True believer, with questions

Abstract

J annetta's thesis that vascular compression is the cause of trigeminal neuralgia has been one of the most fiercely debated issues in the etiology of common pain syndromes. Those who wish to argue for or against his ideas should be required to state their experience and personal beliefs before they put forth scientific views. I am a neurosurgeon who visited Dr. Jannetta in 1973 to learn the truth from the source, and I have performed microvascular decompression for the past 20 years. I see about 100 new patients with tic douloureux each year and offer surgery to about half of them; the remainder can be managed medically Currently, I am performing about 10 microvascular decompressions each year and have completed about 150 of these operations. I am satisfied that vascular compression can be clearly identified in almost every patient who does not have multiple sclerosis. Sometimes the patient's anatomy makes visualization of the entire fifth nerve from brainstem to Meckel's cave difficult; and sometimes a clear view is obtained and no vessel can be found. Jannetta told me that I just do not know what to look for in such cases, but I am not sure that he is correct. The first issue that Jannetta's focus article raises is concern for both the specificity and sensitivity of his observation that vascular compression is the cause of trigeminal neuralgia. It will not suffice to tell us that everyone who has this painful syndrome has vascular compression (sensitivity); we also need to know how many people who do not have pain have the same offending blood vessel (specificity). What is the gold standard for determining that a vessel is compressing the nerve? Is this to be the surgeon's vision, an imaging study, electrophysiological evidence, or an autopsy? s Fortunately, the clinical syn-