Balloon Compression for TN

In an older article, I wrote about the benefits and drawbacks of microvascular decompression. Microvascular decompression is a procedure in which the patient's head is opened up to reveal the trigeminal nerve near the cerebellum; oftentimes, if the nerve pain is caused by pressure from a proximal blood vessel, a sponge is placed between the nerve and the vessel to distance the sensitive cells from the throbbing vessel. Balloon compression is similar to this treatment in that it also involves accessing the trigeminal nerve through an opening in the skull, but instead of trying to preserve the nerve by separating it from the offending blood vessel, the goal of the procedure is to damage it mechanically so it no longer transmits painful signals.

Thus, this procedure- compared to other surgical options- has a negative connotation because it damages rather than restores the nerve. However, this should not be the primary reason a patient shies away from the procedure; indeed, the procedure is generally successful, can be performed on a variety of patients, and is cost-effective. Of course, as with any surgical procedure, there are side effects- some of which are greater for balloon compression.

But what is the procedure like? As mentioned above, balloon compression is a rhizotomy, which means it is performed to damage the nerve. Specifically, this occurs at the point near the base of the skull where the nerve splits into its three "branches." A benefit of balloon compression is that, considering it is a surgical procedure, the process is relatively non-invasive: while the patient is under general anesthesia, the doctor inserts a hollow needle (a tube called a "cannula") through the cheek. The hollow cannula allows the doctor to thread a soft catheter with a balloon tip towards the nerve at the base of the skull. Once there, the balloon is inflated to press the nerve against the skull and the dura, which covers the brain, mechanically damaging the nerve. The balloon is only inflated for about a minute, then it is removed (with the cannula). The procedure in its entirety takes only about 20 min, so it is generally an outpatient procedure. Although considered non-invasive for a surgery (there are very few side effects associated with the actual procedure or general anesthesia), it is nevertheless a final alternative for patients who have not had success with their medication for trigeminal neuralgia.

Unfortunately, because the nerve is being damaged and not preserved, there are side effects. Balloon compression offers only a small chance of losing sensation permanently, but many patients develop at least temporary weakness (especially in the jaw, for chewing) and facial numbness is more severe with this procedure than with other rhizotomy procedures. In fact, masseter (chewing) muscle weakness is practically guaranteed, although new procedures are being developed which employ a shorter compression time and more monitoring during surgery (Brown and Pilitsis), to help reduce muscle weakness. And unfortunate corollary of this development is that, while it does successfully control pain, in many cases the pain has recurred. Yet, there is no procedure which does guarantee against recurrent pain among trigeminal neuralgia patients, so balloon compression is actually a very viable option, particularly as a non-invasive surgical alternative for patients with recurrent pain after microvascular decompression.

Other positive aspects of balloon compression are its cost-effectiveness and the fact that it works well for patients suffering with other coexisting health conditions. Because it only requires general anesthesia and exposes no other nerves, it has few negative interactions with other treatments. Lastly, if the nerve pain cannot be pinpointed, or if it is caused by something other than pressure from a proximal vessel, stopping the nerve signals with balloon compression would be more helpful than microvascular decompression (particularly if the doctor can find no offending blood vessel during the MVD procedure).

Alternative (herbal) treatments for Neuralgia

Here is a short list of several herbal supplements that people have used to augment treatments for neuralgias. Keep in mind that few (actually, none that I could find) of these herbal remedies have been scientifically proven to aid neuralgia; they are on this list because I have encountered them in the course of researching possible neuralgia treatments. Additionally, all of the alternative treatments are most effective when used in conjunction with other, more conventional treatment courses (typically, a combination of herbal supplements and anticonvulsants or antidepressants).

1) Zanthoxylum clava-herculisis. Also known as "toothache tree," this spiny tree can reduce pain from a toothache because chewing on the bark or leaves numbs the teeth and tongue. It can be helpful for trigeminal neuralgia patients because of its "antispasmodic" properties for the face and mouth.

2) Matricaria recutita, commonly known as German Chamomile, is typically used to treat stomachache and IBS (Irritable Bowel Syndrome), because it is a mild laxative. It is also helpful for sleeping (hence the inclusion of chamomile in many "sleeping" teas), and is anti-inflammatory. Most importantly, in studies with animals the plant has exhibited anti- inflammatory and convulsant properties (as stated above, research is lacking to confirm similar results in humans).

