Joan Foster, Patient and Central Texas TNA Support Group Leader

Her Personal Story with Microscopic vs Endoscopic MVD

 Ten years ago, I stood in a treatment room with a neurosurgeon to hear his prognosis following his preliminary exam. Holding a model of the human brain, he indicated where a hole would be cut in the back of my head to perform surgery on a tiny nerve in the middle of my brain.  I was a bit overwhelmed, but maintained my composure during my visit.  As if being a single mother of two children wasn’t hard enough, my quality of life had mysteriously deteriorated over the course of the previous two years. After my appointment with the neurosurgeon, I returned to work, put my head down on my desk, and cried. A decade ago, the internet had not yet connected Texas with the newly-formed Trigeminal Neuralgia Association in Barnegat, New Jersey.  I felt truly alone.

Since that day, I have undergone two surgical vascular decompressions for TN: one with a microscope, and the other with an endoscope.  Therefore I have two different experiences to share: one good and one bad.  My first MVD (with a microscope) was a total failure. After the procedure, the surgeon informed me that he did not see a vessel compressing the nerve. Furthermore, the surgery degraded my hearing.  However, I do not blame the microscope, as there have been thousands of successful microscopic MVDs with good results.  As a support group leader, I stress to patients the importance of a neurosurgeon with TN expertise.  Don’t depend on a “Preferred Provider” from your HMO list.  What you need is an experienced, reliable “Doctor,” specializing in TN.  Ten years ago, there was nobody to tell me this --- I was on an HMO. 

I underwent my second MVD five years later; this time, it was with an endoscope.  Although much controversy exists over microscopic versus endoscopic brain surgery, my personal experience was very good.  Recovery time was less than half of that required for the first MVD, and the procedure relieved 85-90% of my pain. Three years have since passed.  I have residual Type-II TN in my first division, which is the hardest to eradicate.  I control it with a low dose of medication and good vitamin supplements.  I’m doing well.

Jonathan White, MD, Assistant Professor of Neurological Surgery at Southwestern Medical School in Dallas, Texas, made possible my third and most memorable experience with MVD.  Shelly Wilson, the Dallas TNA-SGL, and I were given the rare opportunity to observe (firsthand!) while Dr. White performed an MVD on a TN patient.  Dr. White wanted to demonstrate the difference between the microscopic and endoscopic techniques in TN surgery. From the first incision to the last stitch, the entire procedure took about 2 ½ hours. 

The patient was already prepped before we entered the operating room.  After reviewing the thin cut MRI, Dr. White and his team began by positioning equipment around the patient.  The scrub nurse, who kept sterile, positioned herself high over the patient to hand instruments to the doctors.  A secondary nurse freely moved about the room, performing duties that required contact with non-sterile items, such as positioning stools under the doctors, moving tables, etc.  Dr. White had Chief Resident Dr. Tom Psarros assist him patient throughout the procedure. Two anesthesiologists stood behind a drape, constantly monitoring respiration and vital signs. A third computer medical technologist monitored the hearing and facial nerves.  Shelly and I were free to walk around the OR to observe and learn. 

Right to Left: Shelly Wilson, Chief Resident, Dr. Tom Psarros, Joan Foster, and Dr. Jonathan White packing Junior Mints following MVD surgery.

Dr. White remained stationary, working in a small confined area. The instruments, the smells, and even the sound of the drill reminded me very much of my husband, Dr. Michael Foster, DDS, working on his dental patients.  I watched intently through a second pair of microscope optics as Dr. White confidently manipulated the delicate vessels away from the trigeminal nerve and cushioned it with Merocel.  He inserted the endoscope so that we could visually compare it to the microscope.  The microscope, which most neurosurgeons consider state of the art, was definitely more vivid in color and depth perception. The endoscope seemed very rigid, as it was a hand-manipulated instrument.  Unlike the microscope, the endoscope had the ability to view different angles around the nerve, however with limited depth perception.  The microscope was viewed through lenses, while the endoscope was viewed on a large monitor. 

My goal is not to exclusively promote either instrument.  The decision between microscopic vs. endoscopic MVD belongs entirely to the patient.  Instead, I wish to impress upon my fellow TN patients that the most important thing is to choose a doctor with experience and a solid track record with follow-up.  Being a TN patient myself and listening to so many stories of TN experiences, my conclusion is this:  I want my neurosurgeon to be confident in his/her abilities, well-trained, and have the best technology available to perform effective surgery ONE time.  Statistics will tell you that following an MVD, the pain often returns; in repeat surgery, doctors will look for missed vessels.  In today’s high-technology dental field, there are many tiny intra-oral cameras available; some are small enough to even look at the gum tissue underneath a tooth.  If a patient undergoes a traditional MVD, why not use every avenue of technology to take a second look around and ensure nothing is inadvertently overlooked?  When a patient visits our dental office, we use a x-rays, intra-oral camera, digital camera, laser technology, and 250-350X magnification -- basically, we employ everything we have at our disposal to get the best look at our patients.  When a neurosurgeon is in the middle of the brain, why not employ all the technology at his disposal (i.e. both a microscope and an endoscope) for the best possible and most-thorough look around?  One “hidden” blood vessel could make the difference.

 Additionally, Dr. White worked 100% on the patient.  He was not performing surgeries on multiple patients simultaneously.  I was very impressed with Dr. White’s post-op also.  He does not abruptly remove the patient from medications, but weans them off carefully. During the MVD, he often performs a partial rhizotomy depending on what division of the face the pain was located, to assure that the patient wakes-up pain-free.  My sincere thanks to Dr. Jonathan White for allowing Shelly and I to walk around the OR to observe and learn. 

Updated 4-5-05