Operative procedures.
Intracranial procedures for trigeminal neuralgia were formerly associated with so high a rate of mortality that they were not regarded with favour. Of recent years, however, as the result of the general improvement in technique, it has been clearly demonstrated that, in experienced hands, ‘the ganglion can be readily exposed, hæmorrhage and shock need no longer be considered elements of danger: the risks of the operation are only those associated with every major operation. Recovery from the effects of the operation is rapid; the patients are frequently up and about on the third or fourth day, and the ultimate results are, to say the least, most gratifying to the patient and to the operator.’[74]
The following operations require consideration:—
1. Intracranial resection of the second and third divisions of the fifth nerve (Abbé’s operation).
2. Operations for the removal of the whole or part of the Gasserian ganglion (Hartley-Krause operation and its modifications).
3. Operations on the sensory root of the ganglion (Frazier’s operation).
Intracranial resection of the second and third divisions of the fifth nerve and operations on the ganglion itself resemble one another so closely in their preliminary operative stages that they may be considered together. After the usual preparatory treatment—in which the shaving process may be confined to the temporal region—the incision, commencing well above and behind the external angular frontal process, passes backwards below the level of the temporal crest and terminates immediately in front of the tragus of the ear. The front part of the incision, as depicted in [Fig. 91], is prolonged too far downwards. It should not be carried further forward than the anterior margin of the hairy scalp, any further downward prolongation tending to involve that branch of the facial nerve which is distributed to the anterior belly of the occipito-frontalis muscle.
The incision, carried out methodically, first involves the skin only, pressure being applied by the surgeon on the one side and his assistant on the other, so as to control bleeding. All divided vessels are at once clamped. The operation may be a prolonged one, and in its later stages bleeding from meningeal vessels and emissary veins may not be so readily controlled. It is essential, therefore, that the earlier stages should be as bloodless as possible.
Fig. 90. To illustrate the Operations on the Gasserian Ganglion. s.f., sphenoidal fissure; f.r., foramen rotundum; f.ov., foramen ovale; s.s., Frazier’s operation on the sensory root. The dotted line = the line of section in removal of the lower two-thirds of the ganglion (Jonathan Hutchinson’s operation). The shaded portions = parts removed in intracranial resection of the second and third divisions of the nerve (Abbé’s operation).