Selected Podcast
Diagnosis and Treatment of Trigeminal Neuralgia
William A. Friedman M.D., describes the diagnostic criteria for trigeminal neuralgia as well as other facial pain disorders. He highlights the best medical therapy for trigeminal neuralgia and its limitations and he outlines the three neurosurgical options for treating medically refractory trigeminal neuralgia.
Featuring:
In 1976, Dr. Friedman moved to the University of Florida in Gainesville, Florida. He performed a surgical internship and a neurosurgical residency, from which he graduated in 1982. During residency training he did basic neurophysiology research as an NIH postdoctoral fellow (1 F32 NS0682-02). In 1982, he joined the faculty of the Department of Neurosurgery, as an Assistant Professor. He received an NIH Teacher Investigator Award (NS 00682-02), from July, 1982 - July, 1987, which funded further research into the basic neurophysiology of spinal cord injuries. In addition, this award supported the development of one of the first intraoperative neurophysiology monitoring laboratories, subsequently used to monitor thousands of neurosurgical and orthopedic surgical cases. Dr. Friedman served as Medical Director of the Intraoperative Neurophysiology Service from 1982-1992.
Dr. Friedman was promoted to Associate Professor and received tenure in August, 1987. In August, 1991 he was promoted to Professor. In 1999, he became Chairman of the Department of Neurosurgery. He is the author of more than 300 articles and book chapters and has written a book on radiosurgery. He is a member of numerous professional organizations. Most notably, he is a Past-President of the Congress of Neurological Surgeons, Past President of the Florida Neurosurgical Society, and Past President of the International Stereotactic Radiosurgery Society. He was the Founding Editor of Neurosurgery On Call, the Internet homepage of organized neurosurgery. He was a member of the Shands Hospital Board of Directors for two terms. Dr. Friedman led the Level I Trauma task force which resulted in the establishment of a trauma center at UF Health. He was also the first ACGME Designated Institutional Official (DIO) at UF.
In 1986, Dr. Friedman began collaborative work with Dr. Frank Bova, which led to the development of the University of Florida radiosurgery system. This system was subsequently patented by the University of Florida and licensed to Philips, then Sofamor-Danek, then Varian. The commercial version of the system has become one of the most popular radiosurgical systems worldwide. Drs. Friedman and Bova received the 1990 UF College of Medicine Clinical Research Prize in recognition of this accomplishment. Dr. Friedman is the leader of a multidisciplinary radiosurgery team which has treated over 4500 patients, published more than120 papers and chapters, produced many international meetings, and educated hundreds of visiting physicians. Drs. Bova and Friedman received NIH R01 funding to support their continuing research efforts.
Dr. Friedman is the Director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. During his tenure as Chair of the Department of Neurosurgery he grew the department’s endowed funds to greater than $45 million, much of which is focused on finding a cure for malignant brain tumors. In recent years, Dr. Friedman also worked hard to elevate the quality metrics of the department and became a frequent national neurosurgical speaker on quality improvement. He was the Honored Guest at the 2021 Congress of Neurological Surgeons meeting in Austin, Texas. He published a medical memoir, “Something Awesome: A Life in Neurosurgery,: in 2021 which became an Amazon neurosurgical best seller.
After almost 20 years in the job, Dr. Friedman stepped down as Chair on July 1, 2018 but continues to run a very busy neurosurgical practice. In his spare time he loves travel, hiking, reading, Civil War history, cooking, and time with friends and family.
William A. Friedman, M.D.
Dr. William Alan Friedman was born in Dayton, Ohio on April 25, 1953. He attended high school in Cincinnati, Ohio. He graduated in 1970 as a National Merit Scholar and attended Oberlin College. There he was elected to Phi Beta Kappa before moving on to the Ohio State University College of Medicine. Before graduating summa cum laude from medical school in 1976, he was elected to the Alpha Omega Alpha honor society and received the Maurice B. Rusoff Award for excellence in medicine.In 1976, Dr. Friedman moved to the University of Florida in Gainesville, Florida. He performed a surgical internship and a neurosurgical residency, from which he graduated in 1982. During residency training he did basic neurophysiology research as an NIH postdoctoral fellow (1 F32 NS0682-02). In 1982, he joined the faculty of the Department of Neurosurgery, as an Assistant Professor. He received an NIH Teacher Investigator Award (NS 00682-02), from July, 1982 - July, 1987, which funded further research into the basic neurophysiology of spinal cord injuries. In addition, this award supported the development of one of the first intraoperative neurophysiology monitoring laboratories, subsequently used to monitor thousands of neurosurgical and orthopedic surgical cases. Dr. Friedman served as Medical Director of the Intraoperative Neurophysiology Service from 1982-1992.
