The Surgical Reconsideration

Representative Image

Please, could you turn off the air conditioning?" an elderly gentleman requested in Urdu, as he gingerly sat on the chair in front of me, his wife helping him make the final adjustments. I instantly obliged by switching it off and he acknowledged the act by placing his hand on his heart and nodding his head. He was in his 60s and adorned a white kurta. His eyes looked troubled and were brooding with grief that I wanted to know the source of. "I have an intense pain over the left side of my face," he mumbled, keeping his mouth half closed. "If he opens his mouth more than this, he gets an electric shock down his jaw, sometimes his nose, and even his forehead," his wife explained.

A few medical students interested in neurosurgery were sitting in my office, and I asked them to pay close attention to the patient's history, as I had already made my diagnosis. "He can't touch the left side of his face," his wife continued. "He can touch his right forehead, can rub his right eye, dig his right nostril, but nothing on the left," she narrated as her husband performed all these actions. It was like watching an elderly couple play dumb charades. "He hasn't washed the left side of his face in a while," she concluded. "I haven't shaved in months," he added, pointing to his long glistening silvery beard.

"Even the air of the fan bothers me, and that's why I asked you to turn off the air conditioner. It sends shivers down my spine even if it whiffs past the left side of my face," he said in Urdu, to which the above English translation does no justice.

I wanted to examine him, but he didn't allow me to touch his face. He had poor oral hygiene because he couldn't brush on the left. I turned my gaze to the medical students who had just completed their final year and raised my eyebrows, asking them for a diagnosis. "Trigeminal neuralgia," one of them jumped. "Correct," said the patient's wife, having heard this term umpteen times since they had made the diagnosis three years ago. "He takes 14 pain killers a day, four in the morning and afternoon each and six at night," she said. Even I was shocked. They had tried an injection into the trigeminal nerve, which hadn't worked, and even had a single shot of radiation to the nerve two years ago. Both of these are valid treatments of this condition, but as I studied the MRI in detail, I explained to them that surgery seemed to be the only resort. I pointed out a loop of a dilated and tortuous artery pressing against the trigeminal nerve, and with every heartbeat, it was pulsating against the nerve, sending a current down the distribution of the nerve, which was the entire face.

"We will do everything but we won't have surgery," he gently placed both his palms on the table. "We have lived with this pain, we will die with it," he ordained, as if it was the will of God. The medical students, one of whom was from Ukraine and the other from Kenya, were surprised. I explained to them that India is a vast country and its citizens had varied religious and cultural beliefs, which we must regard and accept respectfully without being judgmental. But I really wanted to help this man, so I came up with an explanation in Hindi that hit close to home.

"Imagine that someone has placed a humongous rock on your chest because of which you can't breathe. Any amount of oxygen or intravenous pain medication is not going to help unless I physically lift that rock of your chest," I simplified. The artery pressing against the nerve was the rock on his chest. Most of us carry that rock metaphorically, and I wanted to say that but I didn't know how in Hindi. I'm guessing you might try to do that too, as you read this.

Amidst the explanation, he had another attack of sharp-shooting lancinating pain, but was unable to wipe the tears that rolled down the left side of his face. We waited till they stopped. After three or four minutes of silence, he said. "We will do the operation." The medical students were excited because they would get to watch what they were googling on their phone. We admitted him the very next day, lest he changed his mind.

Two mornings later, we fixed his head on a clamp and positioned him on his side, so we could make an incision behind his ear. I made a bony window and opened the covering over the cerebellum, which I gently retracted after draining some holy water, more specifically and technically called cerebrospinal fluid. I exposed a little more than usual because I wanted to show all the cranial nerves to the medical students who were watching on a screen what I saw through the microscope.

"That's the hypoglossal nerve," I said, pointing to a thin glistening structure at the base of the skull. "It helps you move your tongue. If it comes into my suction, he'll have half his tongue paralysed." I moved up to the vagus nerve. "That's the nerve that makes your heart skip a beat or race furiously when you're in love," I continued, adding some spice to keep them glued. "I wish I could burn mine," muttered one, who was just recovering from heart break. I quickly moved up to the facial nerve.

"That's what makes you smile," I pointed, and then, finally we reached our target. "And that's the trigeminal nerve. Looks how it is pushed up from below almost like a tumour sitting within it." I gently teased all the arachnoid strands around the nerve and painstakingly mobilised artery from the nerve, making sure nothing snapped. After having separated the two structures that, until a while ago, looked like conjoined twins, we placed a pad of Teflon to make sure the artery didn't bounce back onto the nerve. I inspected the nerve with an endoscope to ensure nothing else was touching it. "And we're done," I pronounced to the students still gawking at the screen with their mouths wide open.

"Dr Peter Jannetta invented this operation in the 1960s," I told them as we closed. "Often, patients go first to dentists with this problem and sometimes get cavities filled and root canals done with no pain relief. Most dentists nowadays are very astute and instantly identify this condition correctly for what it is. But in the past, I've even had a patient who was advised a jaw replacement surgery to relieve this pain," I told them, as they listened, engrossed, to how tricky the diagnosis can be.

I went with the entire entourage to see him in the ICU a few hours later, when he was fully awake. His pain had gone completely. He dug his palm deep into the left half of his face, rubbing his eyes and forehead to prove it. The medical students were in awe. "It's one of the most rewarding operations in neurosurgery and we have Dr Jannetta to thank for that."

The next morning when we walked into his room, he sat reading the newspaper after having brushed and shaved for the first time in months. "You've given me a new life," he burst out in tears, but this time, he was able to wipe them off on his own without a worry. I embraced him. "It was the will of God that we could do this for you," I said prophetically in Urdu.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.