TRIGEMINAL NEURALGIA
DEFINITION
• “Sudden, usually unilateral, severe, brief,
stabbing and recurrent pain in the distribution
of one or more branches of fifth cranial nerve.”
---International association for the study of pain.
• “Unilateral disorder characterized by brief
electric shock like pain, abrupt in onset and
termination, limited to distribution of one or
more divisions of trigeminal nerve.”
---International Headache society
Ophthalmic
Maxillary
Mandibular
Division (V1)
Division (V2)
(V3)
Sensation To The Jaw
Forehead
Cheek,
And LowerAnd
Upper Eye
Lip;Lip, And
It Also
Roof Of The
Provides Mouth. Of
Movement
The Muscles Involved In
Biting, Chewing, And
Swallowing.
HISTORY
Nicolas John
John Locke
Andre Fothergill
(1677)
(1756) (1766)
Early Painful
“Tic
Detailed Affection of
Douloureux”
Description the Face
. .
EPIDEMIOLOGY
• Age - 50-70 years
• Sex predilection – Female (60%)
• Affliction for side : Predilection for right side
• Multiple sclerosis – 1%
• Division of Nerve affected* -Maxillary(V2)- 35%
Mandibular (V3)- 29%
Ophthalmic (V1)- 4%
Maxillary & Mandibular- 19%
All Branches- 1%
*Elise M Jackson et al American Journal of Emergency Medicine,Vol-17,Number 6 ,
Oct 1999
CLASSIFICATION
• Based on Etiology
Idiopathic TN
Secondary TN
• Based on Symptoms
Typical TN Constant pain,pain
Lancinating usually
of
burning
sudden in nature
onset ,
& offset
Atypical TN either from onset or
Pain with elements of
Mixed TN altered from typical TN
both typical and
over time
atypical TN
ETIOLOGY
1. Secondary TN
– Tumors
• Acoustic neuroma
• Chondroma at the level of clivus
• Pontine glioma
• Epidermoid cyst
• Metastases
• Lymphoma
2. Dental Origin
– Vascular defects
• Pontine infarct
• Arteriovenous malformation
– Inflammatory
• Multiple sclerosis
• Sarcoidosis
• Lyme disease neuropathy
PATHOLOGY
cutting or compressing Focal
the trunk of a sensory demylelination
nerve
Brief discharge in
damaged axons.
Neural hyperactivity Ephaptic transmission
CLINICAL FEATURES
Localized ,
Unilateral , Typical TN
Short
Spasmodic
Refractory
Similar To Phase
PAIN Electric Shocks
Free Of
Stabbing , Symptoms
Clutches
Throbbing,
his hands
over Burning,
the affected Attack
side
Crushing,
of face Episode
Pulsating Few Seconds
CLINICAL FEATURES
Trigger Points Precipitate By
Light Touch Or
Pressure,
Eating,
Talking,
Shaving,
Gust Of Wind,
Smiling, Laughing
CLINICAL FEATURES
Spasm Of Facial Frozen Face Or
Muscles Mask Face
DIAGNOSIS
4.
1. Are
Doesthe
theattacks
pain
Case History occur
unilateral?
in attacks?
2.5.Are
Do most of the
?
the attacks
attacks
occur of short
in the region
duration (seconds to
of the trigeminal
6
minutes)?
nerve?
questions
3.
6.Do
Areyou
there
sometimes
unilateral
have
extremely
autonomic
short
attacks?
symptoms?
Trigeminal Neuralgia, Maarten van Kleef, World Institute of Pain , 2009
Clinical
Sensory
Pain Is
o x y s mal Examination
Pa r
Is Normal
Pain May 1969
Be
Pa i n
Provoked Unila I s
By Light te r a l
Touch To Pain Is
The Face Confined To
The Trigeminal
Distribution
DIAGNOSIS
• MRI - to investigate intracranial pathologies
or vascular compression
• Diagnostic inj. Of local anesthetic
MANAGEMENT OF TRIGEMINAL
NEURALGIA
MEDICAL SURGICAL
Carbamazepine Peripheral
• Neurolytic blocks
• Peripheral neurectomy
Oxcarbazepine
Gabapentin Ganglion procedures
• Rhizotomies
• Radiofrequency
Lamotrigine • Glycerol
• Percutaneous microcompression
Topiramate
Open Procedures
• Microvascular decompression
Baclofen
Clonazepam
MEDICINAL MANAGEMENT
1.TN does not respond to analgesics including opiates.
2. Blom (1962) showed a response to anticonvulsants.
3. Carbamazepine is highly specific in only relieving pain
of TN and not any other type of facial pain.
4. It has, therefore, suggested that its response can be
used as a diagnostic indicator.
