Rehabilitation of

patients suffering
Trigeminal Nerve Neuralgi

---------Li
Chenxiao
& Carlos

Gr.14
 Introduction
What is Trigeminal neuralgia?

Trigeminal neuralgia is sudden, usuall
y unilateral, severe brief stabbing pai
n in the distribution of one of more br
anches of the Vth cranial nerve


The condition is the most frequently occ
urring of all the nerve pain disorders. Th
e pain, which comes and goes, feels like
bursts of sharp, stabbing, electric-shocks
.
a i n
p
 Introduction
Anatomy
There are three divisions of V nerve

1. The ophthalmic (V1) supplies sensation to upper face including eyes.

2.The maxillary (V2) supplies sensation to middle face including upper teeth.

3. The mandibular (V3) supplies sensation to lower jaw including anterior two-
thirds of tongue.
 Introduction
Clinical features

Female > Male

Incidence : 4.3 / 100,000

Age group : 50 - 60 years

Paroxysmal recurrent pain of short duration

Trigger point(s), allodynia

Periods of remission

Recurrent episodes of pain with progressively shorter perio
ds of
remission

Distribution of pain :
– localised to Trigeminal nerve
– 80% Maxillary / Mandibular combination
– Right side > Left side

Clinical examination : Usually normal
 Rehabilitation & Treatment
I.Massage Therapy

Step1.Yang Bai point
In the frontal region, 1 finger's breadth superior to the
eyebrow, aligned with the pupil when the eyes are foc
used forward.  Massage it by forefinger for 1-3 minute
s.

Massage Therapy
Dizziness - Eye Disorders - Eyelid Itching - Eyelid Spas
m - Facial Muscle Paralysis - Headache Frontal - Lacri
mation - Lacrimation Upon Wind Exposure - Ptosis - S
upraorbital Neuralgia - Vertigo - Visual Disturbances
 Rehabilitation & Treatment
I.Massage Therapy

Step2.Si Bai point
Below the pupil about one finger's breadth, i
n a depression at the infraorbital foramen. M
ake an effort a little bit to Massage it by foref
inger for 1-3 minutes.
Massage Therapy
Dizziness - Eye Deviation - Eye Disorders - E
yelid Spasm - Facial Edema - Facial Muscle P
aralysis - Facial Pain - Headache - Lacrimatio
n - Mouth Deviation - Respiratory Disorders
- Trigeminal Neuralgia - Visual Disturbances
 Rehabilitation & Treatment
I.Massage Therapy

Step3.Jing Ming point
The crater between the canthus and th
e bridge of a nose. Make an effort a littl
e bit to Massage it for 1-3 minutes.
Massage Therapy
Benefits The Ears ,Benefits The Teeth,
Gums And Lips ,Clears Heat
Chills - Dizziness - Eye Disorders - Hea
dache - Lacrimation - Lacrimation Upo
n Wind Exposure - Visual Disturbances
 Rehabilitation & Treatment
II. Medical Management

The goal of pharmacologic
therapy is to reduce pain.
◦ Carbamazepine (Tegretol) – first line
◦ Oxcarbazepine
◦ Gabapentin (Neurontin)
◦ Lamotrigine Second line
◦ Baclofen
◦ Phenytoin
◦ Clonazepam
Others
◦ Valproate
◦ Mexiletine
◦ Topiramate
 Rehabilitation & Treatment
II. Medical Management

Side-effects occur in some people who take
these medications, more likely if higher doses
are needed.


The most common include:
- drowsiness,
- feeling sick,
- tiredness,
-dizziness.
Quite often these are only temporary, so it is worth persisting with the drug if the pains
ease and side-effects are not too bad.70% of patients get adequate control.


Rarely, these medications can cause serious blood or liver problems. Therefore, tell your
doctor if you develop any of the following whilst taking this drug: fever, sore throat, ulce
rs in your mouth, unexplained bruising or bleeding, yellowing of your skin, a rash - parti
cularly if the rash is of small purple spots, peeling of the skin, abdominal pain, nausea or
vomiting.
 Rehabilitation & Treatment
III. Surgical Management

A surgical procedure is recommended for patients who c
ontinue to experience severe pain or side effects from me
dications.
*Prior to considering surgery, all
trigeminal neuralgia patients should have
a MRI, with close attention being paid to
the posterior fossa.

