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T RI GEM I N A L N EU RA

L GI A AND ITS MANAGEMENT

Rahul Sharma
Dept of OMFS
DAV Dental college
Introduction
Definition

Historical review of trigeminal neuralgia

Tic douloureux

Aetiology
Pathogenesis
General characteristics

Clinical characteristics

Diagnosis

Treatment modalities
Management
INTRODUCTION:

It is the most debilitating form of neuralgia that


affects the sensory branches of the Vth cranial
nerve.

It is a disorder of the peripheral or central fibres of


the trigeminal nerve in which the dominant symptom
is pain in the anterior half of the head.
DEFINITION:
It is defined as sudden, usually
unilateral, severe, brief, stabbing,
lancinating, recurring pain in the
distribution of one or more branches of
the Vth cranial nerve.
HISTORICAL REVIEW OF TRIGEMINAL
NEURALGIA:

JOHN LOCKE in 1677 gave the first full description


with its treatment.

NICHOLAS ANDRE in 1756 coined the term ‘Tic


Doloureux’.

JOHN FOTHERGILL in 1773 published detailed


description of trigeminal neuralgia.
TIC DOULOUREUX:

Tic douloureux painful jerking

It is a truly agonizing condition, in which the patient


may clunch the hand over the face & experience
severe, lancinating pain associated with spasmodic
contractions of the facial muscles during attacks

– a feature that led to use of this term


Trigeminal neuralgia can be classified as-

1. Typical T.N (paroxysmal pain alone)

2. Atypical T.N (paroxysmal pain with


constant pain)

or

1. Primary/ idiopathic

1. Secondary
AETIOLOGY:
Usually idiopathic
Demylination of the nerve
Multiple sclerosis
Petrous ridge compression
Post – traumatic neuralgia
Intracranial tumours
Intracranial vascular abnormalities
Viral etiology
PATHOGENESIS:
GENERAL CHARACTERISTICS:

Incidence: 8 : 1,00,000
Age: 5th – 6th decade of life
Sex: Female > male ; 1.6 > 1.0

Affliction for side: Right > left

Division of trigeminal
nerve involvement: V3 > V2 > V1
Pain distribution in trigeminal
neuralgia
CLINICAL CHARACTERISTICS:
Manifests as a sudden, unilateral, intermittent
paroxysmal, sharp, shooting, lancinating, shock like
pain, elicited by slight touching superficial ‘trigger
points’ which radiates from that point, across the
distribution of one or more branches of the
trigeminal nerve.

Pain is usually confined to one part of one division of


trigeminal nerve.

Pain rarely crosses the midline.

Attacks do not occur during sleep.


Pain is of short duration, but may recur with variable
frequency.

In extreme cases, the patient will have a motionless


face – the ‘frozen or mask like face’.

Common trigger zones include:

Cutaneous Intraoral
Corner of the lips Teeth
Cheek Gingivae
Ala of the nose Tongue
Lateral brow
DIAGNOSIS:

From well taken history


CT – scan
MRI
Diagnostic nerve block
Differential Diagnosis of Trigeminal Neuralgia
Features that differentiate from trigeminal
Diagnosis neuralgia
Cluster headache Longer-lasting pain; orbital or supraorbital; may
cause patient to wake from sleep; autonomic
symptoms
Dental pain (e.g., caries, cracked tooth, pulpitis) Localized; related to biting or hot or cold foods;
visible abnormalities on oral examination
Giant cell arteritis Persistent pain; temporal; often bilateral; jaw
claudication
Glossopharyngeal neuralgia Pain in tongue, mouth, or throat; brought on by
swallowing, talking, or chewing
Intracranial tumors May have other neurologic symptoms or signs
Migraine Longer-lasting pain; associated with photophobia and
phonophobia; family history
Multiple sclerosis Eye symptoms; other neurologic symptoms
Otitis media Pain localized to ear; abnormalities on examination
and tympanogram
Paroxysmal hemicrania Pain in forehead or eye; autonomic symptoms;
responds to treatment with indomethacin (Indocin)
Postherpetic neuralgia Continuous pain; tingling; history of zoster; often first
division
Sinusitis Persistent pain; associated nasal symptoms
Temporomandibular joint syndrome Persistent pain; localized tenderness; jaw
abnormalities
Trigeminal neuropathy Persistent pain; associated sensory loss
TREATMENT MODALITIES:

SURGICAL
MEDICAL
TENS- ?
MEDICAL MANAGEMENT:
It is the first line approach for most of the patients.