Dr. Friedman was promoted to Associate Professor and received tenure in August, 1987. In August, 1991 he was promoted to Professor. In 1999, he became Chairman of the Department of Neurosurgery. He is the author of more than 300 articles and book chapters and has written a book on radiosurgery. He is a member of numerous professional organizations. Most notably, he is a Past-President of the Congress of Neurological Surgeons, Past President of the Florida Neurosurgical Society, and Past President of the International Stereotactic Radiosurgery Society. He was the Founding Editor of Neurosurgery On Call, the Internet homepage of organized neurosurgery. He was a member of the Shands Hospital Board of Directors for two terms. Dr. Friedman led the Level I Trauma task force which resulted in the establishment of a trauma center at UF Health. He was also the first ACGME Designated Institutional Official (DIO) at UF.
In 1986, Dr. Friedman began collaborative work with Dr. Frank Bova, which led to the development of the University of Florida radiosurgery system. This system was subsequently patented by the University of Florida and licensed to Philips, then Sofamor-Danek, then Varian. The commercial version of the system has become one of the most popular radiosurgical systems worldwide. Drs. Friedman and Bova received the 1990 UF College of Medicine Clinical Research Prize in recognition of this accomplishment. Dr. Friedman is the leader of a multidisciplinary radiosurgery team which has treated over 4500 patients, published more than120 papers and chapters, produced many international meetings, and educated hundreds of visiting physicians. Drs. Bova and Friedman received NIH R01 funding to support their continuing research efforts.
Dr. Friedman is the Director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. During his tenure as Chair of the Department of Neurosurgery he grew the department’s endowed funds to greater than $45 million, much of which is focused on finding a cure for malignant brain tumors. In recent years, Dr. Friedman also worked hard to elevate the quality metrics of the department and became a frequent national neurosurgical speaker on quality improvement. He was the Honored Guest at the 2021 Congress of Neurological Surgeons meeting in Austin, Texas. He published a medical memoir, “Something Awesome: A Life in Neurosurgery,: in 2021 which became an Amazon neurosurgical best seller.
After almost 20 years in the job, Dr. Friedman stepped down as Chair on July 1, 2018 but continues to run a very busy neurosurgical practice. In his spare time he loves travel, hiking, reading, Civil War history, cooking, and time with friends and family.
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PR a category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. William Friedman. He's a professor in the Department of Neurosurgery at the UF College of Medicine and the director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. Dr. Friedman practices at UF Health Shands Hospital, and he's here to tell us about diagnosis and treatment of trigeminal neuralgia. Dr. Friedman, welcome to the show. I'm so glad you could join us today. So as we're getting into this topic, I'd like you to describe the different types of facial pain we're discussing here today and the scope of this problem as you see it, the trends. What are we looking at?
Dr William Friedman: Well, we're principally speaking about trigeminal neuralgia. Trigeminal neuralgia is a horribly severe, sharp, stabbing electrical pain that involves one side of the face. It's brought on by touching the face, eating or talking, and can be severe enough that patients seriously consider suicide. It's called the suicide disease. The major treatment for trigeminal neuralgia is medical. It's a drug called carbamazepine, which is remarkably effective at relieving the pain. Unfortunately, over the course of years, the drug becomes less effective until patients have to push the dose up high enough to cause significant side effects, such as sleepiness or dizziness. And at that point, neurosurgery plays a major role.
Melanie Cole (Host): Wow. So it's pretty severe. Do we know what causes it Dr. Friedman? Do we know why some people get it?
Dr William Friedman: Well, the most prevalent theory is that trigeminal neuralgia is caused by a small artery in the back part of the brain, contacting and pulsing against the trigeminal nerve as it comes out of the brain. That's called microvascular decompression, and it was a theory that was popularized years ago by a neurosurgeon at the University of Pittsburgh by the name of Peter Janetta. So the principle procedure that we do for this disease is called a microvascular decompression. It involves making an incision behind the patient's. Removing a piece of bone, about the size of a nickel, and then using the operating microscope to look directly at the trigeminal nerve.
