A Conversation with John Alksne, MD about Dr. Jannetta’s Historic First MVD surgery

By Mervyn Rothstein

John Alksne, MD, is a distinguished neurosurgeon and highly respected researcher in neurological disease. Dr. Alksne is the former Chairman of the Department of Neurological Surgery at UCSD and a member of the FPA Medical Advisory Board.

“The patient woke up. And he had no face pain.”

That’s Dr. John Alksne, recalling the day in 1966 when he was the attending neurosurgeon for Dr. Peter Jannetta in the historic first microvascular decompression surgery, to treat patients suffering the excruciating pain of trigeminal neuralgia – a procedure in which an impinging blood vessel is separated from the trigeminal nerve and a Teflon sponge is placed between them.

Fifty years ago, Jannetta (who died last year at age 84) published his landmark first paper describing that pioneering surgical procedure, and Alksne is talking about that surgical moment – and how it came to be – in honor of that anniversary. Alksne, now 83 years old, is a famed neurosurgeon and researcher in neurological disease. He is a professor of surgery in the division of neurological surgery at the University of California, San Diego, School of Medicine; he was founding chief of the medical school’s neurological surgery division as well as former dean and vice chancellor for health sciences at the medical school.

The first microvascular decompression surgery was performed at Harbor General Hospital, a county hospital in Torrance, California, in southwestern Los Angeles County, that was affiliated with the University of California, Los Angeles. “I was on the U.C.L.A. faculty, but I was based at Harbor General,” Alksne remembers. “It was my first job. I had finished my residency in Seattle in 1963 and had been offered this position by the chairman of neurosurgery at U.C.L.A. Mostly I took care of neurosurgical problems that came in through the emergency room.”

When he was a resident in Seattle, he was “interested in trigeminal neuralgia, because we knew that it was a founding signal of neurosurgery, because people were so desperate with this pain before there were good treatments, and we didn’t have very good medicines at that time,” Alksne says. “We were taught to do a sitting subtemporal extradural approach to the trigeminal nerve, and then follow it up to the base of the skull and then make a cut in the nerve to try to stop the pain. But that would produce a lot of numbness, so patients didn’t particularly like it. When I was in Seattle, my chairman had the idea, and talked me into it, to convert from cutting the nerve to traumatizing the nerve, the idea being that if we traumatize the nerve cells in the ganglion, then some of them would die and might cause some scattered numbness in the face but not as much as you get when you cut the nerve. So we had done those cases.”

Trigeminal neuralgia, though, was still a mystery. “There was no other pain like this,” he says. “It is triggered by a touch, a non-painful touch, and it responds with this electric shock.” Experimenters were trying to understand the neurophysiology of it; “we were trying to understand how to stop it.”

When he got to California, even though he was younger than Jannetta, Alksne was an attending surgeon, and Jannetta was still a resident. The two would talk about trigeminal neuralgia, and “I was very impressed with him,” Alksne says.

Peter Jannetta, MD

Jannetta rarely came to Harbor General. “The chief resident and the upper residents stayed at U.C.L.A., which had much more volume, much more diverse patient care,” Alksne recalls. “But we had joint grand rounds every Saturday morning. Three Saturdays a month I would go up to U.C.L.A., one Saturday everybody would come down to Harbor General. There was no question in my mind that he was the most dedicated and well read of all the residents, and he was very interested in trigeminal neuralgia. He was quoting frequently the reports by Dr. Walter Dandy, back in the 1930s and 1940s, describing patients with trigeminal neuralgia.

Dandy’s innovation “was the idea that instead of doing the standard subtemporal extradural approach, to do the posterior fossa approach, so you can see what’s happening. His reasoning was that some of these patients had small tumors, small meningioma, and you could relieve their pain by removing the meningioma. But we never did it.”

But Jannetta was very impressed. “There were diagrams, there were articles written by Dr. Dandy that were in the literature, but 90 percent of neurosurgery residents didn’t read them. But Peter did.”

When there wasn’t a tumor, “Dr. Dandy had noticed that there were lots of blood vessels around the trigeminal nerve where it entered the brain and warned people about being very careful if you’re going to do the posterior approach to get these arteries out of the way because you could cause a stroke.” Jannetta told Alksne that “he had done cadaver dissections on ‘normal’ patients and never found the abnormality that Dr. Dandy had described in his posterior fossa explorations.” Jannetta decided that a blood vessel impinging on a trigeminal nerve might be the reason behind trigeminal neuralgia.