3) Arctium lappa (Burdock) is traditionally used to treat respiratory disorders, joint pain and urinary problems by stimulating cell regeneration. It helps protect against cell damage and abnormal growth, but it is better applied to joint pain and sciatica, rather than neuralgia.

4) Harpagophytum procumbens (Devil's Claw) is also good for treating (chronic) joint pain. It contains harpagoside and beta-sitosterol, which have anti-inflammatory properties, and is good for chronic lower-back pain. Doloteffin is a standardized preparation of Devil's Claw. Unfortunately, Devil's Claw promotes the secretion of stomach acids, so side effects involve gastric complications such as ulcers and stomach discomfort.

5) Asperula odorata (sweet woodruff) also has anti-spasmodic and sedative effects.

Concerning the treatment of neuralgia, these supplements (although not tested in a loarge-scale, scientific setting) are good because they promote general health, and also tend to have minor side effects. Rare side effects include nausea and vomiting, as well as allergic reactions to chamomile (if you are allergic to pollen). Lastly, keep in mind that none of these treatments are specifically promoted as a means to aiding neuralgia- the properties they exhibit for other symptoms can likewise be helpful with certain forms of neuralgia.

Looking to purchase these alternative treatments? They should be available at most native remedy or herbal supplement stores. I looked online and had difficulty finding any "name brand," alternative products for neuralgia, although one product "SciatiGon" contains the first four supplements I mentioned above, and claims to reduce nerve pain, specifically for sciatica.

Transcutaneous Electrical Nerve Stimulation: Too Experimental for PHN?

Transcutaneous electrical nerve stimulation, also known as TENS or TNS, involves placing tiny electrodes over the region experiencing pain. The electrodes deliver electrical impulses to nearby nerve pathways, relieving the pain (Mayo Clinic). Unfortunately, the process is very experimental: it does not work for everyone, and in fact can exacerbate the pain. The exact reason for relief is not known, although it is believed that the new electrical impulses trigger the release of endorphins, a natural painkiller.

On their website, Aetna lists the following as medically necessary for postherpetic neuraglgia (PHN): tricyclic antidepressants, gabapentin, pregabalin, opioids (oral), antivirals (oral), lidocaine patch, and intrathecal corticosteroids. However, it decrees TENS "experimental and investigational because their effectiveness for this indication has not been established" (Aetna clinical policy bulletin number 0725). According to the same site, there have been findings that report positive effects of TENS on some patients with PHN, but no validated, randomized and controlled study has been conducted. Additionally, in 1995 Reeve and Corabian evaluated evidence for clinical success of TENS on acute and chronic pain and found the results inconclusive.

Overall, TENS offers an interesting alternative to many PHN treatments; however, it raises the question, why use a treatment with significantly less conclusive results when you can use a less-questionable treatment? Admittedly, one positive reason to try TENS is its few side effects: it's not invasive, addictive, can be used for indeterminate amounts of time, and does not interfere with oral medications. It should not, however, be used with patients who have pacemakers because the electrical signals of the two devices could interfere with one another. The side effects that have been experienced with TENS include skin irritation from the electrode pads, and burns from extended exposure to stimulation. Yet, even with minor side effects, TENS has not proved to be any more revolutionary or helpful than other established treatments. Also, on a personal note, although I recognize that there are still many things about the body's processes that we do not understand, and this lack of comprehension does not prevent them from being effective, I would nevertheless favor a treatment that works through a known mechanism (particularly if it yields the same results).

But on the other hand, simply because we have not developed the treatment or the studies to their fullest extent does not mean we should dismiss it; there can be ample room for improvement. in an effort to give equal consideration to both sides of the TENS debate, it should be noted that although the treatment may be cumbersome and experimental, it nevertheless requires little effort from the patient and could be very manageable for people who do not need to travel much. And, of course, it would be very worthwhile if it eliminated PHN pain.

TENS can also be used to administer topical steroid medication through the skin to treat acute pain, because the electrical current it generates helps move the steroids into soft tissue, reducing inflammation. The TENS unit is battery-operated portable; it can be worn around the waist and can be turned on or off as needed for pain control. They can cost anywhere from approximately one hundred dollars, all the way up to six hundred dollars from the top manufacturers. The units are purchased or rented with a prescription, and a physical therapist should be consulted on the proper placement of the electrodes. Generally, TENS is used on a trial basis before being recommended as a long-term treatment. Of course, before using a TENS unit, be sure you have spoken to a physical therapist or doctor and know how to work the device and set the electrical signals at appropriate levels.

