THE TREATMENT OF TRIGEMINAL NEURALGIA BY THE

CEREBELLAR ROUTE
BY WALTER E. DANDY, M.D.
OF BALTIMORE, MD.

THIs report is concerned with the treatment of trigeminal neuralgia by

the subcerebellar route. Soon after its inception a report of the procedure
was read by title at the Richmond meeting of the American Neurological
Association in 1925. At that time its advantages had not yet appeared, and
the old Hartley-Krause procedure as modified by Spiller and Frazier and
others was such a satisfactory and safe procedure it was not then considered
to be a substitute for this widely used method of attack. Gradually, how-
ever, as the cases multiplied, it was discovered empirically that most of the
liabilities which followed the temporal route did not obtain when the nerve
was sectioned by the cerebellar route.
In the Archives of Surgery, in I929, a report of the first eighty-eight
cases was presented. At that time the advantages of this method had become
apparent. At the present time 250 cases of trigeminal neuralgia have been
operated upon by the cerebellar route and it is now used exclusively in our
clinic. Since this publication the procedure has been modified in many ways
which contribute to both its ease and safety. In the last I50 cases there has
been no death either at operation or during their stay in the hospital, and
there have been no post-operative complications.
The steps in the operative approach are as follows: A small curved
incision is made just back of the mastoid on the side of the neuralgia.
(Fig. i.) A small defect is made in the bone, the mastoid process is
rongeured away to, but not into, the mastoid cells. (Fig. i.) The dura is
opened, the cisterna magna is evacuated; the cerebellar lobe is then gently
elevated and the fluid evacuated, after which the fifth nerve is in full view
and is divided either subtotally or totally as desired. The dura is then closed
and the galea and superficial wound reunited. The operation is done either
under avertin or local anesthesia. As a matter of fact, it lends itself very
easily to local aiaesthesia, with which it can be performed almost painlessly
except for the brief moment during which the nerve is sectioned and the pain
at that time is really very slight. An advantage of local aniesthesia is that
the pain fibres in the sensory root may be identified by their sensitivity whenl
touching them; after these fibres have been divided the remainder of the nerve
is insensitive.
Since the report in 1929 the followiing techniical improvements have been
made:
First.-Avertin anaesthesia has been substituted for ether, either by inhal-
ation or per rectum. This is a great advantage because there is no swelling
787
 WALTER E. DANDY
of the cerebellum as obtains with ether and there is therefore ample room
for exposure of the cerebello-pontine angle in all cases. Furthermore, it
provides perfectly smooth breathing which rarely follows ether, and which is
so essential when the sensory root is divided.
Second.-The electrocautery makes it possible to easily coagulate and
divide the petrosal vein should this be necessary. (Fig. 2.) This vein is
merely pinched with forceps through which the current is passed to obliterate
the vessel. The control of the petrosal vein and its branches was really the
only element of danger in the operation and this can now be easily and
I, . ...........I

L.~~ ~ ~~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ _. -
FIG. i.-Showing cutaneous incision and area of bone removed in order to expose the trigeminal nerve
by the cerebellar route.
safely overcome, if necessary, with the cautery. As a matter of fact it is
only once in about fifteen cases that it is necessary to occlude the petrosal
vein for in the remaining cases the sensory root is not at all obscured by
this vessel.
'Third.-Suction is now used to evacuate the fluid in the cisterna lateralis;
this makes it unnecessary to sponge and, therefore, it not only saves time but
avoids any possible injury to the auditory nerve, which lies at a safe distance
posteriorly. Suction is applied indirectly through a pledget of cotton that
is placed in the cisterna lateralis. (Fig. 3.) It acts, therefore, as through
a wick.
788
 TRIGEMINAL NEURALGIA CEREBELLAR ROUTE
Fourth.-Formerly a sharp knife on a long handle was used to divide the
sensory root. The division of the sensory root is now performed much more
easily and safely by using either a blunt hook or by pinching the nerve with
the blades of a long narrow forceps. (Figs. 2 and 3.) It requires very little
force to interrupt the nerve fibres.
Fifth.-The dura is always closed over the entire defect. In one of the
early cases an intracerebellar haemorrhage resulted because of trauma to the
cerebellum when post-operative vomiting thrust the cerebellum against the
sides of the bony defect.
The sensory root may be either partially or totally divided by this pro-