CARBAMAZEPINE:
Trade name: Tegretol
Carbitrol
Dosage: 100 – 2000 mg/day
Side effects: visual blurring
dizziness
skin rashes
rarely hepatic dysfunction, leukemia,
thrombocytopenia, aplastic anemia
PHENYTOIN:

It is usually used in conjunction with carbamazepine.

Trade name: Dilantin


Dosage: 200 - 600 mg/day (qid)
Side effects: slurred speech
abnormal movement
swelling of lymph glands
gingival hypertrophy
hirsustism
folate deficiency
GABAPENTIN:

It is more expensive than other drugs but has a less


side effects.

Trade name: Neurontin


Dosage: 100 - 5000 mg/day (tid-qid)
BACLOFEN:

It is a GABA agonists.
These drugs reduces the central projection painful
afferent impulses.

Trade name: Lioresal


Dosage: 10 mg (tds)
Side effects: fatigue
vomiting
TRICYCLINE ANTIDEPRESSANTS:

Amitriptyline 10 – 300 mg/day


Doxepin 10 – 300 mg/day
Nortriptyline 10 – 150 mg/day
Imipramine 10 – 300 mg/day
SURGICAL MANAGEMENT:
PERIPHERAL INJECTION:

It has been known that injection of destructive


substance into peripheral branches of the trigeminal
nerve, produces anaesthesia in the trigger zones or
in areas of distribution of spontaneous pain.

(A) LONG ACTING ANAESTHETIC AGENTS:

Without adrenaline such as bupivacaine with or


without corticosteroids may be injected at the
most proximal possible nerve site.
Han et al reported that 12 of 35 patients (34.3%)
responded favorably to trigeminal nerve block with 10
% lignocaine and were considered as success for a
total of 37 to 45 months.

Indications –

In patients with lower pain intensity and


shorter pain duration prior to the procedure
(B) ALCOHOL INJECTION:

0.5 – 2 ml of 95 % absolute alcohol can be used


to block the peripheral branches of the
trigeminal nerve.
Aim is to destroy the nerve fibres.
It produces total numbness in the region of
distribution of the nerve that was
anaesthetized.
Complication:
Necrosis of the adjacent tissue
Fibrosis
Alcohol induced neuritis
Oturai et al reported that the calculated half life
for pain relief was less than 1 month in a series
of 45 patients.

Fardy et al reported that median pain free time


was 13 months in 68 patients.
PERIPHERAL GLYCEROL INJECTION;-

Glycerol is found to be difficult to administer because


of its viscosity but is not as painful as absolute alcohol.

1 to 1.5ml of sterile glycerol should be administered


slowly through a wide-bore needle.

Erdem and Alkam treated 157 patients and reported


that the initial success rate was 98%. Pain reoccured in
60 patients and these patients were successfully
reinjected. At the end of 4 years, complete or almost
complete pain relief was obtained in 154 patients.
Disadvantages :

1. swellings

2. Altered sensation/ paraesthesia

OTHER PERIPHERAL INJECTIONS:

- 10% phenol in glycerol


- combination of streptomycin + lidocain
PERIPHERAL NEURECTOMY (NERVE AVULSION):
Oldest & most effective peripheral nerve destructive method
Can be repeated & relatively reliable technique.
It acts by interrupting the flow of a significant number of
afferent impulses to central trigeminal apparatus.
Performed commonly on infraorbital, inferior alveolar, mental
and rarely lingual.