Identify that artery, which is usually the superior cerebellar artery. We dissect that free from a nerve and we place a small sponge in between the nerve and the artery and the sponge is a plastic material. It could either be Avalon or Teflon. That procedure typically takes me about an hour. Most people spend two nights in the hospital and two weeks at home healing up and recuperating. Most of them never have pain again.
Melanie Cole (Host): pretty exciting time in your field when you're talking about these kinds of things. Now, I'd like to step back for just a second, Dr. Friedman, to diagnose these because sometimes the first provider that will see these patients is their primary care provider, and while some of these pains could mimic other symptoms, Are there specific diagnostic criteria for trigeminal neuralgia? Are there other things that mimic those kinds of symptoms that they may present with?
Dr William Friedman: Melanie, this is an extremely important point. So most of these patients will present either to their primary care provider or even more commonly to the dentist because the pain seems to the patient to be coming from their teeth. It's not unusual that patients have multiple dental procedures that fail to relieve the pain before the correct diagnosis is made. So here are the criteria that I use. One, the pain has to be on one side of the face only, and it can't be in other parts of the head besides the face. It's just in the face. Two the pain is intermittent, not constant.
Three, the pain is sharp, stabbing, and electrical. In character four, there are trigger points, and by that I mean that the patient can bring the pain on by touching the face or talking or chewing. And then five, the pain is usually very reliably relieved by tegratol. So if those five criteria apply, the patient almost certainly has trigeminal neuralgia should be treated medically until medicine fails and then referred to a neurosurgeon. Now, there are a number of other diseases that can cause severe facial pain.
In younger women, we tend to see a type of facial pain that is more constant instead of intermittent. And if it's constant for more than 50% of the time, we call that type two trigeminal neuralgia, or a typical trigeminal neuralgia that can still be treated with microvascular decompression or a couple of the other procedures that I'll mention a bit later. But the success rate is lower. Another painful problem of the face. Occursafter a patient develops shingles on the face, typically in the forehead and the eye, and that's called postherpetic neuralgia.
It tends to be a constant severe burning pain, and that is not going to be relieved by most of the typical neurosurgical procedures or drugs. It does require referral to a neurosurgeon who's an expert in facial pain to explore some other options. And finally, Melanie, I'd like to mention that there is a normal physical exam in most of these patients. So the diagnosis is primarily made by history, but there is one test that can be helpful, and that's an MRI scan of the brain incorporating a special sequence called Fiesta or Space T2 imaging, which is very good at showing these little blood vessels in contact with the nerves. So if you're on the fence about whether the patient has trigeminal neuralgia, getting a positive MRI scan for vascular contact can be very helpful.
Melanie Cole (Host): This is so informative. You're laying it out so beautifully. Dr. Friedman, is it understood. That often facial pain syndromes and mood disorders can coexist? And you mentioned this was called sort of the suicide condition, the psychosocial burden of this particular condition and other facial pain conditions. How is this addressed and what do you want other providers to know about multidisciplinary approach working on that psychosocial aspect of this? Because pain is somewhat subjective. However, when it's constant, when it's sharp, when it's severe, these affect the quality of life, as you've said in unbelievable ways.
Dr William Friedman: So you're absolutely right that, any pain disorder can be a life altering disease and certainly trigeminal neuralgia can be as well. I would have to say that this particular pain disorder is fortunately different than many other chronic pain conditions that we see because the operation and the medication are so effective that whatever depression or anxiety the pain is producing frequently, disappear rapidly with complete relief of the pain. So multidisciplinary care is not as frequently needed for trigeminal neuralgia as it is for many other pain disorders.
Melanie Cole (Host): I'm so glad you pointed that out. This is just all such important information. As we get ready to wrap up, is there anything else you'd like to cover as far as facial pain syndromes, anything you feel we missed, and when you feel it's important to refer to the specialists at UF Health Shands Hospital?
Dr William Friedman: Yeah. I just wanna mention that there are two other procedures that we can do surgically. I talked already about my preferred procedure, which is microvascular decompression, but in patients who don't want open surgery or in patients who are too old perhaps or too medically infirm to undergo, prolonged general anesthesia, we do a procedure called radiofrequency lesion. Radiofrequency lesion is an outpatient procedure. We take the patient to the OR. We very briefly anesthetize them with an intravenous injection.