Imaging is performed to rule out other

causes of compression of the trigeminal Neuro-
nerve such as mass lesions, large ectatic destructive
vessels, or other vascular malformations. procedure
 Rehabilitation & Treatment
III. Surgical Management

Gasserian ganglion-level procedures
Surgical
 Microvascular decompression (MVD) decompress
 Ablative treatments

Radiofrequency thermocoagulation (RFT)

Glycerol rhizolysis (GR)

Balloon compression (BC)
Neuro-

Stereotactic radiosurgery (SRS) destructive

Peripheral procedures procedure
 Peripheral neurectomy
 Cryotherapy (cryonanlgesia)
 Alcohol block
 Rehabilitation & Treatment
III. Surgical Management

There are 5 important neurosurgical procedures. Each is eff
ective, but not always, and occasionally has to be repeated.
These procedures are:
1.Gamma Knife radiosurgery (GKRS)
2.Radiofrequency Electrocoagulation (RFE)
3.Glycerol Injection (GLY)
4.Balloon Microcompression (BMC)
5.Microvascular Decompression (MVD)

All of these procedures treat the trigeminal nerve at aro

und the same place, close to where it leaves the brain.
 III. Surgical Management
1.Gamma Knife radiosurgery (GKRS)

It is the most recent and least invasive neurosurgical t
reatment for trigeminal neuralgia.
Of all the surgical procedures, it is least likely to cause c
omplications and uncomfortable new facial sensations
(dysesthesias).


GKRS is a method for treating certain problems in the
brain without making an incision. Two hundred-one b
eams of cobalt-60 radiation are focused precisely on a
specific region in the brain.
In the case of TN, the target area is the trigeminal nerve
, just where it leaves the brain. The treatment does not
require general anesthesia, and the patient stays in th
e hospital for less than five hours.


The success rate is roughly 80%-85%
A single 4 mm isocenter is focused on the left trigeminal nerve for
Gamma Knife treatment.
 III. Surgical Management
2.Radiofrequency Electrocoagulation

It destroys nerve fibers associated with pain.

A needle is inserted through the face and into the opening in th

e skull for the trigeminal nerve. Once the needle is in place, an
electrode is threaded through the needle until the electrode re
sts against the nerve root.

The electrode's position is verified by electrically stimulating t

he trigeminal nerve. A current is passed through the tip of the
electrode until it is heated to the desired temperature for abou
t 70 seconds.

The heated electrode damages the nerve fibers and creates an

area of injury (lesion).

If the pain is not eliminated,

additional lesions may be created.
 III. Surgical Management
3.Glycerol Injection (GLY)

Injection of glycerol into the gasserian ganglion is
a simple and effective treatment.

Using a brief, intravenous anesthetic a needle is in

troduced into the nerve in the base of the skull an
d a small amount of glycerol injected.
The treatment only takes a few minutes.

85%of patients achieve immediate pain relief and

persisting numbness in the face is unusual and inf
ection is rare. Recurrence rates are relatively high:
about ½ will recur over 3 to 4 years. Re-injection
may be performed, but glycerol injections become
less effective after several are performed.
 III. Surgical Management
4.Balloon Microcompression (BMC)

In this treatment a small balloon catheter is introduced t
hrough the needle into the nerve in the skull base.

With the patient anesthetized the balloon is briefly inflate

d to compress the nerve and then removed.

Initial pain relief is high: 93% and pain recurrence simila

r to radiofrequency treatment, about 20% over a few yea
rs. Numbness in the face, unfortunately is high (72%). Inf
ection again is a hazard
0.5~1 ml of contrast
Pear-shape balloon
Compression time: 1~7 min.
 III. Surgical Management
5.Microvascular Decompression (MVD)


It is the operation recommended for a healthy person who does not want n
umbness of the face and is willing to accept a major operation entering the
skull. It relieves trigeminal neuralgia by placing a small pad between the tri
geminal nerve and the blood vessels next to the nerve.
The operation requires making an incision in the back of the
head, creating a small hole in the skull, and lifting an edge of the
brain to expose the trigeminal nerve which is located
approximately two inches deep. The incision is made behind the
ear on the side of the head where the patient feels pain.

The blood vessels that press on the nerve when

the nerve leaves the brain are exposed and
pushed away from the nerve. A small pad is
inserted between the nerve and the vessels.
This relieves the pain in most patients.
 Results of Surgery

95-99% Excellent Pain Control Immedia
tely

75-80% Cure Rate

20-25% Recurrence usually between 1y
ear and 3 years post-operative

5% Complication Rate
 THANK Y
OU~