D tile to o ut '
Tri,ernina1 nrv

h/Knife
I to zut
^ YIXjtk
II eie

FIG. 2.-Instruments used in dividing the various nerves in the posterior cranial fossa. If necessary
the petrosal vein may be obliterated by the cautery. This is only occasionally necessary. The sensory
root is usually divided with a blunt hook, or it may be pinched with the forceps.
cedure with equal facility. In my experience the operation is far easier to
perform than by the temporal route. The average time required is perhaps
one-half hour from the incision to the division of the sensory root, though
in many cases it has been performed in ten to fifteen minutes. This is men-
tioned not as any great point of merit, but because the operative procedure
has been frequently criticized as being very difficult and dangerous. In four
cases in this series the patients have been over eighty years of age.
The advantages of the subcerebellar route are as follows:
789
**t:;,.S.-^I1Ba:,w N_>
WALTER E. DANDY

sia .. . .......: ...:

I.A.--
....

Later

.-. Aw ..
.. .. ...
.

.ffiw
with

cerebro
spIbal
.r..;..X; .., . S.-,.k..l from'.i.
1: cisteriia'.jatetS,
* , . 4 :: :. :: .'

"' '''S-

FIG. 3.-Withdrawal of fluid from the cisterna lateralis by suction applied

through a pledget of cotton. The diagram shows method of partial division of the
sensory root.

790
 TRIGEMINAL NEURALGIA CEREBELLAR ROUTE
(i) In no instance has there been the well-known post-operative keratitis.
It has been shown that the incidence of keratitis following soon after section
of the sensory root is dependent upon the amount of trauma inflicted upon
the nerve. The reason for the absence of keratitis, which is one of the princi-
pal complications of the temporal route, is that only a few seconds are required
to divide the nerve after it has been exposed. This statement does not mean,
of course, that keratitis may not follow at any subsequent time if the eye is
injured following a total section of the nerve.
(2) The motor root of the nerve has never been injured since this route
has been employed because it is at a greater distance from the sensory root
than at any other point in its course. This is of special advantage in opera-
tions for double trigeminal neuralgia, of which we have had eight cases.
Furthermore, if the patient has double tic douloureux, the pain can be cured
on both sides by a single operation using the bilateral cerebellar approach,
such as is used in nearly all exposures of cerebellar tumors. Each cerebellar
lobe is then elevated in turn and the sensory root divided on each side. By the
temporal route two operations are necessary, and, should the motor root be
injured on one side a tremendous responsibility would rest upon preservation
of the motor branch on the other side.
(3) The facial nerve is never injured because it is at a safe distance.
It will be remembered that the facial nerve is injured by the temporal route
when the petrosal nerve is torn from the geniculate ganglion in elevating
the dura from the floor of the middle fossa.
(4) Another important advantage of the cerebellar route is that in
eighteen of our 250 cases tumors have been disclosed in the posterior cranial
fossa. (Figs. 4, 5 and 6), and most of these have been removed at the
same time the sensory root is divided. In all of these cases the tumor was
the cause of the neuralgia and, of course, would have been missed entirely
if the temporal route had been used. It is impossible to differentiate by
clinical tests those cases in which the tic douloureux is caused by a tuinor.
It is worthy of note in passing that in perhaps one-third of the cases of
trigeminal neuralgia a gross lesion is disclosed which we think is responsible
for the trigeminal neuralgia. Aside from tumors the two common causes
are, free arterial loops which lift the sensory root from the brain stem, and
the venous branches which cross the nerve, sometimes dividing it into
two parts.
The incidence of recurrence in the subtotal section of the sensory root by
any method should be mentioned. There have been four recurrences in our
series. I have previously shown that division of the posterior half of the
sensory root will cure the pain in any branch of the nerve and with prac-
tically no loss of sensation. From this observation I have interpreted the
findings to mean that the fibres which are responsible for this unique pain
are collected from all branches of the trigeminal nerve into the posterior part
of the sensory root. However, variations in this distribution must occur and
these doubtless account for the occasional recurrences. In one instance there
was a recurrence in the second branch when only about one-tenth of the
791
WALTER E. DANDY

