Article Type : Editorials
Authors : Mayukh Pandit
Keywords : Neurovascular Compression Syndromes
The word neuro comes from ancient greek, a combining
form meaning nerves and nervous system which builds the compound word:
neurology [1]. Nerve could be defined in simple terms as whitish fibers or
bundle of fibers that forms a part of the system which transmit impulses of
sensation, motion and other stimuli to brain and spinal cord and impulses from
these to muscles and organs. Our brain is the most complex organ of our body
and this complexity of relying information between brain and different parts of
body primarily to and from regions of head and neck including sense of vision,
taste, smell and hearing which is directed from brain by Cranial nerves. Sometimes compression in these cranial nerves could
lead to develop serious chronic vascular compression disorder due to vascular
structure. Compression in nerves could lead to demyelination which leads to
further damage of axons. So, neurovascular compression syndromes are vascular
compression disorder where cranial nerves are compressed due to abberant
vascular structures which directly contact the cisternal portion of nucleus.
Neurovascular compression syndromes most commonly affects the transition zone
between the central and peripheral myelin [2].
There are several forms of neurovascular compression
syndromes known out of which the most common ones are Trigeminal neuralgia and
Hemifacial spasm wheras Geniculate neuralgia, Nervous intermedius neuralgia and
Vestibular Paroxysmia are the less common ones. All this forms of Neurovascular
compression syndromes are chracterised by functional disturbances of cranial
nerves.
Trigeminal Neuralgia
Trigeminal neuralgia is among the most common
Neurovascular compression syndromes known characterized by sudden paroxysmal
attack of pain lasting from few hours to several days and confined to
distribution of one or more divisions of trigeminal nerve. International
Headache Society defines Trigeminal neuralgia as painful unilateral affliction
of face characterized by brief electric shock limited to divisions of
trigeminal nerve [3].
This chronic disorder affects more in women than in
men. Trigeminal neuralgia usually arises from blood vessles typically Superior
Cerebellar arterty which compress the 5th cranial nerve when it
exits the brain stem. This compression causes damage to protective covering
present around the myelin sheath. This injury to myelin sheath are known to
cause suffering of pain which becomes unbearable and patients develops
psychiatric disorders which is followed by development of suicide ideation in
patients. Hence it is also called Suicide
disease because it is believed more than 50% of people commits suicide who
are suffering from this disorder.
Hemifacial Spasm
Hemifacial Spasm also known by the name as Tic Convulsif which are characterized by
irregular and involuntary contraction of facial muscle [4].
Hemifacial spasm usually arises due to offendation of
facial nerve by Anterior Inferior cerebellar artery, due to tumor or injury. It
was first demonstrated and described by Glovers in 1899. This begins with
clonic movement of orbiculis oculi and spreads to corrugators, frontalis,
orbiculi oris, platysma and zygomaticus progressively with years [5]. This
disorder affects more in elderly women wheras frequency is less in men. The
incidence of Hemifacial spasm is approx 0.8per 100,000 persons [6]. This form
of neurovascular compression syndromes are usually observed more in the
subcontinent of Asian countires.
Glossopharyngeal Neuralgia
Glossopharyngeal neuralgia also known by the name as Eagle’s syndromes characterized by brief
stabbing electric shock like pain felt in throat area , back of tongue, or
middle ear and as well as in tonsils. This neuralgia is among the most rare and
less common ones. Glosspharyngeal neuralgia arises due to compression of
glosspharyngeal nerve offended by blood vessels when they exit the brain stem.
This occurs due to trauma, surgical procedure, tumors, and vascular
abnormalities or sometimes due to infections as well. This disorder also affects
more in women than men, usually middle aged and older. The pain due to this
syndrome would be triggered while performing activities like swallowing,
speaking, laughing, chewing or coughing [7]. The duration of this pain would
lasts from few seconds to minutes and will usually affect on one side of face.
Nervous Intermedius Neuralgia
Nervous Intermedius neuralgia also known by the name
as Geniculate neuralgia. This usually
arises from vascular compression which mainly occurs in nervous intermedius by
anterior inferior cerebellar artery. Nervous Intermedius neuralgia was first
discovered and demonstrated by John Nottingham. This is one of the most less
common syndromes which occurs with severe and sharp unilateral peri-auricular
pain and is most often described as ‘ice-prick in the ear’ [8]. The
International Headache Society defines this neuralgia as episodes of pain
usually located deep in the ear which might last for seconds or minutes and are
often triggered by sensory or mechanical stimuli at posterior wall of auditory
canal without any pathology.
