Question 1

What complications are expected from surgery for trigeminal neuralgia?

Dr. Anil Kumar Kansal · Accepted Answer

One complication is anaesthetic: sometimes the patient reacts to anaesthesia. On the surgical side, there can be a haematoma in the cerebellum, sometimes bleeding, sometimes infection, or damage to the nerves. Our infection rate is very low. One patient developed chemical meningitis followed by hydrocephalus and had to be treated with a shunt, but the rest did very well. Initially a few patients complained of partial hearing loss, from traction on the eighth nerve. We now use very minimal traction to decompress the nerve, so the results are good and complications are very minimal.

Question 2

What is the recurrence rate?

Dr. Anil Kumar Kansal · Accepted Answer

Early recurrence is low, about 5% in our experience. We have done more than 100 of these surgeries and have not had to operate again on any of them. Some patients may have mild symptoms, which can be managed with medication or reassurance; otherwise the results are good.

Question 3

Are there any recent advances in the management of paediatric congenital hydrocephalus?

Dr. Anil Kumar Kansal · Accepted Answer

In paediatric congenital hydrocephalus we perform endoscopic third ventriculostomy, with a success rate of around 70 to 80%. A programmable shunt works immediately in nearly every case, with a success rate of around 95%, but shunt failure and infection have to be weighed. Endoscopic third ventriculostomy is therefore the better choice where its predicted success is good: once it succeeds, the chances of any recurrent problem are very low.

Question 4

How long does full recovery take after treatment for trigeminal neuralgia, and what are the complications?

Dr. Anil Kumar Kansal · Accepted Answer

We keep the patient for three or four days, and the pain is usually gone after surgery. We continue the medication for one month and then stop it. We get the patient walking from the next day, and they do very well. We do a post-operative CT scan to check for any bleeding or collection, but we are now achieving near-perfect results.

Question 5

Are the screws inserted in the spine during robotic spine surgery absorbable, or do they have to be removed after the operation?

Dr. Anil Kumar Kansal · Accepted Answer

They are not absorbable. They are non-absorbable and remain in place lifelong.

Question 6

For chronic trigeminal neuralgia that does not respond to medical treatment, what surgical options are there?

Dr. Anil Kumar Kansal · Accepted Answer

There are four options: radiofrequency ablation, glycerol injection, radiosurgery (gamma knife) and microvascular decompression. Initially we tried glycerol injection, radiofrequency ablation and gamma knife, but the results were not good. With glycerol and radiofrequency ablation, some patients are left with numbness of the face, and the pain often comes back after six months to a year. Gamma knife takes a long time to relieve the pain and relieves it only partly, so patients are happy at first because they have avoided surgery, but the end result is poor. We have therefore switched back to microvascular decompression; for the last few years we have done only microvascular decompression, with no injections or radiofrequency ablation, except in patients who cannot undergo surgery. These patients respond very well: 95% are pain-free after surgery, serious complications such as hearing loss or facial numbness occur in less than 1%, the hospital stay is two to four days, the surgery costs around $6,000 to $7,000 at our centre, and medication can be stopped after one month.

Question 7

What investigations establish a definitive diagnosis of trigeminal neuralgia?

Dr. Anil Kumar Kansal · Accepted Answer

The diagnosis is first clinical. Second, a good-quality MRI with CISS sequences is needed, because CISS shows the vascular loops. It can show a tumour, and if the vascular loop can be localised, we can identify where it is compressing the nerve. A good-quality MRA with CISS sequences is what you need to make the diagnosis.

Question 8

What are the success rates and the financial implications of robotic spine surgery?

Dr. Anil Kumar Kansal · Accepted Answer

Financially, robotic assistance adds about $1,000 to $2,000 to a normal spine surgery costing around $7,000. Its advantage is that screw misplacement falls to less than 1%. That matters because you can perform a good operation, but if any screw is misplaced, the whole surgery loses its value. With robotic surgery the screws are placed very accurately, with fewer complications from them, so the surgery is more precise and the results are very good. That is why the extra cost is not significant. At present the robot is used only for screw placement; as it develops further, it may help in other parts of the surgery as well.