Disadvantage:

May produce
full anaesthesia
deep hypoesthesia
INFRAORBITAL NEURECTOMY:

(i) Conventional intraoral approach


(ii)Braun’s transantral approach

Conventional intraoral approach:

A ‘U’ - shaped Caldwell – Luc incision is made


in the upper buccal vestibule in the canine
fossa region.
Mucoperiosteal flap is reflected superiorly to
locate the infraorbital foramen.
Once the nerve is exposed, all the peripheral
branches are held with the hemostat &
avulsed from the skin surface intra orally.
Then the entire trunk is separated from the
skin surface is held with the hemostat at the
exit point from the foramen & is removed by
winding it around hemostat & pulling it out from
the foramen.
Then it may be plugged with polyethylene plug.
Braun’s trans antral approach:

An intra oral incision is made from the


maxillary tuberosity to the midline in the
maxillary vestibule.
A 3 cm window is made in the antero – lateral
wall of the maxillary sinus.
The descending palatine branch of the
trigeminal nerve is identified & traced to the
sphenopalatine ganglion.
The maxillary nerve is sectioned from the
foramen rotundum to the inferior orbital
fissure.
The antral mucoperiosteal flap in the
vestibule is repositioned & sutured back.
INFERIOR ALVEOLAR NEURECTOMY:

(i) Extra oral approach


(ii)Intra oral approach

The extra oral approach:

Done through Ridson’s incision


After reflection of messater, a bony window
is drilled in outer cortex & nerve is lifted with
nerve hook & avulsed from its superior
attachment & mental nerve is avulsed
anteriorly through the same approach.
The intra oral approach:

Done via Dr Ginwalla’s incision


Incision is made along with the anterior
border of asescending ramus, extending
lingually & buccally & ending in a fork like an
inverted Y.
Incision is then deepened on the medial
aspect of ramus.
The temporalis & medial pterygoid muscles
are split at their insertion & inferior alveolar
nerve is located.
The nerve is ligated at two points in the most
superior part visible & divided between the
ligature.
The superior end is cauterized & the lower
end is held securely using a hemostat.
The mental nerve is also similarly ligated in
two points close to the mental foramen &
divided between two.
The remaining nerve is held at the inferior
alveolar end & wound around the hemostat &
excised from the canal.
LINGUAL NEURECTOMY:

An incision is made in the anterior border of


the ramus slightly towards the lingual side.
The lingual aspect is exposed & the lingual
nerve identified in the third molar region just
below the periosteum.
The nerve can be either
avulsed or ligated, cut
and the ends may
be cauterized.
Quinn and Weil found that there was a pain-free
mean period for 37.5 months of mental neurectomy,
38 months after inferior alveolar neurectomy, 44
months after lingual neurectomy and 38.5 months
after infraorbital neurectomy.

Complications :-

1. loss of sensation
2. edema
3. bruising
CRYOTHERAPY:
Barnard first used cryotheraphy in 1981 for
the treatment of the trigeminal neuralgia.
After identifying the affected nerve , it is
then exposed to the cryoprobe intraorally.
Direct application of cryotheraphy probe at
temperatures colder than -60 C are known to
produce Wallerian degeneration without
destroying the nerve sheath itself.
Nerve is exposed for 2 mins freeze followed
by 3 mins thaw cycle.
The freeze – thaw cycle is repeated at least 3
times.
Rahnama and Gaweda used peripheral cryotherapy
as a first line procedure if TENS and
pharmacotherapy were not effective. However ,
cryotherapy is usually performed in patients who
wish to avoid MVD or whom MVD is contraindicated.

Zakrzewska and Nally reported that after 1 year


only 27% were pain free, with a mean time to pain
recurrence of 10 months.
OPEN PROCEDURES ( INTRACRANIAL
PROCEDURES):
(A) Microvascular decompression of the
trigeminal nerve sensory root:
Procedure popularized in 1967 – 1976 by
Jannetta.
Most commonly performed intra cranial open
procedure.
Open craniotomy approach is
used to gain access to the
trigeminal root entry zone
and adjacent brainstem. The
root is examined under the
microscope
A compressing branch of
the superior cerebellar
artery will be seen
medial to the nerve at
the root entry zone.

Incision is made over the mastoid area


Then the trigeminal
nerve is freed from the
compressing / pulsating
artery.

