The Surgery of the Skull and BrainRawling, Louis Bathe
Science
The Surgery of the Skull and Brain
Rawling, Louis Bathe
Brain -- Surgery; Skull -- Surgery
5. _Absence of ocular changes._ After division of the sensory root
ocular changes are absent, due in part to the fact that the ocular
nerves are left intact, and also to the probability that ‘sympathetic
fibres pass to the eye after entering the trigeminal nerve through the
Gasserian ganglion’ (Spiller).
In the consideration of these advantages it should be noted that they
are mainly directed against procedures in which complete extirpation of
the ganglion is attempted, and are of less weight when contrasted with
the partial excision advocated by Hutchinson.
=Frazier’s operation[76] on the sensory root.= ‘A horse-shoe shaped
incision is made, beginning at the middle of the zygoma and terminating
a little below the apex of the lobe of the ear (see Fig. 91). The
musculo-cutaneous flap is made purposely a little larger than the
opening in the skull. An opening is made in the skull with a diameter
not exceeding 3 cm. and extending down as far as the infra-temporal
crest. The dura is separated from the base of the skull with a blunt
retractor as far as the foramen spinosum. The middle meningeal artery is
ligatured and the dura mater incised directly over the third division at
the margin of the foramen ovale and separated from the upper surface of
the ganglion as far back as the sensory root. The latter is picked up
with a blunt hook, grasped with forceps and divided or avulsed. It is
necessary only to expose the posterior portion of the ganglion; the
second and third divisions of the fifth, the structures on the inner
side of the ganglion, and the cavernous sinus, are left undisturbed.’
=Choice of operation.= There are both advantages and disadvantages to
each of the various operations enumerated. There are also other
operations. From my own experience I have come to the conclusion that
the two operations of choice are resection of the second and third
divisions of the fifth nerve and division of the sensory root. The
former of these two operations is carried out when the general condition
of the patient is not altogether satisfactory, presuming, of course,
that the neuralgia is limited to those divisions of the nerve. Under
more favourable circumstances excellent results are obtained by exposure
and division or resection of the sensory root, with, I think, the
minimum risk.
=The results obtained by operation.= The prevailing impression that
these operations are associated with a high mortality is totally
incorrect. From my own experience and from numerous recorded cases, the
mortality may be estimated at not more than 5 per cent.
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