AN INTERVIEW WITH PROF. UGO DELFINO: ALL ABOUT TRIGEMINAL NEURALGIA

It all began 7 years ago; when I was walking along, suddenly and without warning, I was struck by what seemed to be an electric shock that, for about 15 seconds, drove unbearable pain through me, on the left side of my jaw and, from then on, for a long five years, it happened again and again, five or six times during the day. I consulted dentists, neurologists, pain therapists, who, with drugs and also with local anaesthetics in my lower jaw, sought to give me some temporary relief, creating a state of mental confusion, however, which took away my desire to work. Then, finally, I saw a light in this dark and painful tunnel; insofar as an anaesthetist friend, Prof. Fanchiotti, told me about Professor Ugo Delfino, formerly the head physician at the Centre for Pain Therapy at the renowned Molinetti hospital in Turin; who had retired but was involved and still deals with minimal, non-invasive surgery exclusively aimed at resolving trigeminal neuralgia. I believed in him, trusted in his professionalism in this field, I had an operation finally ending my long ordeal. Today, fortunately, God willing, I’m fine and I live a normal life.

Dr. Giorgio d’Ausilio, “Our Health”, aired on Radio Orb..

THE FOLLOWING IS A BRIEF EXTRACT FROM THE INTERVIEW:

Professor Delfino, so: what I would like, straight away: is that you explain to our listeners when, where and why trigeminal neuralgia occurs – but, above all: what is the reason that it happens.

“For now, we have to say that trigeminal neuralgia almost always arises (as you have already disclosed) with a sudden and violent, very painful shock – always this – that is very short and affects a part of the face. Some causes are very well known although many are not: diseases of the mouth but especially those of the teeth – and I refer to neglected teeth, bad teeth, chipped teeth – can be a good trigger of trigeminal neuralgia, just because the branches of this nerve reach our teeth; but there are also neurological diseases. Take multiple sclerosis which is almost always associated with trigeminal neuralgia: many patients not only suffer from multiple sclerosis but, over the years, also have the surprise of this new visitor. Then there are dysmetabolic disorders – which are likely causes; circulatory diseases; and there are so many other causes that, practically, we do not understand precisely.”

Can we say, Professor Delfino, that the increased frequency of trigeminal neuralgia at this time is also due to the ever-increasing life expectancy that could be a contributing factor.

“You explained it very well: we know that trigeminal neuralgia predominantly affects the elderly and old age is when we see neuralgia and predominantly between 60 and 80.”

From what is your tremendous experience of thousands of cases on various possible surgical treatments, what are the techniques most in use today and what are their results?

“It’s what I think is the “crucial “question; because there are a number of techniques of methodology. But we must look at them in their entirety: that is to look at the merits and disadvantages; and so, as I have said before, assuming that in trigeminal neuralgia the affected ganglion does not heal either with drugs or with surgery, the most suitable, effective procedure these days is only the most targeted, less invasive and safer method; because it has limited side effects, it is reversible; and it can last for sometimes 20 to 30 years. This has to be said because there are other methods, much more invasive, sometimes very dangerous (because the complications are sometimes a disaster); but there are other smaller, less invasive procedures, but when they aren’t carried out perfectly, they leave irreversible damage – I mean: the devastating burning sensation that can’t even be alleviated with drugs. Patients are forced to take morphine daily and continuously. That is, we see patients who, with simple trigeminal neuralgia treated these ways, end up in the ranks of drug addicts precisely as a result of the treatments.”

… because they end up taking morphine, essentially.

“Thermotherapy is burning. Now, if the burn is made in the correct place, it has a perfect temperature and is for the perfect length of time (so there are three variants), the procedure is perfect. Instead, we are talking about those who have not had these three variants correctly. You see: these are pain-suffering patients for the rest of their lives. This is the tragedy in the choice of method.”

