Brain MRI

Raymond F. Sekula, Jr., MD, MBA, has dedicated a significant portion of his clinical practice to bringing hope and lasting pain relief to patients with cranial nerve disorders. As a professor of Neurological Surgery at the University of Pittsburgh School of Medicine and director of the Cranial Nerve Disorders Program at UPMC, Dr. Sekula specializes in minimally invasive brain neurosurgery. He is known nationally and internationally for his contributions to brain surgery.

Understanding Cranial Nerve Disorders

Under Dr. Sekula’s leadership in treating cranial nerve disorders, UPMC has continued to be a leading center for the treatment of these conditions. This minimally invasive surgery treats the underlying cause of the disorders, including:

Trigeminal neuralgia occurs more often than other cranial nerve disorders. The National Institute of Neurological Disorders and Stroke reports that 12 out of every 100,000 Americans will receive a diagnosis of trigeminal neuralgia each year.

Dr. Sekula recently sat down with HealthBeat to discuss his ongoing quest to improve the quality of life of patients with facial pain and other cranial neuralgias through ongoing innovations in his clinic, laboratory, and operating room.

Q: What causes facial pain and spasms?

A: In some facial pain disorders, a nearby blood vessel may put too much pressure on

the trigeminal nerve—one of the cranial nerves. This pressure can result in what many patients describe as the most intense pain imaginable. The pain is described as “electrical,” “stabbing,” and “shock-like.”

The pain attacks last no more than one minute or so but can occur hundreds of times each day. The pain can be triggered by light touch, cold air, or facial movement. The severity of pain can affect the patient’s ability to eat, drink, and brush their teeth. Fortunately, many patients can get relief from a minimally invasive surgery known as microvascular decompression.

Q: Can you tell us how microvascular decompression works?

A: After making an opening in the skull the size of a nickel, we use a microscope to locate the precise location where the blood vessel is affecting the nerve. We then separate the two, leaving a special polymer “pillow” in between. Once the blood vessel no longer puts pressure on the nerve, relief is often immediate.

UPMC is a high-volume center for microvascular decompression. We use a dedicated multidisciplinary team. The result of those two facts is that our microvascular decompression patients can safely go to a regular hospital floor after surgery instead of the intensive care unit, which is the norm.

At UPMC, we offer microvascular decompression as a first-line treatment to appropriate patients, regardless of age. Any patient who meets the clinical criteria and is healthy enough to tolerate general anesthesia can receive this surgery.

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Q: What has UPMC’s history been with microvascular decompression?

A: In the mid-1960s, neurosurgeon Dr. Peter Jannetta continued the work of Dr. Walter Dandy and other early neurosurgeons, who noted that the cause of facial pain was likely due to blood vessels compressing the trigeminal nerve.

By the time Dr. Jannetta came to Pittsburgh in 1971, he had developed the surgical procedure we now know as microvascular decompression. He made some major leaps forward and refinements in microvascular decompression at UPMC in the 1970s and 1980s.

I was fortunate to train with Dr. Janetta and complete a fellowship with him. Ultimately, he and I worked as partners for a few years before his retirement. Those were great years, where I learned from him, but also I introduced some new ideas to him, particularly regarding improvement in surgical techniques. It was a collaboration and time of innovation.

Q: How successful is microvascular decompression in curing facial pain?

A: Microvascular decompression works extremely well for people who are eligible to receive the surgery. Currently, 82% of our patients get immediate, complete relief following surgery. An additional 16% get partial relief, requiring occasional or low-dose medication.

One year after surgery, 75% of our patients continue to enjoy complete pain relief, and 8% have partial relief.

I personally have performed more than 1,000 microvascular decompression surgeries for patients with trigeminal neuralgia. The risks my patients face from this surgery are very, very low. The most likely side effect is partial facial numbness at 5%, and the numbers go down significantly from there.

The stroke risk for my patients who are under age 65 is 0.3%, but that rises to only 1.0% among patients over 65. I routinely perform this surgery on patients who are 80 or even older.

My patients face a surgical site infection risk of 1.5% and we went literally 10 years without a single patient experiencing a cerebrospinal fluid leak.

Q: How have you been able to refine microvascular decompression surgery?

A: We’ve been able to make the surgery much more gentle over time. Sort of like an operation on the knee or hip, we’ve been able to continually refine the procedure to make the recovery easier and the operation itself safer. For example, I’m able to perform the operation without the need for rigid fixation of the skull, which can cause headaches; fixed retractors, which can bruise the brain; or sacrifice of veins, which can result in strokes. Anesthesiologists are using more intravenous than inhaled drugs, which allows for a faster recovery.

Our average hospital stay is just over 1 day. We have teams of neurosurgeons who come from other countries to see how we achieve our statistics. Their patients’ length of stay is typically 5 to 6 days.

But the biggest reason for improvement has been more precise patient selection. Unfortunately, microvascular decompression works for only a small subset of people who experience facial pain.

At UPMC Presbyterian, our patients undergo a special thin-slice MRI with a heavily-weighted T2 weighting. This diagnostic scan gives us the best possible view of the cranial nerves and surrounding blood vessels. We work closely with a few of our neuroradiologists, like Dr. Marion Hughes and Dr. Katie Traylor, who help us interpret these studies. This MRI lets us know whether surgery will help a person’s pain or not.

Q: What can be done to help patients who are not surgical candidates?

A: We give these patients various medications to try to reduce their pain. We use anti-seizure medications because nerve pain won’t respond to opioids or non-steroidal anti-inflammatory medications (NSAIDs).

Some patients find that medical therapy brings their symptoms under satisfactory control. But many patients find that their pain either becomes resistant to medication or requires larger doses. Side effects from medications can become challenging over time.

Q: What clinical innovations might be on the horizon for patients with severe facial pain?

A: Because microvascular decompression can’t help everyone with severe facial pain, we need better medical therapies. Through my appointment at the University of Pittsburgh as well as UPMC, I collaborate with some first-rate scientists. My colleague,

Michael Gold, PhD, and I, have applied to receive a multimillion dollar award from the National Institutes of Health to study the fundamental mechanisms of trigeminal neuralgia. Our hope is that we can develop drugs that can help those who cannot be treated with surgery.

Overall, we will continue to refine all of our practices. From my early days in medicine, I have always studied my patients’ results closely. When something doesn’t work, we change it.

We publish our results and our improvements in scientific journals, and we constantly ask ourselves what we can do better. It would be easy to sit back and get comfortable with our successes, but that’s not us.

We’re constantly striving to improve our techniques and make life better for our patients. That has been the most interesting and fulfilling work in my life as a surgeon.

About Neurosurgery

The UPMC Department of Neurosurgery is the largest academic neurosurgical provider in the United States. We perform more than 11,000 procedures each year. We treat conditions of the brain, skull base, spine, and nerves, including the most complex disorders. Whether your condition requires surgery or not, we strive to provide the most advanced, complete care possible. Our surgeons are developing new techniques and tools, including minimally invasive treatments. U.S. News & World Report ranks neurology and neurosurgery at UPMC Presbyterian Shadyside as among the best in the country. We also rank among the top neurosurgery departments in the U.S. for National Institutes of Health funding, a benchmark in research excellence.