I met many patients with trigeminal neuralgia who had not been cured for many years during my outpatient visits. However, when asked in detail, almost all of them replied, “The doctor prescribed medication back then, and it was very effective, but then it didn’t work, and now they expect to have a request for a ‘one-two punch’, and I heard that you are very proficient in this area of surgery, so ……….” I ask some patients with trigeminal neuralgia to come back after a period of medication to decide whether to operate or not, not so they can wait passively, but to receive regular medication. For those who do deserve surgery even after regular treatment, of course they will not postpone the delay, but will be directly scheduled for inpatient treatment. Of course, I know that there are some patients who “can’t wait” to go to other doctors and immediately “get” surgery. Here, I would like to let patients know roughly under what circumstances they can receive surgery, and under what circumstances you may be able to avoid the “cut”. Trigeminal neuralgia is divided into two major categories, primary and secondary. First of all, “secondary trigeminal neuralgia”, as the name implies, occurs after certain factors, that is, there are clear pathological factors that cause trigeminal neuralgia. These pathological factors include various lesions near the trigeminal nerve root, such as tumors (common ones are cholesteatoma, auditory neuroma, meningioma and other tumors located near the pontocerebellar angle), inflammation and its post-inflammatory local adhesions, vascular malformation, hemangioma, etc. For these trigeminal neuralgia with a clear lesion as the cause, the treatment plan is to eliminate the lesion in order to eradicate trigeminal neuralgia. The means of eliminating the lesions is surgery, as the saying goes, “If the broom does not go away, the dust will not run away by itself”. Of course, in recent years, the widely used stereotactic radiation therapy, commonly known as “Gamma Knife”, also has a lesion shrinkage, reduce the pressure and stimulation of the trigeminal nerve effect, for those patients who can not accept surgery, or because of certain circumstances can not accept the cranial direct surgery patients, to ” Gamma knife” treatment also has a certain effect. Of course, direct surgery is “immediate”, and many patients wake up from the surgical anesthesia and no longer have trigeminal neuralgia. So how should patients with “primary trigeminal neuralgia” understand the disease and what treatment options and decisions should be made? Many, many years ago, when people could not find the underlying pathology of the disease, it was called “primary xx or idiopathic xx”. For example, “primary/idiopathic thrombocytopenia”, “primary epilepsy”, “primary immunodeficiency”, and so on. Of course, with the development of medical science, many of these “primary” conditions have since been identified, but for historical reasons, these terms remain in the lexicon of physicians. The cause of the so-called “primary trigeminal neuralgia” is also known, which is that the root of the trigeminal nerve emanating from the cerebral bridge is stimulated by localized compression of small blood vessels, causing abnormal excitation of the trigeminal nerve, and when this nerve is excited, it sends pain signals to the patient’s brain, reporting “There is pain here”, and the patient felt like a knife cut and fire on his face, even though there was nothing on the patient’s face at that time. So, in order to calm the nerves, doctors will give the patient an “anti-seizure drug”. As all trigeminal neuralgia patients know, general painkillers are completely ineffective. From the pathogenesis, this is caused by abnormal excitation of the nerves, and the drugs for epilepsy can calm down the overexcited nerves, so the pain will stop and the symptoms will be controlled. Then, some patients will ask: Since we know the cause, it is the small blood vessel of the trigeminal nerve root that is causing the trouble, so we can just “sweep the broom and clear the dust”. Indeed, this is what we surgeons do: we make a small incision behind the patient’s ear, open the skull and go in, find the small blood vessel at the root of the trigeminal nerve according to the human anatomy that our predecessors told us, separate it from the trigeminal nerve, and use a special spacer to separate the trigeminal nerve from the small blood vessel forever to achieve a lasting effect, so that the patient will not be in danger of pain attacks. In most patients, the trigeminal neuralgia stops immediately after the surgery, but in a few patients, the pain attacks are only reduced and less severe because the normal function of the nerve has not been restored. For this reason, sometimes surgeons also “comb” the sensory roots of the trigeminal nerve to temporarily paralyze the nociceptive function, which has an immediate effect. As mentioned earlier, as a surgeon, I take great pride in being able to use my hands to relieve my patients’ pain. So why do I postpone surgery for some patients? It is important to know that there are some patients, who may not need surgery, and the pain may stop by simply taking medication for a certain period of time. In fact, the current international standard for surgical treatment of primary trigeminal neuralgia is one phrase: intractable primary trigeminal neuralgia that has failed to respond to regular medication. So what is considered “ineffective medication”? Those who take carbamazepine and other drugs as “painkillers” are not considered ineffective because the concentration of drugs in the body of those patients is not regular, and it is not a regular treatment to have one meal after another. It’s like you are hungry one day, full one day, and the result is poor digestion, but can you say it’s because you don’t eat well enough “rice” so you suffer from stomach problems? You can only say that you are sick because you do not eat regularly. The same is true for neurological function. If you don’t take your medication regularly, the trigeminal neuralgia will not be treated, but the result is often worse, and the patient often complains that “the attack is worse”. It is not that the medication is not working, but that it is being taken in the wrong way. As mentioned earlier, many of these patients are mistakenly considered to be “medically ineffective,” and with the patient’s expectation of a “one-size-fits-all” surgery and the physicians’ “eagerness to get the job done,” these patients are “treated” with the goal of “getting the job done. In fact, if the neurology and neurology departments were to be able to provide the necessary care for the patients, they would be able to provide the necessary care. In fact, if neurologists and neurosurgeons carefully explain the causes and treatment of trigeminal neuralgia to patients, and if patients do not rush to get it done and take medication patiently and regularly, a significant number of people can be treated without surgery. Of course, those patients who really “receive regular drug treatment is not effective”, there is no need to be afraid, modern medicine has provided us with very good technical conditions and safety guarantee, this kind of surgery has been safely carried out in many hospitals. In short, for secondary trigeminal neuralgia, surgery should be actively performed to treat the cause, while for primary trigeminal neuralgia, it is important to carefully distinguish between patients who are indeed “ineffective with medication” and those who are “seemingly ineffective” because they are not taking regular medication. As a patient, we should respect science, obey medical advice, and treat carefully. I would like to appeal to you as a patient to have a basic scientific attitude, not to rush to the doctor, and not to have unrealistic expectations of medical treatment. By carefully obeying medical advice, perhaps you can be spared a cut, which not only relieves you of pain, but in reality also reduces the financial burden on you and your family.