We insert a needle through the face and into the trigeminal nerve, and we burn the nerve, and that leaves the patient feeling exactly like they've been to the dentist and had a Novocaine injection. It's very effective at relieving the pain, but you do have to be willing to accept the numbness. Now, that procedure typically takes about 10 minutes and a patient can go home an hour or two later with no more pain. The third procedure that has become increasingly popular is called radiosurgery.
Radiosurgery is also an outpatient procedure where we focus hundreds of small beams of radiation, about five millimeters in diameter, very small. We focus hundreds of those beams on the trigeminal nerve, and that also can relieve pain without the need for open surgery. But there usually is a six to eight week waiting period for the pain to go away. And a lot of the patients I see can't eat. They can't drink. They can't wait that long. But those are other options that are an important part of the surgical armamentarium in treating this kind of pain.
Now, the point that you mentioned is that way too often, We see these patients after they've been treated too long, either with ineffective medication or with dental care, or a combination, when we could have seen them much earlier and relieve of their pain. So, in my clinic, if we get a call from a patient who has any facial pain, complaint, we see them within a week because we know how bad this pain can be.
Melanie Cole (Host): Thank you, Dr. Friedman for joining us today and sharing your incredible expertise. What an informative episode this was. Thank you again, and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.UFhealth.org or to refer your patient and to listen to more podcasts from our experts, you can visit UF health.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thank you so much for joining us.
The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PR a category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. William Friedman. He's a professor in the Department of Neurosurgery at the UF College of Medicine and the director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. Dr. Friedman practices at UF Health Shands Hospital, and he's here to tell us about diagnosis and treatment of trigeminal neuralgia. Dr. Friedman, welcome to the show. I'm so glad you could join us today. So as we're getting into this topic, I'd like you to describe the different types of facial pain we're discussing here today and the scope of this problem as you see it, the trends. What are we looking at?
Dr William Friedman: Well, we're principally speaking about trigeminal neuralgia. Trigeminal neuralgia is a horribly severe, sharp, stabbing electrical pain that involves one side of the face. It's brought on by touching the face, eating or talking, and can be severe enough that patients seriously consider suicide. It's called the suicide disease. The major treatment for trigeminal neuralgia is medical. It's a drug called carbamazepine, which is remarkably effective at relieving the pain. Unfortunately, over the course of years, the drug becomes less effective until patients have to push the dose up high enough to cause significant side effects, such as sleepiness or dizziness. And at that point, neurosurgery plays a major role.
Melanie Cole (Host): Wow. So it's pretty severe. Do we know what causes it Dr. Friedman? Do we know why some people get it?
Dr William Friedman: Well, the most prevalent theory is that trigeminal neuralgia is caused by a small artery in the back part of the brain, contacting and pulsing against the trigeminal nerve as it comes out of the brain. That's called microvascular decompression, and it was a theory that was popularized years ago by a neurosurgeon at the University of Pittsburgh by the name of Peter Janetta. So the principle procedure that we do for this disease is called a microvascular decompression. It involves making an incision behind the patient's. Removing a piece of bone, about the size of a nickel, and then using the operating microscope to look directly at the trigeminal nerve.
Identify that artery, which is usually the superior cerebellar artery. We dissect that free from a nerve and we place a small sponge in between the nerve and the artery and the sponge is a plastic material. It could either be Avalon or Teflon. That procedure typically takes me about an hour. Most people spend two nights in the hospital and two weeks at home healing up and recuperating. Most of them never have pain again.
Melanie Cole (Host): pretty exciting time in your field when you're talking about these kinds of things. Now, I'd like to step back for just a second, Dr. Friedman, to diagnose these because sometimes the first provider that will see these patients is their primary care provider, and while some of these pains could mimic other symptoms, Are there specific diagnostic criteria for trigeminal neuralgia? Are there other things that mimic those kinds of symptoms that they may present with?
Dr William Friedman: Melanie, this is an extremely important point. So most of these patients will present either to their primary care provider or even more commonly to the dentist because the pain seems to the patient to be coming from their teeth. It's not unusual that patients have multiple dental procedures that fail to relieve the pain before the correct diagnosis is made. So here are the criteria that I use. One, the pain has to be on one side of the face only, and it can't be in other parts of the head besides the face. It's just in the face. Two the pain is intermittent, not constant.