Lidocaine Patches and PHN

Postherpetic neuralgia is a complication of shingles, which occurs when the virus that causes chicken pox remains in the body, dormant in nerve cells. Shingles manifests as rash and blisters accompanied by pain, but sometimes the pain remains even after the skin condition has disappeared. This is postherpetic neuralgia. Although there are a number of treatments, including steroids, painkillers, and even antidepressants, lidocaine skin patches offer one easy-to-use alternative with (usually) no side effects.

In a 1999 blind study conducted by the Education and Research in Pain Medicine and Palliative Care (Beth Israel Medical Centre, New York), researchers found that 78% of the subjects preferred the lidocaine patch treatment over that of a placebo. Simply put, lidocaine patches are small patches (much like band-aids) that contain lidocaine, which can be applied directly to the skin to numb the areas experiencing pain.

Dermaflex and Lidoderm are two leading providers of lidocaine patches, with Dermaflex offering 2% lidocaine patches and Lidoderm offering 5%. Although PHN can be treated as effectively with pills (taken orally), which are absorbed internally, the patch has the positive feature of not requiring an increase in dosage. Another positive aspect of the patch is that it requires less attention: a patient can wear up to three patches at a time, for twelve hours without interruption (followed by twelve hours without the patch). Additionally, because the patch is not absorbed internally but through the skin, it carries an even smaller risk of interacting negatively with other medications. Side effects are minimal and rare; they include: Mild redness, swelling, burning, blisters, bruising, irritation, change in skin color, or numbness at the application site. Risk of cardiac arrest is increased for those on antiarrhythmic medications. Of course, if you experience any effects more serious than these (confusion, dizziness, allergic reaction), consult your doctor immediately.

On the other hand, the negative aspect of the treatment is that the patch needs to cover the skin where there is pain. If the region of pain is larger than the patch, it can still be effective (assuming size difference is not extreme and the lidocaine is applied to the most painful region), but the patch cannot be worn on the face, and many patients find it inconvenient to use the patch if the affected skin is not under clothing.

Lidocaine works by blocking sodium channels in the neuron (nerve cell) cell membrane. These sodium channels are responsible for nerve signal movement among nerve cells, and when blocked, the sodium cannot move in and out of the cell to amplify the sensory signals as they travel through the body. Thus, the action potential of the nerves is decreased and the lidocaine produces anaesthetic effects. The lidocaine patch, because it focuses the area being treated, can selectively treat postherpetic neuralgia.

Glycerol Injections

Glycerol injections offer a low-risk surgical option to patients suffering from trigeminal neuralgia. Glycerol injections are one example of a rhizotomy; that is, a surgical procedure during which selected nerves are damaged to stop pain. Typically, the outpatient procedure is very straightforward: a needle is inserted through the skin (in the cheek, next to the mouth) into the trigeminal nerve near the base of the skull. This is the place where the three parts of the nerve come together and exits the skull. Doctors use an x-ray to confirm that the needle is in place, then they inject a small amount of glycerol, which damages the nerve and thus blocks the pain signal. Throughout the short process (it takes only a few minutes), the patient is sedated intravenously.

One very positive aspect of glycerol injections is their almost immediate effects; the glycerol acts quickly and stops nerve activity within a matter of hours. In a study published with the Journal of Neurosurgery by Harold Wilkinson, eighteen patients with trigeminal neuralgia were given sixty injections of 10% phenol, and "eighty-seven percent of injections brought marked or total relief initially." The downside to this procedure, however, is that the pain often returns for many patients. About half of the patients who benefit from glycerol injections will have recurrent pain within three or four years; glycerol injections can be performed more than once, but they are less effective over time (or with increasing number of procedures). In Wilkinson's study, relief lasted for an average of nine months and most patients requested a repeat procedure. Also, "Of those injections that provided initial relief, 37% still provided relief after 1 year and 30% after 2 years."

