T HE purpose of this paper is to revive

Transcription

1 A MODIFICATION OF THE TIFFANY OPERATION FOR TIC DOULOUREUX DONALD M. DOOLEY, M.D., AND E. JEFFERSON BROWDER, M.D. Department of Surgery, Division of Neurosurgery, State University of New York, Downstate Medical Center and the Neurosurgical Service, Kings County Hospital, Brooklyn, New York T HE purpose of this paper is to revive and propose a modification of the operative procedure of subtotal removal of the ganglion of Gasser for the treatment of tic douloureux as proposed and executed by Tiffany 19 in Early surgical treatment for this disease comprised division or avulsion of the peripheral branches of the 5th cranial nerve. These neurectomies resulted in only temporary relief of pain and consequently were abandoned except in special circumstances. After many years of trial and failure with peripheral neurectomies, partial to complete removal of the Gasserian ganglion was practised. During the latter part of the nineteenth century and the first half of this century major contributions dealing with the surgical treatment of tic douloureux were made by Mears, 12 Rose, I4 Horsley et al. s Hartley, 7 Krause, 11 Tiffany, 2~ Spiller and Frazier, TM Keen, ~~ Cushing, 2 Hutchinson, 9 Dandy, 3 Stookey, 17 SjSqvist, ~5 and Taarnh0j. is In 1884 Mears 12 suggested the removal of the Gasscrian ganglion. Rose 14 is accorded the distinction of being the first to carry out this procedure (1890). Horsley et al. s in 1891 described avulsion of the dorsal root of the Gasserian ganglion through a temporal, intradural approach. In 189~ Hartley 7 reported alleviation of the pain of tic douloureux by removal of the s and 3rd divisions of the trigeminus and a portion of the Gasserian ganglion. He did not suggest or practise avoiding the fibers in the ganglion that supply the cornea and his drawings of the face after operation indicate that there were sensory alterations of part of the cutaneous (Received for publication December 14, 1961) 414 area supplied by the ophthahnic division. Tiffany '9 in 1894 proposed sparing of the ophthalmic fibers and suggested that the motor component be preserved although he was not able to obtain this objective invariably. In part his conclusion was "The intracranial operation for the cure of facial neuralgia which should be done is removal of the lower two-thirds of the ganglion of Gasser with the second and third branches at their foramina of exit from the skull, all in one piece, so as to be certain of the amount of tissue taken away ''2~ (Fig. 1). Spiller and Frazier t6 in 1901 published results of dorsalroot section of the 5th cranial nerve in dogs Fro. 1. Tiffany's operation. The lined areas indicate the portion of the dorsal root, ganglion and peripheral nerves removed totally.

2 MODIFIED TIFFANY OPERATI()N FOR TIC DOULOUREUX 415 and found that there was no regeneration of fibers in the spinal tract after division of the dorsal root; consequently removal of all or part of the ganglion was thought unnecessary. In a segment of this article Frazier described the technique of total dorsal-root section of the trigeminal nerve in man. As recorded in the second edition of the monograph On Facial Neuralgia and Its Treatment (1919) Hutchinson 9 had continued to practise the Tiffany operation of subtotal removal of the lower two-thirds of the ganglion and the intracranial parts of the ~n(t and 3rd divisions. He emphasized the latent reduction in the area of cutaneous anesthesia which may occur subsequent to operation. In the 19~0s Frazier, 5 Dandy a and Stookey t7 successively described partial sections of the dorsal root without intentional damage to the Gasserian ganglion. (The partial section of the dorsal root was performed by Frazicr and Stookey through a transtcmporal approach, whereas the partial section by Dandy in most instances was carried out through the posterior cranial fossa.) During the past three decades most neurosurgeons using some type of subtotal section of the sensory root have attempted to obtain permanent relief of pain, prevention of corneal ulceration by sparing of the ophthalmic part of the dorsal root and preservation of the motor root. In 1937 Sjiiqvist 15 proposed trigeminal tractotomy. His objective was retention of tactile sensation of the face with elimination of pain and telnperature. In this procedure section was made in the distal medulla oblongata, severing the