Vestibular Paroxysmia
Vestibular Paroxysmia is among the rarest of
neurovascular compression syndromes which occurs due to vascular compression of
vestibular nerve by blood vessels mainly a loop of Anterior Inferior cerebellar
artery. This disorder was first described by Janetta in 1975 as ‘disabling
positional vertigo’. The symptoms of vestibular paroxysmia includes short
attack of spinning or non-spinning vertigo, which would usually last few
seconds to minutes and occur in a series of upto 30 or more everyday [9].
Vestibular Paroxysmia is one the most controversial syndromes known.
Treatments
The treatment of neurovascular compression syndromes
starts with therapeutic medications at initial stage of this disorder and once
it advances requires surgical procedures for permanent cure.
Medications which are used to treat almost all forms
of neurovascular compression syndromes and are found to be very effective in
controlling the pain and providing relief initially includes [10]:
·
Carbamazepine
·
Baclofen
·
Phenytoin
·
Gabapentin
·
Clonazepam
Carbamazepine is considered as the drug of choice
because it provides very good relief of symptoms initially. But adverse effects
such as hyponatremia are usually observed which may necessitate the
discontinuation of medication. Also this medication provides relief of symptoms
for very short period of time. So, the affected patient would require operative
procedures for long term pain relief.
There are various major and minor surgical procedure
known which are employed to cure Neurovascular compression syndromes for long
term basis of pain relief. Among all the surgical procedure known ,
Microvascular decompression surgery [MVD] have shown the highest pain relief
period of 12-15 years or more. In 1967, Dr Peter Janetta have introduced this
surgical procedure and reported his study in ‘The New England Journal of
Medicine’ . It showed that initial success rate was 82% for complete pain
relief [11]. The main objective of MVD was to separate the offending nerve from
vascular structure by placement of Teflon sponge. Teflon sponge isolates the
nerve from pulsating effect and pressure of blood vessels. There are very
serious complications of MVD widely reported for Trigeminal neuralgia and Hemifacial
spasm such as intracerebellar hematoma with acute hydrocepahalus, status
epilepticus , subarchnoid hemorrhage and also possible infections of brain stem
[12]. Also Teflon could be one of the major causes of recurrence which have
been reported to cause a condition known as Teflon
Granuloma after 5-10 years of operation. Teflon Granuloma both clinically
and pathologically could emulate malignancy. There are also some adverse
reactions observed from Teflon such as frontalis muscle suspension in TMJ surgery
as well as pericardial closure in rheumatic heart surgery [13].
So for proper cure of Neurovascular compression
syndromes one must aim at repositioning of affected cranial nerve with better
alternative which will not produce any adverse effects and would cure
permanently. Working hard on this specific disorder for years observing and
specifically working in innovation of better alternative which would cure all
forms of neurovascular compression syndromes without any adverse outcomes and
with null complications. I designed and invented a surgical implant named as
‘MOLUMA’S’ Surgical Implant which would be able to cure this disorder on
permanent basis with very minimal complications. This invention is named after
my beloved parents Moloy and Uma whom I want to express my heartiest gratitude
by curing and saving lives of sufferings. MOLUMA’S Surgical Implant would be
ensuring proper separation of offending structures and will resist all forms of
displacement along with protecting the surrounding anatomical structures.
MOLUMA’S surgical procedure is designed on the bias of robotics which would be
able to resolve all complications and would produce the best result in terms of
permanent pain relief. I believe healthcare facilities should be made
accessible and affordable to every life residing in perspective of cost. I am
working; innovating, improving and improvising more so that MOLUMA’S Surgical
Procedure would be cost-effective approach so that everyone would be get
treated from these severe painful disorders efficiently and on permanent basis
without any form of major complications and recurrence.
Apart from cure of Neurovascular compression
syndromes, I am working in other fields of incurable disease and innovating
their cure on permanent basis with minimal complications and more importantly
making it very low cost effective ones, so that we could proceed to an era of
‘disease-free’ world with no sufferings from pain and where each and every one
of us can get cured permanently and lead rest our lives prosperously.