V Trigeminal Nerve

CASE HISTORY

For the last few months, Mary, a 55-year-old professor, has been
experiencing sudden attacks of extreme but short-lived pain on the
left side of her face. She described the pain as "hornet stings"
shooting through her jaw. The pain could be elicited by brushing her
teeth, stroking the left side of her face, or talking. She initially thought
her problem was related to her teeth and went to the dentist. Her
dentist was unable to find anything wrong with her teeth and
suggested that she see her family doctor.
When she saw her family doctor, Mary explained that the pain was
most frequent when she was lecturing in class and had become so
frequent and severe that she was finding it difficult to continue
teaching. The doctor did a neurologic examination and found that her
cranial nerves were functioning normally. He suggested that her pain
was probably due to hyperexcitablilty of her fifth cranial nerve (the
trigeminal nerve) and diagnosed trigeminal neuralgia. To treat this
condition he prescribed carbamazepine. Initially, Mary's symptoms
improved; however, months later they returned and, despite trials
with other anticonvul-sants, the pain persisted. Because Mary was
not improving, her doctor ordered magnetic resonance imaging
(MRI) and referred her to a neurosurgeon for consideration of surgi-
cal treatment of her condition.

ANATOMY OF THE TRIGEMINAL NERVE

Embryologically, the trigeminal nerve is the nerve of the first branchial
arch. The name trigeminal (literally, three twins) refers to the fact that
the fifth cranial nerve has three major divisions: the ophthalmic (Vt),
maxillary (V2), and mandibular (V3) divisions (Figures V—1 and V—2).
It is the major sensory nerve of the face and innervates several muscles
that are listed in Table V—1.
The trigeminal nerve emerges on the midlateral surface of the pons
as a large sensory root and a smaller motor root. Its sensory ganglion
(the semilunar or trigeminal or gasserian ganglion) sits in a depression
called the trigeminal cave (Meckel's cave), in the floor of the middle
cranial fossa. Sensory axons at the distal aspect of the ganglion form the
three major divisions (Vi, V2, and V3). The motor axons travel with the
mandibular division (V 3).
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