fig. 1). Every patient experienced complete relief of pain without significant objective impairment of facial sensation. Several patients noted mild subjective differences in tactile sensation, but this difference seldom could be demonstrated objectively for longer than a few days postoperatively. The results were gratifying but the mechanism of relief was difficult to explain. During this period it was learned that Taarnh~j in Copenhagen was accomplishing equally satisfactory results by decompression of the posterior root of the trigeminal nerve. His subsequent publication I verified the reports that we had obtained, but it was difficult to understand how the two procedures, both decompressing the fibers of the nerve, but at widely separated points, could accomplish the same results. Numerous observers concluded after Taarnhgj's report that the causative factor of trigeminal neuralgia was compression of the posterior root. If such were the ease, how could decompression of one or more branches peripheral to the ganglia afford complete relief of pain and no loss of facial sensation? The experience gained from our first 10 patients was presented in 195~