trigeminal neuralgia - dr sanjana ravindra

TRIGEMINAL NEURALGIA: THE DIAGNOSIS AND MANAGEMENT OF THIS EXCRUCIATING AND POORLY UNDERSTOOD FACIAL PAIN

TRIGEMINAL NEURALGIA: THE DIAGNOSIS AND MANAGEMENTOF THIS EXCRUCIATING AND POORLY UNDERSTOOD FACIAL PAINZakrzewska JM, McMillan R.Postgrad Med J 2011;87:410 - 416

Terminologies PAIN : an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damageNOCICEPTION: noxious stimulus originating from the sensory receptorSUFFERING: refers to how human reacts to perception of painNEURALGIA : actual pain in a nerve, several nerves or groups of nervesNEUROPATHY : disturbance in function or damage to the nervesNEUROPATHIC PAIN: any abnormality in components of the nervous system itself rather than to noxious stimulation of otherwise normal neural structures as with superficial & deep somatic pain disordersPAROXYSMAL : sudden recurrence or intensification ofsymptoms, such as aspasmor seizure. These short, frequent, and stereotyped symptomsNEUROPATHIC FACIAL PAIN : pain around the mouth or face that arises from a primary lesion or dysfunction of the nervous system

ANATOMY

www.teachme anatomy.com

The trigeminal nerve, CN V, is the fifth paired cranial nerve. It is also the largest cranial nerve.TN is the nerve responsible for most of the sensation in the face. It is bilaterally present. The motar component supplies masticatory muscles, mylohyoid, anterior belly of digastric tensor tympani, tensor veli palatineSensory root comprises of y ganglion is present on the termporal bone or the meckels cave.From there, it divides into 3 branchesFirst division is known as V1 provides sensation to the eye, upper eyelid and foreheadV2 provides sensation to the cheek, lower eyelid, nostril, upper lip and gumV3 providessensation to the area of the jaw, lower lip and gum. Also controls muscles responsible for chewing3

Trigeminal Neuralgia : sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve.The International Association for the Study of PainDEFINITION

Zakrzewska JM, McMillan R. Trigeminal Neura;gia: the diagnosis and management of this excruciating and poorly understood facial pain.Postgrad Med J 2011;87:410 - 416

Painful unilateral affliction of the face, characterized by brief electric shock like pain limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking, and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination and may remit for varying periods.Indian Headache Society DEFINITION

Synonyms Tic DouloureuxTrifacial neuralgia Fothergills disease

Synonyms

French word

It is named so because pain paroxysm are usually accompanied by spasm of the ipsilateral facial muscles.7

HISTORY

INCIDENCE(Penman, 1968).(Katusik et al., 1990 ; Rothman and Monson, 1973).

Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. 2007;334:201-205.

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Etiology

Joffroy A, Levivier M, Massager N. Trigeminal neuralgia Pathophysiology and treatment. Acta neurol. belg., 2001, 101, 20-25.

Dental pathosis is belived by some investigators to be involved with the onset of trigeminal neuralgiaAllergic- it can be secondary to an allergic and hypersensitivity reaction causing edema of the trigeminal nerve rootMechanical factors like pressure due to aneurysms of the intrapetrous portion of the ICA tat may erode through the floor of the intracranial fossa to exert a pulsatile irritation on the ventral side of te trigeminal ganglionAnomalies of superior cerebellar artery most recently blamed cause of trigeminal neuralgia. It lies in contact with te sensory root of the nerve and implicated as a cause of demyelnationSecondary lesion conditions such as carcinoma of the maxillary antrum, nasopharyngeal carcinoma, tumors of peripheral; nerve root, intracranial vascular anomalies, and multiple sclerosis may be presented with TN10

Pathophysiology

Nurmikko TJ, Eldridge PR, Trigeminal neuralgia- pathophysiology, diagnosis and current treatment. Br J Anaesth 2001; 87: 117-32.

Classic TN- pain is generated because of compression of the trigeminal nerve most commonly at the root entry zone by an artery or vein. Compression of the trigeminal root can be caused by superior cerebellar artery or tortuous vein11

Pathophysiology Ignition theoryDevor and colleagues

It is likely that both central and peripheral changes occur, which would explain why not all patients with a treated compression of the nerve get permanent relief

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International headache society

Types

THOSE WITH SYMPTOMATIC TRIGEMINAL neuralgia have either a compression of Tn caused by tumors or other structural abnormalities such as artieriovenous malformations, of multiple sclerosisClasical TN includes all cases with no definitive etiology identified apart from vascular compression of trigeminal nerve13

ATYPICAL TRIGEMINAL NEURALGIAPRE- TRIGEMINAL NEURALGIAMULTIPLE SCLEROSIS RELATED TRIGEMINAL NEURALGIAFAILED TRIGEMINAL NEURALGIA

Types

ATYPICAL TRIGEMINAL NEURALGIA:

MULTIPLE SCLEROSIS RELATED TN: symptoms of MS related TN are identical to typical TN. Bilateral TN is more commonly seen in people with MS. MS involves formation of demyelinating plaques within the brain.

PRE- TRIGEMINAL NEURALGIA: - Days to years before the first attack of TN pain, some sufferers experience odd sensations of pain,( such as toothache) or discomfort( parasthesia).FAILED TRIGEMINAL NEURALGIA:In certain cases, all medications, surgical procedures prove ineffective in controlling TN pain.Such individual also suffer from additional trigeminal neuropathy as a result of destructive intervention they underwent.

Clinical features

CLINICAL FEATURES

Extreme cases- motionless face- frozen/ mask like face

Quality of tn PAIN TYPICALLY ARISES IN THE PERSONS, WHO HAVE NO ABNORMAL NEUROLOGIC DEFICIT SUCH AS LOSS OF CORNEAL REFLEXES, ANESTHESIA, PARESTHESIA, MUSCULAR ATROPHY OR WEAKNESS ETCEven though there is a refractory period ie complete lack of pain between the attacks, some patients report a dull ache inbetween the attack The paroxysms occur in cycles, each cycle lasting for weeks or months and with time the cycle appears closer and closer.with each attack the pain seems to become more intense and unbearable.

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Trigger factors

Trigger zones and trigger points

The pain is provoked by light touch- trigger zones is an area of facial skin or oral mucosa where low intensity mechanical stimulation (light touch,an air puff, or even hair bending can elicit typical facial pain). Reported trigger factors are:specific area that, when stimulated by touch, pain, or pressure, excites an attack of neurologic pain.19

Patients description of pain


Patients description of pain that are pathognomic for TNThese descriptors imply not only the sharpness of the pain but also its rapidity and severity. Many patients vividly remember their first attack, and surgeons have gone so far as to say that patients who have a memorable onset are more likely to have good outcomes.13 The pain develops rapidly and lasts for no more than 2 min. Sometimes it is difficult for patients to appreciate that there are very short breaks between each attack of pain. Characteristically there is a refractory period. The severity of the pain varies from mild to extremely severe, resulting in weight loss and inability to maintain good oral hygiene22

WHITE AND SWEET DIAGNOSTIC CRITERIA FOR TRIGEMINAL NEURALGIA

Okeson JP. Bells Orofacial pains. 6th edition. 2005.

Investigations

MRI showing neurovascular compression of right trigeminalnerve.Zakrzewska JM, McMillan R. Trigeminal Neura;gia: the diagnosis and management of this excruciating and poorly understood facial pain.Postgrad Med J 2011;87:410 - 416

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Differential diagnosis


SYMPTOM TRIGEMINAL NEURALGIA PULPITISCHARACTERShooting, stabbing, sharp, electricSharp, aching, throbbingSITE/ RADIATIONTrigeminal nerve distribution only, intraoral and extraoralAround a tooth, intraoralSEVERITYModerate to severeMild to moderateDURATION1-60 s Refractory periodRapid but no refractory periodPERIODICITYRapid onset and termination, complete periods of remission weeks to monthsUnlikely to be more than 6 monthsPROVOKING FACTORSLight touch, non- nociceptiveNo change on postural changesHot/ cold applied to teeth Increases on lying down position RELIEVING FACTORSKeeping still, drugsAvoid eating on that side, drugsASSOCIATED FACTORSLA placed in trigger area relives pain, severe depression and weight lossDecayed tooth, exposed dentine

SYMPTOM TRIGEMINAL NEURALGIA NEUROPATHIC TRIGEMINAL PAINCHARACTERShooting, stabbing, sharp, electricAching, throbbingSITE/ RADIATIONTrigeminal nerve distribution only, intraoral and extraoralAround a tooth or area of past trauma/ dental surgery or facial traumaSEVERITYModerate to severeModerate. Continuous soon after surgeryDURATION1-60 s Refractory periodContinuous soon after injury PERIODICITYRapid onset and termination, complete periods of remission weeks to monthsContinuous PROVOKING FACTORSLight touch, non- nociceptiveLight touch RELIEVING FACTORSKeeping still, drugsAvoid touchASSOCIATED FACTORSLA placed in trigger area relives pain, severe depression and weight lossHistory of dental treatment or trauma in the area, may be loss of sensation, allodynia near pain, LA relives pain

NEURALGIA : actual pain in a nerve, several nerves or groups of nervesNEUROPATHY : disturbance in function or damage to the nervesNeuropathic facial pain (NFP) is defined as pain around the mouth or face that arises from a primary lesion or dysfunction of the nervous systemNeuralgia is a symptom of nerve dysfunction present within the brain stem or within the nerve segment running to the trigeminal ganglion located within the base of the middle cranial fossa

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SYMPTOM TRIGEMINAL NEURALGIA TMDCHARACTERShooting, stabbing, sharp, electricDull, aching, nagging, sharp at timesSITE/ RADIATIONTrigeminal nerve distribution only, intraoral and extraoralPre- auricular, radiates down mandible, temple area, may be postauricular or neckSEVERITYModerate to severeMild to severeDURATION1-60 s Refractory periodLats for hours, mainly continuous can be episodic PERIODICITYRapid onset and termination, complete periods of remission weeks to monthsTends to build up slowly and diminish slowly, lasts for yearsPROVOKING FACTORSLight touch, non- nociceptiveClenching teeth, prolonged chewing, yawningRELIEVING FACTORSKeeping still, drugsRest, decrease mouth openingASSOCIATED FACTORSLA placed in trigger area relives pain, severe depression and weight lossMuscle pain in other parts of the body, limited opening, clicking on wide opening

SYMPTOM TRIGEMINAL NEURALGIA SHORT UNILATERAL NEURALGIFORMWITH AUTONOMIC SYMPTOMS OR CONJUNCTIVAL TEARING CHARACTERShooting, stabbing, sharp, electricBurning, stabbing, sharpSITE/ RADIATIONTrigeminal nerve distribution only, intraoral and extraoralPeriorbital but can affect maxillary divisionSEVERITYModerate to severeSevereDURATION1-60 s Refractory periodEpisodic 5-240s PERIODICITYRapid onset and termination, complete periods of remission weeks to monthsNumerous, can be periods of complete remissionPROVOKING FACTORSLight touch, non- nociceptiveLight touch RELIEVING FACTORSKeeping still, drugsNilASSOCIATED FACTORSLA placed in trigger area relives pain, severe depression and weight lossOften restless

SYMPTOM TRIGEMINAL NEURALGIA PAROXYSMAL HEMICRANIACHARACTERShooting, stabbing, sharp, electricThrobbing, BoringSITE/ RADIATIONTrigeminal nerve distribution only, intraoral and extraoralOrbit, templeSEVERITYModerate to severeSevereDURATION1-60 s Refractory periodEpisodic 2-30 minPERIODICITYRapid onset and termination, complete periods of remission weeks to months1-40 a day, can be periods of complete remissionPROVOKING FACTORSLight touch, non- nociceptiveNilRELIEVING FACTORSKeeping still, drugsIndometacinASSOCIATED FACTORSLA placed in trigger area relives pain, severe depression and weight lossMay have migrainous features

Treatment Pharmacological treatment Surgical treatment


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Drug Daily dose Mechanism UseSide effects Carbamazepine TEGRETOL, CARBATOL200- 1000 mg in 2 divided dozeSlows recovery rate of voltage- gated sodium channels, modulates activated calcium channel activity and activates descending inhibitory modulation system Begin with small doses, depending on tolerability, retard version useful at night Nausea, drowsiness, fatigue, dizziness, memory problem, diplopia, nystagmus, liver dysfunctionOxcarbazepine 300 1800 mg daily in 2 divided doses - -Use on a four times daily basesDecreased blood sodium level, dizziness, fatigue, headache, tremors, drowsiness, dimished concentration, diplopia and stammeringGabapentin NEURONTIN1200- 3600 mg daily in 3-4 divided dose Unknown. But possibly includes blockage of voltage- gated calcium channels by binding to alpha subunitsInjected weekly into trigger zones Fatigue, dizziness, ataxia, nystagmus and tremor

Pharmacological treatment

Drug Daily dose Mechanism UseSide effects Phenytoin EPILEPTIN EPTOIN300- 500 mg daily Promotes sodium efflux from neuronsAlong with carbamazepineNystagmus, ataxia, slurred speech, decreased coordination, mental confusion Lamotrigine LAMITOR100- 150 mg daily in 2 divided doses Decreases repetitive firing of sodium channels by slowing the recovery rate of voltage- gated channels.Initially very slow escalation. Can use along with carbamazepine Decreased blood sodium level, dizziness, fatigue, headache, tremors, drowsiness, dimished concentration, diplopia and stammering

Pharmacological treatment

Surgical treatment


PERIPHERAL TECHNIQUESCryotherapyNeurectomiesPeripheral radiofrequency thermocoagulations (RFT s)Injections- alcohol, phenol & streptomycin


Insuuficient evidence to support use of peripheral treatments39

THERAPEUTIC BLOCK

PERCUTANEOUS PROCEDURES AT THE LEVEL OF GASSERIAN GANGLION

Under heavy sedation/ short GAGanglion is then lesioned under heat(RFT)INJ OF GLYCEROLMechanical compression by use of a balloon41

GAMMA KNIFE SURGERY

Ablative procedureTargets the trigeminal root entry zone in post cranial fossaFocuses a beam of radiation at this pointGamma Knife contains 192- 201 cobalt-60 sources of approximately 30 curies 42

MICROVASCULAR DECOMPRESSION

MVD is a surgical procedure to relieve the symptoms (pain, muscle twitching) caused by compression of a nerve by an artery or vein. MVD involves surgically opening the skull (craniotomy) and exposing the nerve at the base of the brainstem to insert a tiny sponge between the compressing vessel and the nerve. This sponge isolates the nerve from the pulsating effect and pressure of the blood vessel.

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PATIENT INFORMATION


As well as knowing the optimal drugs to use, it is importantthat doctors understand how patients can maximise the effectsof these drugs. We provide information leaflets, which includesome of the following instructions:

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President of theConfederate States of America[47] American politician who was a U.S. Representative and Senator from Mississippi, the 23rd U.S. Secretary of War, and thePresident of the Confederate States of Americaduring theAmerican Civil War. One of India's biggest film stars,Salman Khan, was diagnosed with TN in 2011. He underwent surgery in the USAll-IrelandwinningGaelic footballerChristy Toyewas diagnosed with the condition in 2013. He spent five months in his bedroom at home, returned for the 2014 season

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Reason for choosing this article

Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71:1183e90.

Nurmikko TJ, Eldridge PR, Trigeminal neuralgia- pathophysiology, diagnosis and current treatment. Br J Anaesth 2001; 87: 117-32.

Joffroy A, Levivier M, Massager N. Trigeminal neuralgia Pathophysiology and treatment. Acta neurol. belg., 2001, 101, 20-25.

Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Clin Evid (Online);2009:1207.

Tyler-Kabara EC, Kassam AB, Horowitz MH, et al. Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 2002;96:527e31

Gupta A, Singh SK, Sahu R. Trigeminal Neuralgia A review Journal of dentofacial sciences 2012; 1(1): 27-31

REFERENCES

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REFERENCESBennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. 2007;334:201-205.Zakrzewska JM, Linskey ME. Trigeminal neuralgia. In: Zakrzewska JM, ed. Orofacial Pain. New York: Oxford University Press; 2008, pp 119-134.Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain 2001;124:2347e60.Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol 2008;15:1013e28.Weigel G, Casey KF. Striking Back. The Trigeminal Neuralgia Handbook. Barnegat Light: The Trigeminal Neuralgia Association, 2000 Wiffen P, Collins S, McQuay H, et al. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2005;(3):CD001133Tolle T, Dukes E, Sadosky A. Patient burden of trigeminal neuralgia: results from a cross-sectional survey of health state impairment and treatment patterns in six European countries. Pain Pract 2006;6:153e60

B D Chaurasia. Human Anatomy Regional and Applied Dissection and Clinical Vol.3 CBS Publishers & Distributers;2004.Okeson JP. Bells Orofacial pains. 6th edition. 2005.www.teachme anatomy.comGreenberg, Glick.,BURKETS Oral Medicine 12th Edition: 2012, CBS PublishersLaskin MD, strauss RA. Oral and maxillofacial surgery clinics. 2003Textbook of Oral & Maxillofacial Surgery by Neelima Anil Malik, 2 nd Edition 2008, Jaypee PublishersPereira EAC. Trigeminal Neuralgia-Divided but Not Classified.Anesth Pain. 2012;2(2):101-2. Serivani SJ, Mathews ES, Maciewicz RJ. Trigeminal Neuralgia. Oral surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100:527-38Rothman KJ, Monson RR. Survival in trigeminal neuralgia. J Chronic Dis 1973;26:303e9.

REFERENCES

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trigeminal neuralgia - dr sanjana ravindra

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