Surgical Treatments
Indications
• Medication cannot control pain
• Patients cannot tolerate the adverse effects of the
medication
• Medically complex patients with polypharmacy for
other conditions.
PERCUTANEOUS
TECHNIQUES
Approach To Trigeminal root
RADIOFREQUENCY THERMOCOAGULATION
Radiofrequency electrode - Capacity to definitely
destroy pain fibres.
Electrocoagulation of
gasserian ganglion -
Introduced first by
Kirschner (1931) & later
modified by Sweet (1970)
• An electrode is advanced
into the Gasserian
ganglion, and heated to
thermally damage the
nervous tissue.
Broggi G, Franzini A, Lasio G. Long-term results of percutaneous retrogasserian thermorhizotomy for
essential trigeminal neuralgia: considerations in 1000 consecutive patients. Neurosurg. 1990;26:783-787.
THERMAL RHIZOTOMY
• Uses heat to selectively destroy A-
and C nociceptive fibers of trigeminal
branches while preserving A- and
touch fibers.
• The Gasserian ganglion and nerve
fibers are accessed by inserting a
needle into the cheek and through
the foramen ovale.
GLYCEROL RHIZOTOMY
• A needle placed through the foramen
ovale.
• Fluoroscopy and return of CSF are used
to confirm the location of the needle in
the trigeminal cistern.
• The amount of glycerol injected and
the patient’s head position can be
used selectively to affect different
trigeminal divisions.
BALLOON COMPRESSION
• Consists of inserting a needle through the
foramen ovale and advancing a Fogarty balloon
catheter into Meckel’s cave.
• Fluoroscopy is used to confirm its position.
•
• Once it is in position the balloon is inflated with
X-ray contrast medium upto 0.75 ml.
• When inflated, the balloon should take up the
pear shape of Meckel’s cave and it should
remain inflated for 1 minute
PERIPHERAL NERVE
PROCEDURES
Peripheral Alcohol Block
• Alcohol injections – Intraoral injection of 100% absolute
alcohol (0.5 – 1ml).
– Duration of pain relief- Fardy & Patton reported pain
relief for mean of 11 months*
• Disadvantages-
– Results are variable
– Repeated injections cause local tissue toxicity,
inflammation & Fibrosis
– Burning alcohol neuritis
– Avascular necrosis
Fardy MJ, Patton DWP. Complications associated with peripheral alcohol injections in
the management of trigeminal neuralgia. Br J Oral Maxillofac Surg. 1994;32:387-391.
Peripheral Injections
• Long acting local anaesthetic agents – without
adrenaline
• Bupivacaine with or without corticosteroids at the
most proximal possible nerve site.
PERIPHERAL NEURECTOMY
• Oldest and most effective peripheral nerve
destructive technique.
• Acts by interrupting the flow of a significant number
of afferent impulses to central trigeminal apparatus
• Performed most commonly on infraorbital , inferior
alveolar-mental and rarely lingual nerves.
Infraorbital Neurectomy
Incision upper buccal vestibule
Mucoperiosteal flap reflected
Nerve exposed & peripheral
branches are avulsed from mucosa
intraorally
Entire trunk is held with
haemostat at the exit point from
foramen & pulled out
Foramen is plugged with inert material
BRAUN’S TRANSANTRAL
APPROACH(1977)
Advantages –
• Provides direct access & better visualization.
Complications-
• Inadvertent section of the vessels in Pterygopalatine
fossa
• Inadvertent sectioning of the branches of
Sphenopalatine Ganglion
Inferior Alveolar Neurectomy
Approaches
1) Extraoral (Risdon’s incision)
2) Intraoral ( Dr Ginwalla’s incision)
Dr.Ginwalla’s Incision
Lingual Neurectaomy
Vertical incision made at inner border of
ascending ramus extending from coronoid
process down to level of floor of mouth
Nerve seen at the border of medial pterygoid
muscle
In region of floor of mouth , nerve lies more
superficially , found between ant pillar of
fauces at the root of tongue
Grasped with haemostat &
Avulsed/Cauterized/Cut
Closure
OPEN PROCEDURE
Microvascular Decompression
TRIGEMINAL ROOT SECTION
• Extradural sensory root section
• Intradural root section
• Trigeminal tractotomy
GAMMA KNIFE RADIOSURGERY
*Kondziolka D, Perez B, Flickinger JC, Habeck M, Lunsford D. Gamma knife
radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol.
1998;55:1524-1529.
CRYO THERAPY
INDICATIONS
• patients who wish to avoid MVD
• MVD is contraindicated
MECHANISM
Direct application of cryotherapy probe at temp
colder than -60ºC are known to produce Wallerian
degeneration of the nerve.