Question 9

In general, what are the success rates of these surgical procedures, and what are the absolute contraindications?

Dr. Anil Kumar Kansal · Accepted Answer

Absolute contraindications are cardiac problems, any bleeding or coagulation disorder, and any severe infection in the body. In trigeminal neuralgia, if the patient responds well to medication and the pain is controlled with minimal doses, we do not operate unless the patient wants it. If the pain is not relieved, we go ahead with these surgeries.

Question 10

Take a 65-year-old woman with nerve compression in the spine who could be managed with physiotherapy and medication, where it is clear to the surgeon that surgery might keep her remaining years pain-free. How do doctors make that cost-benefit decision?

Dr. Anil Kumar Kansal · Accepted Answer

First, we look at how severe the pain is and how many painkiller tablets the patient takes in a week. If the patient is taking two or three painkillers a day, or cannot carry out daily activities or walk 500 metres, we consider surgery. Second, if there is a neurological deficit, such as weakness of the limbs or bladder and bowel involvement, we advise surgery. The long-term result and the finances will both be better; otherwise the patient takes long-term medication, which will cost the same or even more after some time.

Question 11

We recently shared a trigeminal neuralgia case with you from DR Congo where the patient had been receiving other procedures locally. How should African doctors approach such surgical decisions, which are often cost-driven?

Dr. Anil Kumar Kansal · Accepted Answer

Trigeminal neuralgia is a very complex disease because everybody treats it in their own way. Some say no treatment is needed, but the patient is in severe pain; one of my patients could not eat or feed himself because of it. Earlier in my career I gave hundreds of glycerol injections at a leading neurosurgical hospital in Delhi, but patients came back six months or a year later with the pain returned. Even on three or four medications, patients still have pain for 10 days a month, which hampers their work and their lives. Considering everything, microvascular decompression is better: about six months of medication costs as much as the surgery, complications are low and the results are good, so in the long term it is also financially beneficial.

Question 12

When a patient faces a choice between conservative treatment from a neurologist and surgery, how should that decision be made?

Dr. Anil Kumar Kansal · Accepted Answer

It is a combined branch, not neurosurgeon versus neurologist: everybody has to work together and go by the results and what is required. In Parkinson's disease, the neurologist treats for the first five years or so, because while the drugs are working well no surgery is required. Once the patient stops responding to medication, drug side effects appear, or life becomes very compromised, deep brain stimulation (DBS) has a role, and the neurologist and neurosurgeon have to be on the same page about it. Complications are now reduced. DBS is costly, around $30,000 to $40,000 at our centre, but the results are excellent; we recently performed it for a patient with dystonia who could not stand properly and had abnormal movement on one side, and the patient did very well.

Question 13

If a Parkinson's diagnosis is confirmed and surgery has good results, why should the patient lose years of quality life on medication first?

Dr. Anil Kumar Kansal · Accepted Answer

Initially, the medication dose required is very small and the patient does very well on it. As the disease progresses, the dose has to be increased, and after three or four years it is so high that the patient takes the drugs four or five times a day and is still not comfortable. That is the ideal time to operate. It is not surgery alone but medical treatment combined with surgery; knowing the proper timing and indication for surgery is what makes it work.

Question 14

How do you see the approach of making local doctors the care custodians, with direct access to specialists in India?

Dr. Anil Kumar Kansal · Accepted Answer

This is the proper system: the patient should go to the primary doctor, then to secondary and tertiary care. Once we operate and the patient goes back, they need the local doctor for every kind of help. Local doctors should be free to talk to us about problems they face with a patient, because if a patient has a post-operative complication back home, I cannot manage it from here. Even within India, when patients come from small towns, we send them back to their local doctor and stay in touch, and the patient benefits more. Our target is not surgery; it is treating the patient.

Question 15

Should the Africa-to-India care pathway be free of commercial agents?

Dr. Anil Kumar Kansal · Accepted Answer

Yes, it should be agent-free. First, treatment should be based on requirement: we should do only what is required. Second, it should be done perfectly, because it involves your reputation, my reputation and my country's reputation. We will not treat anybody unnecessarily for money.

Live Discussion with Dr. Anil Kumar Kansal