TRIGEMINAL NEURALGIA

Presented byWita I.Septina

Supervised byHarmas Yazid Yusuf, drg. SpBM

INTRODUCTION

• Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve.

• Incidence 4-5 cases : 100.000

• TN or Tic douloureux occur patients > 50 years.

• Male : Female ratio 2 : 3

• Unilateral (97%). Most affected V2 and V3.

• The pain is intense, usually sharp, electric shocklike pain in face, lasting periods of seconds to 2 minutes ,

ANATOMY TRIGEMINAL NERVE

• Cranial Nerve V o Sensoric Portio major o Motoric Portio minoro Sensoric + motoric Ganglion Semilunare

Gasseri

Fig 1. DistributionTrigeminal nerve

1.Typical Trigeminal Neuralgia(Tic Douloureux)

• Most common form of TN

• Caused by blood vessels compressing the trigeminal nerve root enters the brain stem

• Irritation from repeated pulsations caused hyperactivity of the trigeminal nerve nucleus resulting TN pain

• Fig 2

CLASSIFICATION

(a) (b) (c)

Fig 2. Anatomy Trigeminal nerve and Trigeminal neuralgia

CLASSIFICATION

2. Atypical Trigeminal Neuralgia• Unilateral

• Prominent constant

• Boring or burning pain

• Caused by vascular compression upon a specific part of trigeminal nerve (portio minor)

• A more severe from or progression of typical TN

3. Pre - Trigeminal Neuralgia

Symptoms : odd sensations of pain or discomfort before the first attack of TN pain

4. Multiple Sclerosis-Related Trigeminal Neuralgia• The symptoms & characteristics identical Typical TN• 2 - 4% patients with TN have multiple sclerosis (MS)• MS formation of demyelinating plaques within the brain• First attack of pain younger patients , bilateral

CLASSIFICATION

CLASSIFICATION

5. Secondary Trigeminal Neuralgia• Caused by a lesion (tumor)

• A tumor compresses or distorts the trigeminal nerve facial numbness, weakness of chewing muscles, constant pain

• Fig 3.

6. Post-Traumatic Trigeminal Neuralgia

• Develop following cranio-facial trauma, dental trauma, sinus trauma, destructive procedures (rhizotomies)

• Injury caused severe pain, constant ,triggers such as wind and cold, start immediately or days to years following injury

Fig. 3 MRI--- Tumor compressed trigeminal nerve

7. Failed Trigeminal Neuralgia Medications, microvascular decompression, and

destructive rhizotomy procedure ineffective in controlling TN pain

CLASSIFICATION

ETIOLOGY

1.Blood vessels compression at the trigeminal nerve root

2.Demyelination nerve3.A tumor compresses trigeminal nerve4.Injury to the trigeminal nerve5.Un known

Clinical Features

1. Severe paroxysmal pain2. The pain intense, stabbing, electrical shock- like, one

side3. Frequently pain free between attacks.4. Lasting only seconds to two minutes 5. Each attack spontaneously or be triggered by specific

light stimulation 6. Common triggers include touch, talking, eating, drinking,

chewing, tooth brushing, hair combing and kissing.

Fig. 4 Progression of Trigeminal Neuralgia

DIAGNOSIS

• Anamnesis • Clinical examination• CT scan and MRI• MRIA

Differential Diagnosis

1.Glossopharyngeal neuralgia2.Occipital neuralgia3.Paroxysmal hemicrania syndromes4.Migraine and cluster headaches5.Trigeminal neuropathy

TREATMENT

• Medication• Surgical procedure

TREATMENT

Medication

• Carbamazepin (Tegretol)o Anticonvulsants, Drug of choice for TN, effective dose 600 -1200

mg/ day for 3-4 x/ day o Maintenance dosage 200 mg/d to prevent recurrences

o Side effect : drowsiness, mental confusion, dizziness, nystagmus,ataxia

• Oxycarbazepine (Trileptal)o Side effect : nausea, fatique, tremoro Dose : 2 x 300mg, maximum dose : 2400-3000 mg/day

TREATMENT

• Phenytoin (Dilantin)o Dose: 300-500mg/day for 3x/day

• Side effect : nystagmus, dysarthria, gingival hyperplasia, hypertrichosis, allergic skin rash

• Gabapentin (Neurontin)o Dose : 1200 - 3600mg/d, initial dose ; 3x300mg/d.o Side effect : somnolen, ataxia, fatique

TREATMENT

• Baclophen (Lioresal)

Antispasmodic agents

Initial dose : 2-3 x 5 mg/ day. Duration of action short

Side effect : nausea, fatique

TREATMENT

Surgical Procedure For patients medical therapy has failed surgery is a viable and

effective option

• Microvascular decompression

• Nerve Injury/ Destructive Procedure (Rhizotomy)• Percutaneus Glycerol Rhizotomy• Percutaneus Balloon Compression Rhizotomy• Radiofrequency Rhizotomy• Stereotactic Radiosurgery (Gamma Knife)• Microsurgical Rhizotomy

TREATMENT

• Microvascular decompressiono non-destructive technique

o Under general anesthesia, incising the skin behind the ear (Craniotomy)

o Identify an arterial loop compressing the nerve pad the vascular structure with Teflon felt

o Complication: CSF leaks, hearing loss, permanent anesthesia over the face

TREATMENT

• Nerve Injury/ DestructiveProcedure (Rhizotomy)

1. Percutaneus Glycerol Rhizotomy The surgeon introduces a trocar or needle lateral to the

corner of the mouth into foramen ovale glycerol–ganglion Gasseri nerve injury

2. Percutaneus Ballon Compression Rhizotomy Under general anestesia – operator insert a balloon

catheter through the the foramen ovale the region of the ganglion

3. Radiofrequency Rhizotomy Intravena sedation electroda insert to ganglion

electroda to heat thermal injury to ganglion

4. Strereotactic Radiosurgery (Gamma Knife) Gamma Knife Radiosurgery target the nerve with

stereotactic MRI, determined radiation dose to guickly relief pain without facial sensory loss

5. Microsurgical Ryzotomy

TREATMENT

CONCLUSION

• Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve.

• Treatment for TN medication is the initial therapy if pharmacologic treatment fails surgical procedure.