spinal tract of the 5th cranial nerve. Although this operation has not enjoyed widespread usage, probably because of higher morbidity and mortality, it none the less attains the objective set forth. In 1955~ Taarnh0j *s published the results following the "decompression" of the dorsal root and ganglion of the trigeminal nerve in patients with major trigeminal neuralgia. Several surgeons have modified this method with variable rcsults. In the neurosurgieal clinic of the Kings County Hospital in Brooklyn, New York, most of the proposed methods of surgical FIG. ~. "Standard" section of lower two-thirds of tile dorsal root. treatment for tic douloureux have been given trials. During the 1930s and early 1940s most patients with tie douloureux were submitted to partial section of the dorsal root. In partieular it was noted that section of the lateral two-thirds of the dorsal root resulted in loss of cutaneous sensibilities of the area supplied by the ~n(t and 3rd divisions of the trigeminus exclusive of that triangle of skin bounded by lines drawn from the external eanthus of the eye to the upper alae nasi thence along the mid-lateral nose to the inner eanthus of the eye and then along the mid palpebral fissure to the external canthus (Fig. ~). It was found that if complete loss of cutaneous sensation of all the area supplied by the maxillary division was to be attained it was necessary to divide at least the lateral three-fourths of the dorsal root. In doing so the lateral half of the upper eyelid was made anesthetic and analgesic and frequently the corneal reflex was abolished (Fig. 3). In all events, if the corneal reflex was to be preserved by a "standard" differential section, then the triangle of skin as described retained normal sensibilities. More importantly a "trigger" zone of the clinical syndrome under consideration may be, and

3 416 DONALD M. DOOLEY AND E. JEFFERSON BROWDER Fro. 3. Three-quarter section of the dorsal root of the trigeminus illustrating the ablation of the corneal sensation. frequently is, located in the skin of the upper part of the alae nasi. Some of the patients submitted to a differential section of the lateral two-thirds of the dorsal root had recurrence of symptoms since enduring analgesia of the "trigger" zone was not produced by the section. In addition it is to be recalled that the total zone of sensory loss demonstrable shortly after operation is greater than that found 6 months or 1 year later. Therefore a surgical procedure that would produce analgesia and anesthesia of the total area supplied by the ~nd and 3rd divisions of the trigeminus with preservation of the corneal reflex and function of the masticator muscles was sought. There was evolved an operation by one of the authors (E.J.B.) comprising division of the lateral two-thirds of the dorsal root of the trigeminal nerve and a rostral extension of this incision from the termination of the most medial part of the root section through the ganglion to the crotch formed by the ophthalmic and maxillary nerves (Fig. 4). No part of the ganglion was removed. At this time (1946) it was not appreciated that a somewhat similar procedure had been proposed and used by Tiffany 19,2~ 0894, 1896) and employed by Hutchinson 9 (1919). This operation effectively abolishes appreciation of touch, heat, cold and pinprick of all the cutaneous zone supplied by the ~nd and 3rd divisions of the trigeminus. The end results are in accord with those published by both Tiffany and Hutchinson. Anatomically there still exists a deficit in our knowledge regarding the manner in which fibers from the three divisions of the trigeminal nerve traverse the ganglion, course through the dorsal root and take their position in the medulla oblongata. It is obvious that the modified Tiffany operation divides all the pain-carrying pathways from the face except those coursing over the ophthalmic division. Moreover, it is evident from our clinical results that section of the lateral twothirds of the dorsal root produces a complete loss of cutaneous sensibility of the area subserved by the mandibular division but not all of that subserved by the maxillary division. Phylogenetically one notes variations in the structure of the ganglion of the 5th cranial nerve, such as partial or complete separation of the ganglion into ophthalmicomaxillary and mandibular divisions and into FIG. 4. Operation proposed by Dr. Jefferson Browder.

