Trigeminal Neuralgia: Pain, Treatment, Symptoms,

Diagnosis
Trigeminal Neuralgia

Trigeminal Neuralgia Pain Information

The sharp facial pain of trigeminal neuralgia (also known as tic douloureux) usually arises from pressure on
the trigeminal nerve caused by a blood vessel, usually the superior cerebellar artery.

 Other causes are tumor and multiple sclerosis, injury/damage to a nerve or lack of protective insulation of
trigeminal nerve.
 About four in 100,000 people experience trigeminal neuralgia per year, and the condition is most common in
males.

Symptoms

 Symptoms consist of intermittent shooting pain on one side of

the face emanating from one or more branches of the
trigeminal nerve.
 Symptoms, which last a few seconds, may be set off by
chewing, swallowing, talking or other sensory stimulation the
face.

Diagnosis

 Medical history and physical examination are key to diagnosing

trigeminal neuralgia. The history should determine the
following:
o An accurate description of pain localization to determine which divisions of trigeminal nerve are affected
o Determine the time of onset and what triggers the pain
o Determine what medications and dosages of medication have been tried
o Determine history of herpetic vesicles
 A magnetic resonance imaging (MRI) of the brain is used to rule out the possibility of tumor.

Treatment

Medical therapy

 The first line of treatment is medication.

 The drug of choice is carbamazepine (Tegretol™), which eliminates or brings acceptable pain relief in 69 percent
of patients.
 Baclofen (Lioresal™) is the second drug of choice and may be more effective if used with low-dose
carbamazepine.
 Other medications that may be effective include pimozide, phenytoin (Dilantin™), capsaicin, clonazepam
(Klonopin™) and amitriptyline (Elavil™).

Surgical procedures
  Percutaneous trigeminal radiofrequency rhizotomy
o This procedure selectively destroys pain-causing nerve fibers while
preserving touch fibers.
o Lesioning techniques include radiofrequency thermocoagulation,
glycerol injection and mechanical trauma. They are used for
patients who are poor candidates for major surgery.
o Complications can include weakness in chewing, facial numbness,
changes in tearing or salivation and, less often, corneal ulcers,
severe aching pain (anesthesia dolorosa) or meningitis.


 Microvascular decompression of the trigeminal nerve

o This surgical technique involves microsurgery to move the vessel,
causing compression away from the trigeminal nerve.
o Relief is often long lived; however the incidence of facial numbness
is much less than in selective rhizotomy and anesthesia dolorosa Trigeminal Neuralgia Patient: The
does not occur. Story of April
o The procedure is best for patients younger than 65 with no significant medical or surgical risk factors.
o Possible complications include asceptic meningitis, with head and neck stiffness; major neurological
problems, including deafness and facial nerve dysfunction; mild sensory loss; cranial nerve palsy,
causing double vision, facial weakness, hearing loss; and, on very rare occasions, postoperative bleeding
and death.
o Microvascular decompression brings complete relief to 75 percent to 80 percent of patients. The
recurrence rate is 5 percent to 17 percent.
 Glycerol injection
o This treatment is similar to that for radiofrequency rhizotomy. A needle is inserted in the region of the
trigeminal ganglion, and glycerol (a colorless fatty liquid used in many food and skin products) is
deposited nearby.
o Results of this procedure are less predictable because after the glycerol is injected its location cannot be
controlled precisely.
o Although 80 percent of patients treated with glycerol initially experience respite from trigeminal neuralgia,
more than half of these experience a return of the pain within five years after surgery.
o A small degree of numbness in the area of the pain remains after the procedure.
 Balloon compression
o This treatment is based on older treatments for trigeminal neuralgia consisting of massage or partial
injury of the trigeminal nerve.
o A small balloon is passed through a catheter (narrow tube) into the skull to the location of the trigeminal
ganglion. There it is inflated, and compression causes partial injury to the trigeminal ganglion.
o Pain is no longer transmitted to the brain, so the trigeminal neuralgia is, in effect, blocked.
o Because this procedure is new, results are less known and few surgeons are using this method.
 Stereotactic radiosurgery
o The treatment involves focusing radiation on the trigeminal nerve. The radiation will cause injury to the
nerve preventing it from transmitting the pain.
o There are different machines available to perform this procedure, including Gamma Knife, X-Knife,
Cyberknife and Novalis. UCLA uses Novalis. This machine is able to shape the beam to the shape of the
target.
o The success of this procedure is 90 percent to 95 percent with few side effects.

http://neurosurgery.ucla.edu/body.cfm?id=241
Part Two: Treatment of Trigeminal Neuralgia

III.  Surgery

B. Microvascular Decompression Surgery

     Microvascular decompression (MVD) surgery is performed under general

anesthesia, through an incision and small thumbprint sized bony opening
behind the ear (craniotomy). The surgeon peers into the opening through an
operative microscope, looks around the cerebellum (a structure of the brain)
and visualizes the trigeminal nerve as it arises from the brain stem
(the trigeminal nerve root entry zone).

    The aim of MVD surgery is to alleviate neurovascular compression upon

the trigeminal nerve root. This permits the trigeminal nerve nucleus to recover from its
state of hyperactivity and return to a normal, pain free condition. Micro-instruments are
used to mobilize the offending vessels away from the trigeminal nerve root. The
decompression is permanently maintained by inert implants, such as those made of
shredded Teflon® felt, between the offending vessels and nerve. 
  

Prior  During
to MVD,
MVD. the
vessel
is
mobili
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away
from
the
nerve
root
entry
zone.
 

The   MVD
decom has
 pressi resulte
on is d in
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Inert shredded Teflon®   Operating microscopes

felt implants.

