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Pediatric TN Issues: Four Key Points

As we have mentioned, this site is administered by four TN Mamas:  Tracy, Meg, Stacie & Ang.  We all came together because we all have kids with this awful condition.  Different pairs of us met just from having kids with TN, but the four of us really came together and bonded and found this purpose because all four of us made it to the same neurosurgeon.  Because of that, the four of us now have kids who are currently TN pain free and medication free.

We don’t want to make this site all about him, and while he knows about the site and ‘follows’ us (Hi!), he doesn’t want it to be about him either.  We all realize that Facial Pain conditions are complex, and that MVD isn’t the end-all be-all answer for everyone.  We also realize there are other neurosurgeons out there.

However, Dr. Mark Linksey, while not a ‘pediatric’ neurosurgeon, has done wonderful things for our kids and many others struggling with TN.   Since first working with TN patients during his residency under the creator of the MVD, Dr. Peter Jeanetta, he has continued to study TN, and is extremely knowledgeable about it and other facial pain conditions.  He is also a member of TNA – The Facial Pain Associatrion Medical Advisory Board.

So, following is a piece written by Dr. Linskey about what he feels are the four key points that need to be ‘out there’ and discussed for pediatric TN patients.

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1)      Traditional US Medical Healthcare training, structure and Culture

In the US Adult Neurologists go through four years (48 months) of training in a neurology residency right out of medical school. However, “pediatric neurologists” do not do a neurology residency.  They do a 3 year general pediatrics residency followed by a 1-2 year “pediatric neurology” fellowship which usually only includes 3-6 months of adult neurology exposure and training, and in some programs includes none at all.  Since less than 1% of TN occurs in patients under the age of 18, most pediatric neurologists do not see a case of TN in their career.

Furthermore there is an assumption inherent in patient referral patterns that children are better cared for by “Pediatric Neurosurgeons” than adult neurosurgeons.  Most pediatric neurologists preferentially refer surgical patients to “pediatric neurosurgeons” despite the fact that even if they were trained in TN surgeries like MVD during their residency (all neurosurgeons go through similar  7 year residency training), given the rarity of the syndrome in pediatric patients, their ongoing surgical experience in TN surgeries may be minimal to none.

What is needed is referral to a neurosurgeon trained and experienced in TN surgery who is comfortable operating on children (whether they are predominantly an adult neurosurgeon, or one of the extremely rare pediatric neurosurgeons who operates on adults with this condition)

Patients and their parents get trapped within this system.

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2)      The problem of out-of-state subspecialty referral for rare or “orphan” pediatric diseases under State Medicaid and perhaps now even under Affordable Care Act individual State Exchange insurance policies as well –

If patients have good primary third party insurance, referral out of state to a neurosurgical TN subspecialist is usually not a problem. However, according to the CMS (Center for Medicare and Medicaid Services) 2012 annual report, in 2011 43.5 million of the 73.9 million children age 0-17 in the US received their healthcare services through MedicaidThis is 59% of all children in the US. These children represent 50% of all patients enrolled in Medicaid across the US (the rest are adults either under a poverty line or permanently disabled).

Unlike Medicare which is federal and is portable state-to-state, Medicaid is individually run by each state and there are significant barriers to approving care outside of the state, as well as barriers to out-of-state hospitals accepting another state’s Medicaid reimbursement rate. This problem appears to also be developing for health insurance plans being offered and sold on individual state health insurance exchanges under the new Affordable Care Act (ACA).

Depending on the size and location of the state in question, there may, or may not, be a very experienced TN subspecialty neurosurgeon who is comfortable operating on children in their own state.  These barriers to out-of-stet referrals then can become significant barriers to access and quality of care.

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3)      The unique problem of high-dose anti-epileptic drug use in children as opposed to adults (this is not “benign” treatment”) as well as TN in children –

TN patients are initially treated with one, or more anti-epileptic drugs (AEDs).  The doses of these AEDs needed in TN is usually orders of magnitude higher than doses usually used to successfully treat epilepsy. Unfortunately these drugs are not selective.  They have general electrical suppressive effects throughout the brain.  In children the brain is still developing and the effect of these drugs at these doses are potentially much more severe than in their adult counterparts.

These drugs at TN doses interfere with learning and memory during the key learning period in life. This interferes with their grades and impairs their competitiveness for higher educational and career opportunities.  They are general suppressants and they interfere with successful peer socialization and interaction at a time when adolescents are developing their social self confidence, and a feel for their place in society.  If the child is young enough, the may even be erroneously diagnosed with ADHD (Attention Deficit Hyperactivity Disorder).

Even the syndrome of TN by itself is potentially devastating for adolescents from a socialization perspective, particularly in adolescents.  Imagine being afraid to have someone touch your face or kiss you if you are an adolescent (especially girls) and the effect that would have on you socially at this vulnerable time. Many even withdraw and become almost social recluses.

Getting them off these meds and pain-free and allowing them to learn, compete, professionally track, socialize and gain personal self-confidence is a crucial need.

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4)      The importance of finding the right surgeon – In my opinion the TN subspecialty surgeon needs to be very well trained and experienced.  For MVD surgery this very specifically means that the surgeon in question:

A)     Has been trained by a well-known and established master in the technique (not picked it up on their own or trained by someone who is not a known MVD expert)

B)      Has overcome their personal learning curve for the procedure which for MVD, in my opinion, is at least 50 cases.

C)      Has an ongoing regular surgical volume to maintain outcome excellence and keep complication rates as low as possible (studies suggest 6-24 MVD’s per year)

D)     Only operates with experienced intra-operative ABR (auditory brainstem evoked response) monitoring to minimize hearing loss risk

E)      Works with an intact experienced team including neuroanesthesia, neurotechnicians experienced with shredded Teflon felt and microsurgery, a dedicated neuro-ICU and neuro nurses

F)      Ideally is analyzing and publishing their own surgical results in the peer-reviewed literature for comparative purposes

That last point, I (Meg) need to emphasize, and I believe the other TN Mamas will agree.  Two of us (Ang & Meg) came to Dr. Linskey for re-dos after our child’s first MVD failed.  MVD, to someone who is an experienced neurosurgeon, is not a super complex surgery, but it is delicate and ‘elegant’.  There is also important information, like the possible location of compressions, that is not widely known by those who do not practice this surgery regularly.  And MVD is something you want to get right the first time.

Stacie has also developed a more in depth questionnaire that she used for neurosurgeons here.

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I hope you all find this helpful.  These are points that have to become part of the discussion for pediatric – and for most of the points all – TN patients.

Discussion

One thought on “Pediatric TN Issues: Four Key Points

  1. Thank you for gathering this detailed report. It helps those of us new to TN, young children with TN, and starting to locate a competent neurosurgeon that specializes in TN. Everyday I feel more and more confident with my decision to consult with Dr. Linskey. I feel blessed to have met you ladies.

    Like

    Posted by Dana Fryar-Homier | April 27, 2015, 3:15 pm

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