4 MODIFIED TIFFANY OPERATION FOR TIC DOULOUREUX 417 ophthalmic and maxillo-mandibular divisions. 1,2~ Krause H in 1896, in reporting the dissections of the dorsal root of the 5th cranial nerve in man, found it to comprise a plexus of intermingling fibers, particularly in the medial half of the root presumably including the ophthalmic and maxillary portions. Frazier and Whitehead 6 in 19s examined the Gasserian ganglia of 9 human embryos from the Carnegie Embryological Collection and constructed wax plate models of the specimens. They traced the development of the ganglion from an embryo of 5 mm. crown-rump length to one of 80 mm. and concluded that the human ganglion from the time that it can be identified definitely is never completely separated into three parts. They did observe precocious development of the clusters of cells in the ophthalmic region, and associated with this, grooves on the external surfaces partially separating the ganglion into three portions corresponding to the three divisions. Using the binocular microscope it was possible to observe that there was a considerable area on the ventral surface of the ganglion common to both maxillary and mandibular portions, and many fibers from cells in the maxillary part found their way into the mandibular trunk and vice versa. More importantly, they observed that the fibers in the sensory root ran parallel in separate bundles and did not intermingle. An opposite finding was reported by van Nouhuijs 13 in After dissecting 88 ganglia and dorsal roots from adult human cadavers it was concluded that there was "marked interweaving and anastomosing" of fibers in the sensory root and he did not find three separate bundles as described by Frazier and Whitehead. Davis and Haven* in 1988 investigated this anatomical feature and reported findings in agreement with van Nouhuijs. DISCUSSION It seems permissible to restate briefly the modification of Tiffany's operation as proposed herein and to state the end results of this procedure. Section of the lateral two- thirds of the dorsal root is carried out just retro-ganglionically as if this were the entire operation. Beginning at the medial termination of the dorsal-root section a groove is made through the ganglion to the fork formed by the ophthalmic and maxillary nerves. Successively picking up small portions of the ganglion with the forceps effectively separates the ophthalmic and the maxillomandibular portions of the semilunar ganglion. The ganglion has a rather rich blood supply and the groove is made as suggested above to obviate troublesome bleeding. This results in complete analgesia and anesthesia of the cutaneous zone supplied by the maxillary and mandibular divisions. It is well known that the skin on the proximal superior portion of the nose is supplied by a branch of the supraorbital nerve. This cutaneous zone remains unaltered. Postoperatively many patients complain for variable periods, usually a month or 6 weeks, of "sand" in the eye of the affected side. In view of the fact that one can demonstrate diminution to absence of the corneal reflex over the lower half of the cornea in the majority of patients subjected to this operation, it would seem that the line between normal and abnormal cutaneous sensibility falls directly across the mid part of the cornea. The concept that the corneal reflex is mediated over the ophthalmic division is recorded in most textbooks. This finding of decreased sensitivity of the inferior half of the cornea has been demonstrated repeatedly following the modified Tiffany operation. A review of the literature fails to disclose the observation that the lower half of the cornea may be so affected with retention of normal sensation of the upper half, following any surgical procedure for tic douloureux. This is not to say that the corneal reflex is not mediated over the ophthalmic division since operative damage to the Gasserian ganglion may have implicated some fibers subserving the lower half of the cornea. It is to be restated that there result from the modified Tiffany operation anesthesia and analgesia of the cutaneous covering of the lower eyelid as well as the palpebral conjunctiva of this