But the chairman of neurosurgery at U.C.L.A. refused to let Jannetta do a posterior fossa exploration on a trigeminal neuralgia patient. “Dr. Jannetta was complaining to me about that – the chairman is so rigid, he wants me to do it the old-fashioned way, the subtemporal extradural approach, but when you do that you don’t see the part of the nerve that Dr. Dandy was talking about. All you see is the part that’s in what we call Meckel’s cave,” the area that houses the trigeminal ganglion.

Jannetta was frustrated, Alksne recalls. “He was in his chief residency year, he had gone to all these meetings, he had given talks about his findings, and he wanted to explore a posterior fossa approach.

Then, one day, Alksne “had a patient with trigeminal neuralgia come in through the Harbor General emergency room, a county no-insurance patient, and the doctors in the emergency room called me to see him. I went down and he had excruciating trigeminal neuralgia. He was in his mid-50s and he would agree to anything to get rid of his pain. I called Peter and I said, I think we have a patient, you can join me and we can do a posterior fossa approach.”

But Harbor General didn’t have operating microscopes. “Harbor General was a poor man’s hospital. The only person who had his own operating microscope at U.C.L.A. was Dr. Robert Rand. He was the son of a former neurosurgeon, and he had a busy practice and enough cash flow so that even though the hospital wouldn’t buy him an operating microscope he bought one himself. Dr. Jannetta had to call him and say, Hey, this is an opportunity. Dr. Rand had to go to the U.C.L.A. hospital, get his microscope and put it in the back of his car. Which meant taking the microscope apart, because these come with stands and arms that reach out over the patient. It’s not like your standard bench microscope. So it wouldn’t have happened without Dr. Rand. We got it all put together, set up and ready to go.”

The next day, Jannetta and Alksne “scrubbed in. I had consented the patient for partial section of his trigeminal nerve, because that was the standard of care and what we would have to do if we didn’t find anything. But that was O.K., and the patient was quite happy with whatever approach we wanted, to take care of his pain.”

Jannetta had devised his approach, “not what I would consider the standard posterior fossa approach. Sometimes we did trigeminal sections for patients with cancer through the posterior fossa, but we were coming in under the cerebellum and working our way up. But Peter had developed this plan in the cadaver lab to start out as if you were doing it in a more traditional way and then open the tentorium so we would be able to go into the posterior fossa without exposing it in the temporal fossa. And we would see the trigeminal nerve come out of Meckel’s cave and go across to the spinal fluid and into the pons,” in the brain stem.

Alksne was scrubbed and helping, but Jannetta “was doing the procedure. I had never done one. And when we got to the trigeminal nerve, lo and behold there were looping vessels impinging and distorting it. I saw it, I remember it, I know it.”

Jannetta “dissected the vessels off the nerve, and separated them away.” (No Teflon sponge was used for this first procedure.) “He was very excited, because it was exactly what he expected, what Dr. Dandy had described and drawn pictures of in his article. But then he was nervous – what if the guy woke up and still had his trigeminal neuralgia? We talked about it and we agreed, that because the patient was consented for a partial trigeminal nerve section, we did a partial trigeminal nerve section, even though Jannetta had seen what he wanted to see and had done what he wanted to do.

The surgery was complete. And “the patient woke up. And he had no face pain. We knew that we had solved the problem by moving the vessel. But we also knew that we solved part of the problem by making a small cut in the nerve.”

When Jannetta wrote his first papers, or gave talks at his first few conferences, Alksne recalls, “there was a negative reaction in the neurosurgical community, because people said you may have just been damaging the nerve by trying to move those vessels. That doesn’t mean that those vessels caused trigeminal neuralgia.”

But future surgeries, refining the procedure – adding the Teflon sponge – and eliminating cutting the nerve, and the success of those surgeries, proved that Jannetta was right. It all began more than 50 years ago, and microvascular decompression continues to eliminate devastating pain in thousands of victims of trigeminal neuralgia – and give people back their lives.

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