ft-ftwwowl 0 bU

(U

( bia

2: 4)

... .. .. _
0 v

. I9."% -

.i
U)
*0

U)

* (U.

:
co

CSIO

4.

792
 TRIGEMINAL NEURALGIA CEREBELLAR ROUTE
anterior part of the sensory root remained. Should a recurrence develop it
is a very simple matter to again open the incision, elevate the cerebellum and
complete the section of the nerve. The existence of the cisterna lateralis
prevents the formation of adhesions and, therefore, there are no difficulties
in a second stage at any later time. Because of the possibility of recurrence
it is my plan in patients of advanced age to totally divide the nerve rather
than to run the slightest risk of another attack. In younger people I feel it is
much more important to preserve the sensation of the face intact or nearly
so, and run the slight risk which a partial division entails.
Mention should perhaps also be made in this connection of the use of this
approach for patients who have carcinoma of the tongue and pharynx. Relief
of pain for such patients is not possible by alcoholic injections or by periph-
eral division of nerves. Such pain is referable to the sensory domain of
both the fifth and the ninth nerves, and by the cerebellar approach (under
5kin incision
\ B~~one, rernovcdm\a

I~~~~~ ~~~ .......

FIG. 6.-Aneurism of basilar artery causing trigeminal neuralgia.

novocaine) both the fifth and the ninth nerves may be divided intracranially
and with practically the same ease as obtains for the division of the fifth
nerve alone.
The same operative approach is also used in dividing the eighth nerve for
Meniere's disease, and the ninth nerve for glossopharyngeal neuralgia.
To Recapitulate.-The operation as now improved, is, in safe hands, one
of the safest in cranial surgery. It almost entirely avoids the complications
which still follow section of the nerve by the temporal route.
DiscuSSION.-DR. CHARLES H. FRAZIER (Philadelphia) remarked that although
the sensory root from the ganglion to the pons in man is but two centimetres long, yet
there has been considerable controversy in the past years as to its structure, more
specifically as to the arrangement of its fasciculi, first with regard to disassociated
forms of sensation such as pain, temperature, and touch, and secondly as to the arrange-
ment of the fasciculi and their relation with the three different portions of the ganglion
and the three peripheral divisions.
In Doctor Dandy's paper certain statements have been made with regard to the
root at its entrance to the pons. The speaker's experience with the root has been at
its entrance to the ganglion, only two centimetres distant. In a recent communication
793
 WALTER E. DANDY
Van Nouhuys, of Holland (the statement appearing in one of our recent surgical
journals), from a study of the anatomical structure of thirty-eight gasserian ganglions
which he had dissected anatomically, stated: First, that the sensory root of the fifth
nerve is not composed of three parts that correspond to the three peripheral branches;
and, secondly, that the operation of partial section of the sensory root, assuming that
the pain is carried by bundles having a definite location, is not based on anatomical
facts, and therefore cannot be regarded as an absolutely reliable procedure.
Doctor Frazier was not qualified to pass judgment upon the technic employed in
the examination by Van Nouhuys, the so-called Zerfaserungsmethode, or a teasing
process, but he had been advised by Doctor Spiller, who has had a fundamental training
in pathological technic, that the method is most deceptive and may lead to very mis-
leading conclusions. Doctor Spiller called my attention to the fact that in i9g0 he
showed that the location of the degeneration of the spinal root by the Marchi method
depends on the part of the sensory root cut. He also showed in I9IO that the tactile
fibres leave the sensory root at its entrance into the pons and do not form a part of
the spinal root.
But wholly apart from the criticism of the technic Van Nouhuys used in his ana-
tomical studies, he wanted at this time to take exception to his conclusion based upon