5 418 DONALD M. DOOLEY AND E. JEFFERSON BROWDER lid, and diminution of sensibility of the lower half of the affected cornea whereas the cutaneous covering of the upper eyelid, its palpebral conjunctiva and the upper half of the cornea retain normal sensibilities. It would therefore appear that the "inferior corneal reflex" is mediated largely over the maxillary nerve. CONCLUSION 1. A brief historical accouut of the surgical procedures for the alleviation of pain associated with tic douloureux has been presented. 2. Among the advocated operations for this disease that of Tiffany has been revived and a modification proposed as described herein. 3. The end results following the modified Tiffany procedure have been recorded. 4. Observations concerning a postoperative dampening to absence of sensibility of the inferior half of the cornea are discussed. REFERENCES 1. ALLEN, W.F. Localization in the ganglion semilunate of the cat. J. comp. Neurol., 1934, 38: CUSHING, H. A method of total extirpation of the Gasserian ganglion for trigeminal neuralgia. By a route through the temporal fossa and beneath the middle meningeal artery. J. Amer. med. Ass., 1900, 34: DANNY, W.E. Section of the sensory root of the trigeminal nerve at the pone. Preliminary report of the operative procedure. Johns Hopk. Hosp. Bull., 1935, 36: DAVIS, L., and HAVEN, H.A. Surgical anatomy of the sensory root of the trigeminal nerve. Arch. Neurol. Psychiat., Chicago, 1933, 29: FRAZIER, C.H. A refinement in the radical operation for trigeminal neuralgia. J. Amer. reed. Ass., 19~1, 76: FRAZIER, C. H., and WHITEHEAD, E. The morphology of the Gasserian ganglion. Brain, 1935, ~8: HARTLEY, F. Intracranial neurectomy of the sec- ond and third divisions of the fifth nerve. A new method. N. Y. med. J., 1893, 65: HORSLEY, V., TAYLOR, J., and COLMAN, W.S. Renaarks on the various surgical procedures devised for the relief or cure of trigeminal neuralgia (tic douloureux). Brit. reed. J., 1891, 2: ; ; HUTCHINSON, J. On facial neuralgia and its treatment, with special reference to the surgery of the fifth nerve and the Gasserian ganglion. New York: W. Wood & Co., 1919, 316 pp. 10. KEEN, W.W. Remarks on operations on the Gasserian ganglion, with a report of five additional cases. Amer. J. reed. Sci., 1896, n.s. 111: KRAUSE, F. Die Neuralgic des Tiigeminus, nebst der Anatomie und Physiologic des Nerven. Leipzig: F. C. W. Vogel, 1896, xii, 360 pp. 13. MEARS, J. E. Study of the pathological changes occurring in trifacial neuralgia, with the report of a case in which three inches of the inferior dental nerve were excised. Med. News, Philad., 1884, 45: VAN NouHuIJs, F. GasseriaR ganglion with reference to operative treatment of trigeminal neuralgia. Ned. Maandschr. Verlosk. (Geneesk.), , 16: RosE, W. Removal of the Gasserian ganglion for severe neuralgia. Lancet, 1890, 2: SJiiQVIST, O. Eine neue Operationsmethode ben Trigelninusneuralgie: Durchschneidung des TractUN spinalis trigemini. Zbl. Neurochir., 1987, 2: SPILLER, W. G., and FHAZIF~R, C.H. The division of the sensory root of the trigeminus for the relief of tic douloureux; an experimental, pathological and clinical study, with a prelinfinary report of one surgically successful case. Philad. reed. J., 1901, 8: STOOKEY, B. Differential section of the trigeminal root in the surgical treatment of trigeminal neuralgia. Ann. Surg., 1938, 87: TAARNHOJ, P. Decompression of the trigeminal root and the posterior part of the ganglion as treatment in trigeminal neuralgia. Preliminary eommunieatiom J. Neurosurg., 1953, 9: TIFFANY, L. McL. Intraeranial neurectomy and removal of the Gasserian ganglion. Ann. Surg., 1894, 19: TIFFANY, L. McL. Intracranial operations for the cure of facial neuralgia. Trans. Amer. surg. Ass., 1896, 14: VAN VALKENBUUG, C. T. Zur vergleiehenden Anatomic des mesencephalen Trigeminusanteils. Folia Neurobiol., , 5: