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Trigeminal Neuralgia and it’s Latest Treatment Options

Presentation by: Dr. Sundus Wahid Dr. Xainab Rasheed

Introduction

Trigeminal neuralgia, also referred to as tic douloureux, is a distinct, painful disorder of the face that is easily evoked by trivial stimuli. The International Association for the Study of Pain defines classical idiopathic trigeminal neuralgia (TN) as “a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve.”

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Anatomy of the Trigeminal Nerve

The trigeminal nerve is the fifth of twelve pairs of cranial nerves enervating the face and head. It has three divisions ophthalmic V1, maxillary V2 and mandibular V3. The trigeminal nerves function in sensing facial touch, pain and temperature, as well as controlling muscles used for chewing

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Pathway of Trigeminal Nerve Trigeminal Neuralgia and it's treatment options 4 .

Types of Trigeminal Neuralgia  Typical Trigeminal Neuralgia (Tic Douloureux)  This is the most common form of TN. Idiopathic and Essential TN. Nearly all cases of typical TN are caused by blood vessels compressing the trigeminal nerve root as it enters the brain stem Trigeminal Neuralgia and it's treatment options 5 . that has previously been termed Classical.

prominent constant and severe aching. Trigeminal Neuralgia and it's treatment options 6 . boring or burning pain superimposed upon otherwise typical TN symptoms.Types of Trigeminal Neuralgia  Atypical Trigeminal Neuralgia  Atypical TN is characterized by a unilateral.

may be symptoms of pre-trigeminal neuralgia Trigeminal Neuralgia and it's treatment options 7 . (such as a toothache) or discomfort (like "pins and needles". parasthesia). some sufferers experience odd sensations in the trigeminal distributions destined to become affected by TN.Types of Trigeminal Neuralgia  Pre-Trigeminal Neuralgia  Days to years before the first attack of TN pain. These odd sensations of pain.

Types of Trigeminal Neuralgia  Multiple SclerosisRelated Trigeminal Neuralgia  The symptoms and characteristics of multiple sclerosis (MS)-related TN are identical to those for typical TN. Two to four percent of patients with TN have evidence of multiple sclerosis and about 1% of patients suffering from multiple sclerosis develop TN. Trigeminal Neuralgia and it's treatment options 8 .

is referred to as secondary trigeminal neuralgia. A tumor that severely compresses or distorts the trigeminal nerve may cause facial numbness.Types of Trigeminal Neuralgia  Secondary or Tumor Related Trigeminal Neuralgia  Trigeminal neuralgia pain caused by a lesion. weakness of chewing muscles. and/or constant aching pain Trigeminal Neuralgia and it's treatment options 9 . such as a tumor.

Trigeminal Neuropathy or Post-Traumatic TN may develop following cranio-facial trauma (such as from a car accident). sinus trauma (such as following Caldwell Luc procedures) but most commonly following destructive procedures (rhizotomies) used for treatment of TN. These pain conditions are caused by irreparable damage to the trigeminal nerve and secondary hyperactivity of the trigeminal Trigeminal Neuralgia and it's nerve nucleus. Trigeminal Neuropathy or PostTraumatic Trigeminal Neuralgia  Injury to the trigeminal nerve may cause this severe pain condition. dental trauma. treatment options 10 .

Aetiology of Trigeminal Neuralgia  Tumors:       Acoustic neurinoma Chondroma at the level of clivus Pontine glioma Epidermoid Metastasis Lymphoma Pontine infarct Aerteriovenous malformation in the vicinity Persistence of primitive trigeminal artery Vascular decompression by superior cerebellar artery Multiple sclerosis Sarcoidosis Lyme disease neuropathy Trigeminal Neuralgia and it's treatment options 11  Vascular defects:      Inflammatory:    .

Trigeminal Neuralgia and it's treatment options 12 Demyelination of nerve fibers:  .primary or secondary .leads to uncontrolled firing of unmyelinated nerve fibres suggesting a partly central mechanism. Other experts hold that the painful stimuli are a result of an abnormality within the central nervous system. Demyelination of nerve.Pathophysiology of Trigeminal Neuralgia Increased refractory period of pain threshold:  The true cause of TN is unknown. A common hypothesis is that chronic irritation of the nerve by an artery leads to a greater than normal excitability of the nerve. This hyperexcitability then causes the brain to interpret normal sensory stimuli as exceedingly painful.

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Pathophysiology of Trigeminal Neuralgia (continued) Vascular decompression:  Arterial decompression is reported among 85% of the patients going under mitral valve disease and about 68% of venous decompression has been reported among such patients. Herpes simplex reactivation has been reported among 27-94% patients going under surgical procedures for treatment of trigeminal neuralgia. HSV is associated with altered trigeminal ganglionic function Viral agents:  Trigeminal Neuralgia and it's treatment options 14 .

Diagnosis of Trigeminal Neuralgia          History of the patient Imaging studies CT scan MRI MRA Conventional angiogram Enlarged views on the pontine area Clinical neurophysiology testing (blink reflex study). It indicates the bilateral delay in response to the stimulation on the pathological side. Selective blocking with local anesthetic at the nerve ending is helpful in determination of effected periphery Trigeminal Neuralgia and it's treatment options 15 .

Trigeminal Neuralgia : Epidermoid tumour  45 yr male with 3 yr of classic Trigeminal neuralgia MRI Trigeminal Neuralgia and it's treatment options 16 .

but with significant pain-free intervals  Usually unilateral  Almost exclusively a disorder of adults  Most common sights are mandibular or maxillary division of trigeminal nerve. severe. lacerating. opthalmic is rare. burning pain) lasting for not more than two seconds  Repetitious. Trigeminal Neuralgia and it's treatment options 17 . brief pain (Not constant.Characteristics of Trigeminal Neuralgia (TIC DOULOUREUX)  Confined to one or two divisions of the trigeminal nerve. most often within the lower two thirds of the face  Sudden.

Trigger Zones  Can be triggered by a non painful stimulus. Stimuli can be:  Touching  Applying heat or cold to the cheek or gum  Yawning. chewing  Wind blowing on the face  Gustatory stimuli or/and vibration Trigeminal Neuralgia and it's treatment options 18 . talking.

Sectioning and Avulsions including cryosurgery and neurectomy Microsurgical Rhizotomy Stereotactic Radiosurgery Medullary tractotomy Trigeminal Neuralgia and it's treatment options 19 .Treatment Options   Medical treatment options  Conventional drugs Microvascular Decompression Surgery Percutaneous Rhizotomies 1. Percutaneous Glycerol Injection 2. Radiofrequency Rhizotomy Surgical treatment options        Gamma Knife Radiosurgery Peripheral Trigeminal Nerve Blocks. Percutaneous Balloon Compression Rhizotomy 3.

Medical Treatment Options Carbamazepine (Tegretol®):  Dose: ranges from 600 to 1600 mg divided in three or four doses per day Trigeminal Neuralgia and it's treatment options 20 .

Medical Treatment Options Trileptal (Oxycarbazepine)  The dose usually begins at 300 mg twice a day and is gradually increased to achieve pain control. The maximum dose is 2400-3000 mg per day. Trigeminal Neuralgia and it's treatment options 21 .

Medical Treatment Options Phenytoin (Dilantin®)  Phenytoin relieves tic pain in over half of TN sufferers at doses of 300 to 500 mg. Trigeminal Neuralgia and it's treatment options 22 . divided into three doses per day.

Trigeminal Neuralgia and it's treatment options 23 . Baclophen has a short duration of function so sufferers with severe TN may need to take doses every 3 to 4 hours.Medical Treatment Options Baclophen (Lioresal®)  The usual dosage taken for complete pain relief is between 50 and 60 mg per day.

Trigeminal Neuralgia and it's treatment options 24 .Medical Treatment Options Gabapentin (Neurontin®)  The starting dose is usually 300mg three times a day and this is increased to a maximal dose.

Latest Surgical Treatment Options Trigeminal Neuralgia and it's treatment options 25 .

Microvascular Decompression Anatomical Approach Trigeminal Neuralgia and it's treatment options 26 .

the vessel is mobilized away from the nerve root entry zone. 27 Trigeminal Neuralgia and it's treatment options .Surgical Treatment Options  Microvascular Decompression Surgery alleviates neurovascular compression by placing inert shredded Teflon® felt implants between offending vessels and the trigeminal nerve root. The decompression is maintained with shredded Teflon® felt implants. During MVD. MVD has resulted in permanent alleviation of the neurovascular compression. Prior to MVD.

a controlled injury to the trigeminal nerve and Gasserion ganglion may be produced in one of three ways: 1) Percutaneous Glycerol Injection .Surgical Treatment Options  Percutaneous Rhizotomies involve inserting a needle through the cheek and into an opening at skull base (foramen ovale).glycerol is injected into the space around the Gasserion ganglion. There. Trigeminal Neuralgia and it's treatment options 28 . and chemically damages the nervous tissue.

a balloon is inflated next to the Gasserion ganglion. compressing and mechanically damaging the nervous tissue. 3) Radiofrequency Rhizotomy an electrode is advanced into the Gasserion ganglion. Trigeminal Neuralgia and it's treatment options 29 .Surgical Treatment Options 2) Percutaneous Balloon Compression Rhizotomy . and heated to thermally damage the nervous tissue.

Trigeminal Neuralgia and it's treatment options 30 .Surgical Treatment Options   Gamma Knife Radiosurgery focuses cobalt radiation upon the trigeminal nerve root. It is passed through foramen ovale into the trigeminal ganglion at the site of the defect. producing a delayed injury to nervous tissue that is similar to that produced by other percutaneous rhizotomy techniques. Radio Frequency Thermocoagulation: The needle used here is a reusable radio frequency electrode.

Trigeminal Neuralgia and it's treatment options 31 . Sectioning and Avulsions including cryotherapy involve injuring the peripheral portions of the trigeminal nerve external to the skull.Surgical Treatment Options  Peripheral Trigeminal Nerve Blocks.

Surgical Treatment Options  Microsurgical Rhizotomy involves surgical exposure and cutting of the trigeminal nerve root near its entry into the brain stem. Trigeminal Neuralgia and it's treatment options 32 .

80Gy.Surgical Treatment Options    Stereotactic Radiosurgery is used for the treatment of idiopathic TN. Gamma unit is used primarily 4mm single isocenter targeted 2 -4mm anterior to junction of pons and trigeminal nerve – 30% isodose is delivered to brain stem Dosage 70 . Trigeminal Neuralgia and it's treatment options 33 .

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