After freeing the


nerve, the nerve is
separated from the
artery by placing a
piece of Teflon between
them.
Non absorbable
insulating sponge may
also be placed.
• Jannetta reported first time
performing MVD with a binocular
dissecting microscope.
• He also described-
pain in 3rd division ------ rostral
compression
pain in 2nd division ------ medial
compression
pain in 1st division ------ caudal
compression
Cause and location of compression and
prognosis :-
Therapeutic success is greater when vascular
contact is arterial in comparison to venous or
mixed arterial and venous contact.

Other factors affecting prognosis:-

Szapiro et al reported that patients with pain


in 2 or 3 branches of trigeminal nerve
responded to MVD less favorable than those
with pain 1 branch alone.
Results:-
• Barker et al ( followed avg period 6.2 years)
reported – pain reduced to 98% in 64% pts
(without medication)
- pain reduced to 75% in 4% pts.
(intermediate pain with medication)

recurrence rate less than 2% 5 years after MVD


less than 1% 10 years after MVD
Complications :-

• According to data available mortality rate after


MVD is 0.3% to 1%.

HEARING LOSS– permanent complete or partial


hearing loss is reported in 1% to 19%.
Intraoperative monitoring of brainstem auditory
evoked potential is valuable to reduce occurrence
of hearing.
SENSORY LOSS – sensory deficit following
MVD in 12% to 31% of all patients including
patients with sensory deficit before MVD.
PERCUTANEOUS RHIZOTOMY:

Mapping of trigeminal nerve :-


intraoperative topographic mapping of trigeminal
nerve root using electrophysiological methods
might be used as a guide for performing PSR.

• Gudmundsson et al reported that 3rd division


remained ventalateral throughout the interval
from the ganglion to the pons, 1st div. dorsolateral,
with 2nd div fibers being in an intermediate
position.
Indications:-
• PSR is performed in addition to or in place
of MVD,
1. In whom posterior fossa exploration
fails to reveal significant compression
of the trigeminal sensory root.
2. In whom MVD is technically infeasible
3. In whom MVD results in poor results
and no significant vascular compression
was present.
SURGICAL TECHNIQUE:-

Extradural sensory root section- Frazier’s


approach (1901)–
also known as the subtemporal extradural
retrogasserian rhizotomy
here sensory root is divided, sparing the
motor root as close to the brainstem as
possible.
• Rarely used and it is of historical value,
because of profound sensory loss and high
incidence of anesthesia dolorosa.
b. Intradural root section:-
- described by Wilkin (1966).
- superior to extradural approach as it has
less chance of damage to superior petrosal
nerve and facial nerve, less chance of
bleeding.
Young and wilkins reported that in 89%
patients 1/3rd to 1/2nd of cross-sectional
area of sensory root was cut in its
caudolateral aspect about 2 to 5 mm from
pons, while in 11%, 2/3rd of the nerve root
was cut.
(c) Trigeminal tractotomy:

It is also known as the medullary tractotomy.


This is not usually done.
The descending tract of the trigeminal nerve
is sectioned at the junction of the
cervicomedullary region.
Results:-

• Excellent results ---- 48% to 86%

• Young and Wilkins reported –


recurrence of pain, failure rate 1 year
after surgery was 17% and yearly
failure rates thereafter avg 2.6%.
Complications:-
• Post operative no or mild sensory deficit in
82%.

• Other complications –
- brainstem infarction
- ipsilateral deafness of neural origin
- leak of CSF
GASSERIAN GANGLION PROCEDURES:

In 1990 – Harris, Tapatas and Hartel separately


introduced percutaneous approaches to the ganglion via
foramen ovale.

This is done on the


Gasserian ganglion
which involve either
mechanically or
chemically damaging
parts of the trigeminal
nerve.
In 1931 Kirschner introduced percutaneous
electrocoagulation of the Gasserian ganglion.

Since then, three main percutaneous Gasserian


ganglion procedures are being used with variable
success rate-

a. Percutaneous Radiofrequency Thermocoagulation


of Trigeminal ganglion.

b. Percutaneous Glycerol gangliolysis of the


Trigeminal Ganglion.

c. Percutaneous Balloon Micro-compression of the


Trigeminal Ganglion.
Technique of needle penetration:

The foramen ovale is best


visualize with the x – ray tube
placed for a submentocortex
position.
Infiltration of the skin &
cheek is done with local
anaesthetic agent on the
affected side.