the result of the speaker's experience with subtotal section of the sensory root. Having
performed the operation upon the root over 720 times, he felt entitled to an expression
of opinion.
He was convinced and submitted in evidence a series of anaesthesia charts selected
at random which show that if one sections the outer third of the root, one will have
anaesthesia in the mandibular division; that if one sections the middle third of the
root, there will be anwesthesia in the maxillary division; likewise, if one sections the
inner portion of the root, there will be anaesthesia in the ophthalmic division; in any
combination of these operations there will be a corresponding area of anaesthesia.
Subtotal section of the sensory root, therefore, despite Van Nouhuys' statement to
the contrary, has proven an absolutely reliable procedure in that it permanently relieves
the patient of pain; and, furthermore, if one leaves the ophthalmic portion of the root
intact, there is no possibility of trophic keratitis as a complication. He did not see
why the motor root is any more readily damaged by the temporal route than by Doctor
Dandy's suboccipital route, so there is no greater danger in injuring the root.
As to the percentages of bilateral cases, Doctor Dandy's was very much higher
than his. Of almost 2,000 cases of major trigeminal neuralgia which have passed
through the clinic, he had knowledge all together of only some twenty cases.
With regard to facial paralysis after the operation, this has been avoided alto-
gether by observing a simple point in the operative technic, to leave on that portion
of the skull jvst behind the ganglion the posterior surface of the ganglion. If one
makes sure to leave on this aspect of the base of the skull, just above the surface of
the petrous bone, a single layer of the dura, one may always avoid injuring the
trochlear nerve.
The temporal route in the hands of the majority of surgeons will be the safer of
the two routes, and if it guarantees permanent relief with a hazard of 0.2 per cent.,
this route should be given preference.
In a recent article (ANNALS OF SURGERY, vol. xciv, pp. IOI3-IOI7, December, I93I)
Van Wagenen, an impartial observer and an experienced neurosurgeon, in conclusions
as to his experience with five cases of section of the sensory root by the suboccipital
route, said: "The impression is gained from these and other cases that while the opera-
tion is considerably more hazardous and difficult than through the temporal route, it
is a valuable adjunct to one's neurosurgical armamentarium. No evidence has been
gained from this series of cases that the type or area of anesthesia differs from that
which occurs when the trigeminal root is sectioned via the temporal fossa, provided the
root is divided."
794
 TRIGEMINAL NEURALGIA CEREBELLAR ROUTE
DR. WALTER E. DANDY (Baltimore): The point at which the sensory root is
divided may account for the difference between the results in Doctor Frazier's operation
and mine. I think unquestionably the fibers are responsible for the pain, and these
particular fibers must descend into the spinal root.
It was largely the inferior results with the temporal route that led me to search
for a different attack. I think it very unfair to make assertions that this approach is
highly dangerous when I have done 150 such operations without a death or undesirable
operative sequele. On the contrary, it is, in safe hands, a very safe procedure, and
certainly no more dangerous than the temporal route. I think, unquestionably, the results
that are obtainable by this method are much superior to those resulting from the
temporal route.
If one is willing to disregard all of the advantages of the cerebellar route, the
incidence of r,emovable tumors in the posterior fossa and causing trigeminal neuralgia
would alone be sufficient reason for the cerebellar instead of the temporal approach.
All of these tumors would, of course, be missed if the sensory root were sectioned by
the temporal route. Nor can one differentiate by clinical observations a tic due to a
tumor from those in which there is no tumor.

795