    Following the microvascular decompression, the bone and incision are closed. The
patient is awoken from the anesthetic and is taken to the recovery room. Most patients
then remain in hospital for a couple of days, and gradually return to full activities within a
few weeks. TN pain relief is usually immediate, and medications are gradually
discontinued over two weeks following surgery. If pain does recur, it may be
more easily treated with medications than before, or retreated with any of the
neurosurgical procedure options.

    MVD is a non-destructive technique, and has the best potential for long-term relief or
cure of TN pain. However, there is a small risk of complications related to
cranial nerve damage including hearing loss and facial numbness. Intra-
Operative Monitoring has improved the safety of this procedure. Other risks
include the rare incidence of post-operative infection, inflammation or healing
difficulty leading to CSF leak. The risk of developing some facial numbness is
very small, and the development of deafferentation pain or anesthesia
dolorosa is almost unheard of. Other serious complications related to stroke,
bleeding, or swelling are exceptionally rare at centres with special expertise in
performing MVD surgery. 

. Types of Rhizotomies

a. Percutaneous Glycerol
Rhizotomy

     This is performed under local

anesthetic. A needle (typically 3.5" x
20 G spinal needle) is inserted in the
skin beside the mouth, and directed
through an opening at the base of the
skull (through the foramen ovale). A
harmless dye may be injected to
confirm the needle is in the precise
location, as seen on an x-ray. The
chemical glycerol is then injected into
the space surrounding the Gasserion
ganglion. This glycerol produces a
relatively mild injury to the nerve with
minimal risk of permanent facial
numbness. While the majority of patients achieve early relief of TN pain with
this technique, half of them will suffer a reoccurrence of pain within a few
years. Repeat glycerol rhizotomy or other procedure may then be performed.

Glycerol is a clear viscous liquid   X-ray imaging is used to direct the

chemical percutaneous needle to the
Gasserion ganglion
  

b. Percutaneous Balloon Compression Rhizotomy

     An alternative means to affect a percutaneous trigeminal rhizotomy is with

a balloon compression procedure.  This is performed while the patient is
under general anesthesia. The needle advanced to the Gasserion ganglion is
larger in caliber, and allows for the passage of a special catheter fitted with an
inflatable balloon. The balloon is inflated to compress and mechanically injure
the trigeminal nerve root and Gasserion ganglion. This form of percutaneous
rhizotomy is particularly effective for pain involving the upper face (V1), as it
has a small chance of causing permanent loss of sensation to the
cornea. However, many patients develop at least temporary weakness of the
chewing muscles following this balloon compression procedure, and the
degree of facial numbness is often more severe than with a glycerol
rhizotomy.

  

    
  

The introduced canula is positioned and balloon   The balloon is then inflated, injuring the
catheter advanced. nerve.

c. Radiofrequency Rhizotomy

     Another method of percutaneous rhizotomy is referred to as

radiofrequency rhizotomy. This procedure is performed with intravenous
sedation, although patients must be awake enough through the procedure to
describe the degree and extent of facial numbness produced by the
radiofrequency lesion. The specialized electrode is advanced to the Gasserion
ganglion, and its correct position tested with gentle electrical stimulation that
produces tingling sensations in the face. The electrode is then heated to
produce a thermal injury to the nerve, while the patient receives strong
sedation. This form of percutaneous rhizotomy has the best long-term pain
control, with about three-quartres of patients free of pain after five years.
However, the long term success is dependent upon some degree of
permanent facial numbness, and there is an associated risk of causing painful
numbness or anesthesia dolorosa.
  

    

A specialized electrode is positioned in the   The electrode is heated with radiofrequency

Gasserion ganglion. current causing thermal injury of the nerve.

d. Stereotactic Radiosurgery
(Gamma Knife)

     Recently, a new technique allows

for focused radiation to be delivered
to the trigeminal nerve root and
produces injury and results similar to
the other percutaneous rhizotomy
procedures.  Gamma Knife
Radiosurgery is performed by
applying a frame to the patient’s head
and then obtaining a MRI.  The
patient is then positioned in the
Gamma Knife, where up to 201
focused beams of cobalt radiation are
directed at the trigeminal nerve root. 
This affects a delayed injury upon the trigeminal nerve and reduces TN pain
within a few weeks in most patients. Higher doses of radiation may produce
better pain control, but increase risks of developing facial numbness and other
side effects. Details regarding the long-term effects and risks of this radiation
treatment are still being studied. 

e. Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions

     Some TN sufferers have

increased susceptibility to surgical
complications involved in the
procedures listed above. These
include the very elderly, frail or
medically infirm. A relatively simple
means to injure the trigeminal nerve
may be directed to trigeminal nerve
branches exiting the skull, just under
the skin or mouth lining. This portion of the nerve may be injured by injection
of alcohol, cutting (sectioning) or avulsion of the nerve branch. While these
techniques are usually effective immediately, they also cause severe or
complete numbness of the affected area, at least temporarily. TN pain often
recurs and therefore other surgical
interventions are usually chosen for
long-term disease control. 
f. Microsurgical Rhizotomy

     Surgical exposure and cutting of the trigeminal nerve root was introduced
decades ago and is an effective means to control TN pain, especially when
the lower face (V3) is involved. This operation, however, has been largely
replaced with microvascular decompression surgery and the percutaneous
rhizotomy techniques. In rare situations, microsurgical rhizotomy of the
trigeminal root may still be performed. This usually causes only partial loss of
lower facial sensation (or numbness).

http://www.umanitoba.ca/cranial_nerves/trigeminal_neuralgia/manuscript/rhizotomies.html