Three, the pain is sharp, stabbing, and electrical. In character four, there are trigger points, and by that I mean that the patient can bring the pain on by touching the face or talking or chewing. And then five, the pain is usually very reliably relieved by tegratol. So if those five criteria apply, the patient almost certainly has trigeminal neuralgia should be treated medically until medicine fails and then referred to a neurosurgeon. Now, there are a number of other diseases that can cause severe facial pain.
In younger women, we tend to see a type of facial pain that is more constant instead of intermittent. And if it's constant for more than 50% of the time, we call that type two trigeminal neuralgia, or a typical trigeminal neuralgia that can still be treated with microvascular decompression or a couple of the other procedures that I'll mention a bit later. But the success rate is lower. Another painful problem of the face. Occursafter a patient develops shingles on the face, typically in the forehead and the eye, and that's called postherpetic neuralgia.
It tends to be a constant severe burning pain, and that is not going to be relieved by most of the typical neurosurgical procedures or drugs. It does require referral to a neurosurgeon who's an expert in facial pain to explore some other options. And finally, Melanie, I'd like to mention that there is a normal physical exam in most of these patients. So the diagnosis is primarily made by history, but there is one test that can be helpful, and that's an MRI scan of the brain incorporating a special sequence called Fiesta or Space T2 imaging, which is very good at showing these little blood vessels in contact with the nerves. So if you're on the fence about whether the patient has trigeminal neuralgia, getting a positive MRI scan for vascular contact can be very helpful.
Melanie Cole (Host): This is so informative. You're laying it out so beautifully. Dr. Friedman, is it understood. That often facial pain syndromes and mood disorders can coexist? And you mentioned this was called sort of the suicide condition, the psychosocial burden of this particular condition and other facial pain conditions. How is this addressed and what do you want other providers to know about multidisciplinary approach working on that psychosocial aspect of this? Because pain is somewhat subjective. However, when it's constant, when it's sharp, when it's severe, these affect the quality of life, as you've said in unbelievable ways.
Dr William Friedman: So you're absolutely right that, any pain disorder can be a life altering disease and certainly trigeminal neuralgia can be as well. I would have to say that this particular pain disorder is fortunately different than many other chronic pain conditions that we see because the operation and the medication are so effective that whatever depression or anxiety the pain is producing frequently, disappear rapidly with complete relief of the pain. So multidisciplinary care is not as frequently needed for trigeminal neuralgia as it is for many other pain disorders.
Melanie Cole (Host): I'm so glad you pointed that out. This is just all such important information. As we get ready to wrap up, is there anything else you'd like to cover as far as facial pain syndromes, anything you feel we missed, and when you feel it's important to refer to the specialists at UF Health Shands Hospital?
Dr William Friedman: Yeah. I just wanna mention that there are two other procedures that we can do surgically. I talked already about my preferred procedure, which is microvascular decompression, but in patients who don't want open surgery or in patients who are too old perhaps or too medically infirm to undergo, prolonged general anesthesia, we do a procedure called radiofrequency lesion. Radiofrequency lesion is an outpatient procedure. We take the patient to the OR. We very briefly anesthetize them with an intravenous injection.
We insert a needle through the face and into the trigeminal nerve, and we burn the nerve, and that leaves the patient feeling exactly like they've been to the dentist and had a Novocaine injection. It's very effective at relieving the pain, but you do have to be willing to accept the numbness. Now, that procedure typically takes about 10 minutes and a patient can go home an hour or two later with no more pain. The third procedure that has become increasingly popular is called radiosurgery.
Radiosurgery is also an outpatient procedure where we focus hundreds of small beams of radiation, about five millimeters in diameter, very small. We focus hundreds of those beams on the trigeminal nerve, and that also can relieve pain without the need for open surgery. But there usually is a six to eight week waiting period for the pain to go away. And a lot of the patients I see can't eat. They can't drink. They can't wait that long. But those are other options that are an important part of the surgical armamentarium in treating this kind of pain.
Now, the point that you mentioned is that way too often, We see these patients after they've been treated too long, either with ineffective medication or with dental care, or a combination, when we could have seen them much earlier and relieve of their pain. So, in my clinic, if we get a call from a patient who has any facial pain, complaint, we see them within a week because we know how bad this pain can be.
Melanie Cole (Host): Thank you, Dr. Friedman for joining us today and sharing your incredible expertise. What an informative episode this was. Thank you again, and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.UFhealth.org or to refer your patient and to listen to more podcasts from our experts, you can visit UF health.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thank you so much for joining us.