The Weight We Have Chosen to Carry
A patient walked into my OPD not long ago with a familiar story — pain that could be triggered by a breeze, a bite of food, the wrong angle of a toothbrush. I began the way I always do: confirming the diagnosis of Trigeminal Neuralgia, then explaining why Microvascular Decompression, not another year of medication, offered him the best chance at lasting relief. He stopped me before I had finished the sentence. While waiting outside, he told me, he had already spoken to three other patients in the room. One had undergone the same surgery two weeks earlier, and was there only to get the stitches removed. That patient told him exactly what the first two weeks felt like. Another patient also had Trigeminal Neuralgia and was still deciding whether to go ahead with surgery. The two of them talked about the same fear. A third patient had Hemifacial Spasm and was there only to decide a date for surgery. By the time he sat down in front of me, he had already made up his mind. I had barely finished a sentence. I have thought about that waiting room episode often. Nothing I say in a consultation will ever be as persuasive as an ordinary conversation between strangers who happen to be sitting in the same room, waiting for the same door to open. What convinced him was not my explanation of risk and benefit. It was the accumulated, unrehearsed testimony of people who had already walked the road he was about to take. Why Trigeminal Neuralgia Treatment Became a Life’s Focus A pain with no patience for ordinary explanations Trigeminal Neuralgia is widely regarded as one of the most severe forms of facial pain in medicine, with attacks triggered by something as ordinary as a breeze, a shave, or the touch of a pillow. Twenty-two years ago, that severity was the entire reason this dedicated work began. Not a technique chosen for its elegance. Not a subspecialty selected for its rarity. A patient’s pain, and the conviction that it could be relieved, properly, with the right hands and the right care. It is worth pausing on why this particular family of conditions resists the ordinary tools of medicine for so long before a patient ever reaches a neurosurgeon’s office. A pulsing artery, over years, wears a groove into the sheath of a nearby nerve, the way water eventually shapes stone. The nerve does not break. It misfires — sending pain, spasm, or a swallowing reflex gone wrong, in response to sensations that should never have triggered anything at all. No pill silences a nerve rubbed raw in this way for long, which is precisely why so many patients arrive having already tried, and exhausted, every medication available to them. This focus soon extended to Hemifacial Spasm and Glossopharyngeal Neuralgia as well. The three conditions look different on the surface, but share the same underlying mechanism: a blood vessel compressing a cranial nerve, producing symptoms far more disabling than their physical cause would suggest. Facial pain, involuntary facial spasm, and pain or difficulty with swallowing are each disabling in their own way, and each has been treated with the same seriousness of surgical attention as the first. What Twenty-Two Years of Microvascular Decompression Surgery Teaches Repetition builds a kind of sight More than 3000 Microvascular Decompressions later, across all three conditions, the number itself means little on its own. What matters is what’s behind that number. Repetition builds a kind of pattern recognition nothing else can. Over the years, I have come to recognise almost every variation a nerve and vessel can produce. And the outcomes have stayed steady — because this same operation has been done, at this scale, for over two decades. Very few centres anywhere in the world have performed this surgery, across these three conditions, this many times. I say this as fact, not as a boast — and as a reminder of where the real solution lies. Medicine can dull the pain for a while. It cannot move the vessel off the nerve. Only surgery does that. The number matters less than what it represents — pattern recognition that only experience can build. There is a particular moment, familiar now in a way it was not twenty years ago, when the microscope reveals the offending vessel lying against the nerve root, and the shape of the problem simply announces itself. That recognition is not instinct. It is the residue of thousands of prior encounters with the same anatomy, filed away without ever having been consciously counted. Why No Neurosurgeon Can Operate Alone The team behind one pair of hands Volume alone does not make a centre good, and it has never been the whole story here. It is possible to accumulate high case numbers without genuine attention to patient wellbeing. That is not the intent behind this work. The same concern that started it — treating pain that surgery could actually resolve — eventually led beyond the operating room, to the founding of a dedicated foundation. Two counsellors now work within it specifically for patients living with these conditions, because correcting a nerve surgically does not, by itself, undo months or years of a person having organised their life around avoiding pain. That requires conversation, patience, and time that a surgical schedule alone does not provide. I stand at the centre of a system built, patient by patient, over twenty years — and I lean on it every single time. None of this, it should be said plainly, is the work of one person. As the operating neurosurgeon, I stand at the centre of a system built, patient by patient, over twenty years — and I lean on it every single time. Two assisting neurosurgeon colleagues share the table with me for every procedure. An anaesthesia team that has now anaesthetised MVD patients for over twenty years understands this surgery’s particular demands in a way that cannot be taught quickly. A postoperative care
