Harvey Cushing's case series of trigeminal neuralgia at the Johns Hopkins Hospital: A surgeon's quest to advance the treatment of the 'suicide disease'

Background: A review of Dr. Harvey Cushing's surgical cases at the Johns Hopkins Hospital provided insight into his early work on trigeminal neuralgia (TN). There was perhaps no other affliction that captured his attention in the way that TN did, and he built a remarkable legacy of successful treatment. At the time, surgical interventions carried an operative mortality of 20%. Methods: The Johns Hopkins Hospital surgical records from 1896-1912 were reviewed to contribute new cases to the 20 reports provided by Dr. Cushing in his early publications in 1900 and 1905. This review uncovered 123 TN cases, representing 168 interventions. Results: At the start of his career, Cushing treated TN mainly through Gasserion ganglion extirpations and peripheral neurectomies; however, he nearly abandoned these methods in favor of sensory root avulsion after 1906 and did not perform alcohol injections until his later years at Hopkins. Overall, Cushing had a 0.6% mortality rate; additionally, 91% of patients were improved at the time of discharge. However, 26% of patients had a recurrence requiring further intervention by Cushing. Conclusion: Modern day interventions of TN are reflective of the legacy left to us by Harvey Cushing, a pioneering forefather in neurosurgery. He pioneered the infra-arterial approach to excision of the Gasserion ganglion in face of problematic bleeding and later the use of sensory root avulsion to spare motor function. Through the evolution of his legacy and the refinement of original approaches, the quest to advance the treatment of TN took him along the trigeminal nerve from the periphery into the brain.