The logistics of the procedure are obviously very straightforward, and because it is so non-invasive, there are relatively few side effects associated with the surgery. Adverse effects to anesthesia are minimal (because the treatment is administered within such a short time), and other major problems include damage to the wrong nerve, or a failure to access the trigeminal nerve, as well as bleeding from the puncture site. The goal of the x-ray, of course, is to help target the correct nerve and prevent administering the glycerol to the incorrect site. More commonly, most patients experience mild facial numbness and/or tingling as a result of the damaged nerve, but this fades over time (unfortunately, numbness can persist for up to six months, which is not much shorter than the time frame for which the injection may be effective).

But how does the procedure really work? According to the National Institute of Neurological Disorders and Stroke, "The glycerol injection bathes the ganglion (the central part of the nerve from which the nerve impulses are transmitted) and damages the insulation of trigeminal nerve fibers." Glycerol and phenol (glycerol more commonly) are used as sympathetic blocks for nerve signals. On one hand, phenol dissolves nerve fibers and kills the nerve tissue prematurely (a process called "necrosis,") during which the dying cells do not signal to the immune system as normally-dying cells would do, leading to a build-up of dead tissue. This is why the injection is only administered in small amounts and to very specific regions of the nerve. Glycerol also prevents the nerve from producing signals by breaking up the nerve fibers. Over time, the pain may return as the nerve repairs and re-myelinates (coats) itself, although studies on rats indicate that examination of phenol- or glycerol- affected nerves can be morphologically distinguished from healthy nerves.

Biofeedback: What Is It?

According to the National Pain Foundation, biofeedback "allows you to train your mind and body to control or normalize the way you respond to pain. It makes you more aware of your body and helps you learn how to relax and relieve pain." For people whose pain is the result of stress or muscle pressure applied to all the wrong places, biofeedback offers one form of holistic, "alternative" treatment.

In August 2008, Massage Magazine published an article about biofeedback and "brain training:" "The New Generation of Mind-Body Therapies." Basically, these techniques are responses to the theory that problems like hypertension and anxiety disorders can be controlled by our minds. Rather than exclusively functioning from the autonomic nervous system (which operates the unconscious activity within the body, such as breathing and heart rate), scientists recognize the role of conscious regulation as well. Biofeedback is similar to the placebo effect- not in the sense that it is a "hoax," but rather that the mind can affect the body's physical responses.

But how exactly does biofeedback work? The University of Maryland Medical Center states, "Researchers aren't exactly sure how or why biofeedback works." As disheartening or even disconcerting as this may sound, there is nothing involved in biofeedback techniques that could pose any threat to the patient's well-being; the worst result one could expect to experience would be a lack of improvement. Unfortunately, this may be the case for many neuralgia sufferers. Although biofeedback is listed as an alternative treatment for neuralgia, no studies have clearly linked biofeedback as a solution to neuralgia. Generally, the technique is most effective for people with stress-related pain, so biofeedback therapy would only be useful to patients whose pain is a result of elevated blood pressure or muscle strain. Nevertheless, it is something to consider.

The actual therapy process involves learning to control (not completely, but to a much greater extent) bodily processes such as heart rate, blood pressure, and muscle tension. Electrodes are attached to the patient's skin so that these processes (typically muscle tension, skin temperature, or brain wave activity) show up on a monitor, either audibly or visually. The therapist leads the patient through mental exercises (usually intended to relax the person or focus their thoughts) until the patient can learn to identify the mental exercises that trigger desired responses. For example, in the case of urinary incontinence, a person can overcome their loss of bladder control by learning what muscles need to be contracted. For pain or stress, the therapist can use the monitor to detect where a patient is tense, and then pinpoint what thoughts or feelings cause tension. Ultimately, the goal of the session is to help the patient become more aware of processes that normally occur unconsciously, so he or she can react to them consciously.

As stated above, one of the best things about biofeedback is that there are no side effects; however, its usefulness for neuralgia patients is yet to be determined (unless your pain is distinctly stress-related). Although sessions range in technique and length depending on the biofeedback specialist, they are typically shorter than an hour. Some patients claim to see results within 8 weeks (one session per week), but treatment generally requires at least ten weekly sessions- and at least twenty for conditions like high blood pressure. The mental exercises, however, are techniques that the patient can use independently, outside the session. Cost for each session can be anywhere from about $35-$85.