Precisely in this context, I ask you: where and how is this problem addressed surgically? You said a while ago that you cannot talk of “healing” trigeminal neuralgia – but then I ask: why has the pain gone? Can you explain why the pain disappears with your surgical technique and clarify once and for all how does it work? You even said before that you could extend this absence of pain for even 20 to 30 years – so after a while the problem, in theory, could reappear…

“The trigeminal nerve has branches that affect our entire face. These branches converge on a ganglion: the Gasserian ganglion. This ganglion is inside the skull. The sensory nerves that lead to the ganglion are not all the same – there are sensory nerves of different types: motor nerves, touch-sensitive nerves, pain-sensitive nerves. The first two, motor and touch sensitive (tactile), are bigger nerves – outside is the myelin that covers and protects them. The pain-sensitive nerves – the thinner nerves, the C nerves, – have no myelin coating. When we reach the ganglion and administer a minimum dose of ethanol (which is 95% alcohol), the most delicate nerve fibers, i.e. the C nerves, are damaged. That is why the patient, after one week, no longer feels the pain, resumes their motility, perfect just as before, even the tactile component.”

So, it’s essentially (I use a somewhat journalistic term) “interrupted” a certain connection.

“Yes, to understand the trigeminal nerve function, you have to imagine an electrical circuit. You break the wires in a certain area, so the stimulus starts from the periphery but arrives at the ganglion and there, there is the interruption created by ethanol, administered at a minimum dose. Your question, however, also included another aspect, that is, the technique. The technique, unlike the others, is to reach, in the sedated patient with fluoroscopy, and so under radiology, a natural hole called the “foramen ovale” which we have at the base of the skull, more exactly in the sphenoid bone; and a needle passes through this 5 mm hole and the tip of the needle is brought 4-5 mm deep within the ganglion. So without cutting, without injections, without risk, in an easy way and, therefore, unfelt by the patient, we reach the ganglion. We administer a dose of 0.2 milliliters of ethanol, which corresponds to 3 drops, a minimum dose but centered on the ganglion, and we have a benefit that can last 20-30 years.”

Sure. It is therefore essentially surgery that is not invasive.

“It’s not invasive, because the needle travels under the cheek under observation, so it’s not a needle that is wandering around our head, in our cheeks. It’s a needle that is inserted into the cheek when I can already see the hole. So the whole brain, the whole nervous part, does not realize what’s going on – so obviously there is no risk.”

May I ask you another thing: is this procedure quick, or does it take some time…?

“As I mentioned before: uncoated nerves are the pain-sensitive nerves, which are thinner ones and the damaged ones. By treating these nerves, takes away the pain. Over the decades, our body repairs them – so it may happen that the nerve repairs itself and the procedure can be repeated. While, instead, with the other methods this does not happen because: the body repairs chemical damage but there is no possibility of repairing thermal damage, burning. So there is an extraordinary, remarkable difference: one is chemical damage reversible over the decades, the other is an outright block.”

Have you ever seen the arrival of patients, operated on using different techniques, to whom after, various problems have arisen? That is, in those patients, my understanding is that it is very difficult for you to do something. Or are the post-operative damages that you see really irreversible?

“The point is exactly this: more and more frequently we see patients who have undergone operations that have created insensitivity in the treated area or, worse still, cause a continuous burning sensation in the area where the trigeminal nerve damage was done. These are the patients, in increasing numbers, for whom nothing can be done, in which the damage was excessive. The burn no longer has any chance of being repaired, neither with drugs or surgery, nor with the time.”

I would like to conclude by asking a final question: if you, Professor Delfino, unfortunately ended up with trigeminal neuralgia; Okay, so, what surgical procedure would you accept for your illness?

“I reply with all frankness: I hope some of my colleagues learn my method; because I know that with that, at the worst, if it doesn’t make me well, it won’t harm me – but I’m sure that, made with the simplicity and precision I’ve been doing all these years, the benefit for me will be certain, because the method is safe, minimally invasive and there is no risk of any complications.”

That’s it. Thank you Professor for everything you’ve told us, thank you all for your kind attention and until the next time, everyone, in the next episode of Our Health. Goodbye.

“Thank you, Doctor.”