Three points of Hartel are


marked on the side of the face
using marking ink.
First point – a perpendicular line is drawn from the lateral
orbital rim to the inferior border of the mandible.
Second point – marked at 15 mm lateral to the angle of
the mouth on the perpendicular first line
Third point – marked at the level of TMJ 2.5 cm from the
centre of the external auditory meatus.
(A) Percutaneous radiofrequency thermocoagulation:

It was first introduced by Kirschner (1931) &


later modified by Sweet (1970).

Technique:
The patient is sedated with a short
acting sedative and vital signs are
monitored.
The electrode is inserted through the
cheek under fluoroscopy into foramen
ovale.
The patient is awakened briefly to
accurately locate the position of the
electrode.
Indication:

Toxicity of drugs
Failure of response to the other modalities
Dependence on the drugs for life time.
Elderly patients
Medically compromised patients
Advantages:

Comparative low rate of recurrence


Zero mortality
Thermocoagulation preserves the motor
function of the trigeminal nerve
Can avoid major surgical procedure
Disadvantage:
May cause
anaesthesia dolorosa
loss of corneal reflex
Meningitis (rarely)
(B) Percutaneous glycerol rhizotomy:

Glycerol is a neurolytic alcohol which can be


used to chemically destroy the nerve root.
Advantages:

Simple technique
Lower incidence
of anaesthesia
dolorosa

Complication:

Post operative headache, nausea, vomiting


Meningitis
Post operative herpes simplex perioralis
(C) Percutaneous balloon compression:

This is a mechanical means of destruction of


the trigeminal nerve introduced by Mullan &
Lichtor in 1980.

Technique:
A no. 4 Fogarthy’s catheter is introduced with
fluoroscopic guidance.
A 0.7 mm balloon is inflated for 1 – 2 minutes.
STEREOTACTIC RADIOSURGERY (GAMMA KNIFE):

This has been recently introduced in treatment


of trigeminal neuralgia.
This consists of multiple rays( 201 beams) of
high energy photons concentrated with absolute
accuracy on the target, i.e., on the trigeminal
nerve root.
This can be used to destroy
the specific components of
the nerve.

The source of radiation is


Co60.
Massager et al recommended that the nerve was
targeted at a distance of 5 to 8 mm from the
brainstem to optimize pain control and minimize
complications.

Indications:-

-GKS is considered to be a good choice after


failure of medication, MVD and percutaneous
ablative surgery.
-also effective for patients with TN
associated with MS, tumor and atypical TN.
DOSE:-

-IN BETWEEN 65- 90 GY

-The irradiation dose does not exceed 90 Gy.

- Pollock et al reported that 90 Gy of radiation


might be correlated with a better facial pain
outcome, but complication increased markedly
after 90 Gy radiosurgery.
Complications

In 15% cases- sensory disturbances


(numbness, dysesthesia, paraesthesia,
sensory loss.

Others- Masticatory dysfunction,


Keratitis
Anesthesia dolorosa
CYBERKNIFE RADIOSURGERY

CKS uses X-rays


produced by linear
acceleration radiation.
X-ray is biologically
identical to gamma
rays. CKS uses a single
high energy photon
beam fixed to as
robotic arm.
Unlike a GK a head
frame not required.
A patients is fixed to the treatment
table with a firm plastic mask and the
robotic arm is guided by a series of X-
rays images of the skull taken during
irradiation.

CKS for TN has high rates of initial pain


control and short latency to pain relief
compared with those for GKS.
CONCLUSION

Surgical approaches are performed when medication


can not control pain, patients can not tolerate the
adverse effects of the medication, or in medically
complex patients with polypharmacy for other
conditions

MVD is generally performed when the patient is


healthy and relatively young.

PSR is performed in addition to or in place of MVD,


whom posterior fossa exploration fails to reveal
significant compression of the trigeminal sensory root.
Thank you