From the University of Maryland Medical Center: "Specialists who provide biofeedback training range from psychiatrists and psychologists to nurses, dentists, and physicians. The Association for Applied Psychology and Biofeedback (www.aapb.org) is a good resource for finding qualified biofeedback practitioners in your area."

TN and the Myth of Upper Cervical Care?

In 1997, author James Tomasi treated his trigeminal neuralgia with upper cervical chiropractic adjustment and was cured of his pain; he subsequently published the book "What Time Tuesday," detailing his experiences with TN, the pain that almost drove him to suicide, and the procedure that cured him.

According to the NUCCA (National Upper Cervical Chiropractic Association), upper cervical care procedures were developed more than forty years ago and, since that time, have gained popularity within the medical community. Generally, upper cervical corrections involve adjusting the large, first vertebrae of the spinal column, called the "atlas." When misaligned- either from everyday activities over time, or trauma to the neck- the atlas can compress the brainstem and cause pressure where previously there was none. The pain of a misaligned atlas can manifest itself in many different ways, and patients with everything from back pain to indigestion have experienced some positive results with upper cervical correction (UCC). Ideally, when a chiropractor corrects the atlas alignment, he (or she) helps straighten the spinal column and removes pressure on any nerves that the misaligned bone may be pressing.

The procedure seems to offer viability for TN patients because it deals with pressure at the base of the brain, near the brain stem, which is the region more invasive techniques- such as microvascular decompression- address (this is where the trigeminal nerve exits the brain). Yet, it is only recently that TN has been treated with UCC. Why? First, there have not been clinical trials that evaluate the connection between TN and upper cervical corrections, and there are no statistics to gauge the success rates of such procedures for TN patients. Second, there is a lot of political tension between the medical and chiropractic community. Seemingly floating between "alternative" treatments and medical procedures, the niche that chiropracticity has carved for itself is very self-contained; because of this, little advertisement is made for chiropractic treatments. Third, not many TN patients seem to have used UCC to treat their pain, so testimonials are few and far between (except, of course, Tomasi's book). Because of all these reasons, it seems difficult to even offer an opinion as to whether the upper cervical correction is worthwhile. Personally, I would tend to avoid such techniques, but I fully recognize that much of that tendency is simply a result of the doctor-vs.-chiropractor bias. There are many cases in which chiropractors are the only viable option (a misaligned spine, for example), but for many people (myself included), the breadth of symptoms that chiropractors can cure makes it seem more "holistic" and less precise.

But that is not fair to the chiropractic field. The spinal column is a central part of the human anatomy, and its involvement with so many physiological roles means that its negative effects can manifest themselves in many places and many ways. Those who have experienced chiropractic treatment- specifically, UCC- can testify that the process is very thorough, with little guesswork involved (assuming the chiropractor is qualified and by-the-book). There are a number of different techniques to re-align the atlas (which can vary from chiropractor to chiropractor), but many involve the use of a "percussion adjusting instrument" which applies a precise, split-second sound vibration to one end of the atlas (just below the ear). This generates a slight pressure (about 3 lbs) that causes the vibration to move through the atlas to realign it. The instrument itself resembles some kind of power tool- an electric drill, perhaps- but the procedure is painless; the patient only feels a slight pressure like a brief tap or massage. The "stylus" on the instrument (the rod that applies the pressure) can be aimed to a particular degree, based off x-rays taken before the procedure.

There are a lot of positive aspects to UCC: it is painless, eases symptoms almost immediately, and there are few side effects. Although the procedure does not involve any cutting or other invasive techniques, however, it is important that your chiropractor be meticulous and well-qualified. The spinal column, for all its strength, is a delicate instrument, and further damage can create even more drastic problems; for example, pressure to a nerve can increase pain, and pressure to a vessel can cut off blood flow, causing a stroke. The negative aspects of UCC- besides its side effects, which result primarily from negligent chiropractors- include the cost of the procedure over time. Ideally, one would only need to have their atlas corrected once (cost for this includes the cost of x-rays, but varies from chiropractor to chiropractor), but the treatment can also entail repeated visits if the patient continually misaligns his/her spine. Luckily, this can often be avoided with basic preventative measures, such as not falling asleep on the couch or with one's head at an awkward angle. Ultimately, in the search for relief from TN, UCC may be included in the list of possible treatments, particularly as a non-invasive alternative with few side effects. With the low risk, UCC may be a reasonable option to try before surgery.