Dr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO:4118 TAMILNADU-INDIA(ASIA)

IntroductionIntroduction

Treatment of neuralgias lays a Treatment of neuralgias lays a challenging task to the surgeons.challenging task to the surgeons.

Various medical and surgical procedures Various medical and surgical procedures have been proposed to treat them.have been proposed to treat them.

Success lies in complete control of pain Success lies in complete control of pain and other symptoms – which is rarely and other symptoms – which is rarely achieved –due to the recurrence which achieved –due to the recurrence which follows with all the procedures.follows with all the procedures.

Protocol for diagnostic nerve blocksProtocol for diagnostic nerve blocks

Materials requiredMaterials required 1cc syringe, 25 gauze needle, normal 1cc syringe, 25 gauze needle, normal

saline, LA without adrenaline.saline, LA without adrenaline.Always begin injections at the site of pain Always begin injections at the site of pain

and then move proximally.and then move proximally.Inject 0.5 ml of normal saline at test site. Inject 0.5 ml of normal saline at test site.

wait for 5 min, if pain is relieved then wait for 5 min, if pain is relieved then psychogenic pain is likely.psychogenic pain is likely.

Cont….Cont…. If pain persists, the inject 0.5 ml of 2 % If pain persists, the inject 0.5 ml of 2 %

lignocaine without adrenaline at surface lignocaine without adrenaline at surface site and wait for 5 min, if pain is relieved site and wait for 5 min, if pain is relieved then direct therapy at small nociceptor then direct therapy at small nociceptor fibres.fibres.

If pain persists, inject little deeper and wait If pain persists, inject little deeper and wait for 5 min, if pain is relieved then consider for 5 min, if pain is relieved then consider musculoskeletal origin of pain.musculoskeletal origin of pain.

If pain is not relieved, inject more proximal If pain is not relieved, inject more proximal portion of nerve, if pain is relieved, direct portion of nerve, if pain is relieved, direct therapy at site.therapy at site.

TREATMENT MODALITIESTREATMENT MODALITIES

Two types:Two types:

Medical managementMedical management

Surgical managementSurgical management

CONT…..CONT…..

Once the diagnosis of trigeminal neuralgia Once the diagnosis of trigeminal neuralgia is made – first medicinal treatment is is made – first medicinal treatment is advocated.advocated.

If the patient does not respond to it, the If the patient does not respond to it, the only surgical treatment is opted.only surgical treatment is opted.

Medical managementMedical management

TN does nor respond to analgesics and TN does nor respond to analgesics and opioids.opioids.

Blom (1962) showed response to Blom (1962) showed response to anticonvulsants.anticonvulsants.

Carbamazepine (Tegretol)Carbamazepine (Tegretol) is highly is highly specific in only relieving pain of TN and specific in only relieving pain of TN and not any other type of facial pain.not any other type of facial pain.

Dose:Dose: 100 mg thrice/day. Maximum dose 100 mg thrice/day. Maximum dose of upto 1200 mg / day.of upto 1200 mg / day.

Side effects of carbamazepineSide effects of carbamazepine

Visual blurring, dizziness, skin rashes and Visual blurring, dizziness, skin rashes and ataxiaataxia

Rarely – heptic dysfunction, leukopenia, Rarely – heptic dysfunction, leukopenia, thromobocytopenia – aplastic anemia.thromobocytopenia – aplastic anemia.

Other drugsOther drugs

1.1. Phenytoin (Dilantin) – 100mg –tdsPhenytoin (Dilantin) – 100mg –tds2.2. Sodium valproate – 600 mg / daySodium valproate – 600 mg / day3.3. Baclofen – 10 mg tdsBaclofen – 10 mg tds4.4. Gabapentin Gabapentin 5.5. Lamotrigine Lamotrigine 6.6. Felbamate Felbamate 7.7. Topiramate Topiramate

Surgical modalitiesSurgical modalities

Peripheral / central injections:Peripheral / central injections: Peripherally - mental, inferior alveolar, Peripherally - mental, inferior alveolar,

infra orbital nerves.infra orbital nerves. Intracranially - trigeminal ganglion.Intracranially - trigeminal ganglion.

drugs used:drugs used:1. long acting local anesthetics1. long acting local anesthetics2. alcohol – 95%2. alcohol – 95%3. phenols3. phenols

Peripheral neurectomy Peripheral neurectomy (nerve avulsion)(nerve avulsion)

Oldest and most effective peripheral nerve Oldest and most effective peripheral nerve destructive technique.destructive technique.

Acts by interrupting the flow of a significant Acts by interrupting the flow of a significant number of afferent impulses to central trigeminal number of afferent impulses to central trigeminal apparatus.apparatus.

Commonly – infraorbital, mental and inferior Commonly – infraorbital, mental and inferior alveolar nerves.alveolar nerves.

To achieve better results the nerve is avulsed To achieve better results the nerve is avulsed both from the bone as well as from the soft both from the bone as well as from the soft tissues.tissues.

ApproachesApproaches

Inferior alveolar nerve :Inferior alveolar nerve :1. intraoral – Ginwalla’s technique1. intraoral – Ginwalla’s technique2. extraoral – Risdon’s approach2. extraoral – Risdon’s approach

Infraorbital nerve:Infraorbital nerve:1. intraoral – vestibular – caldwell –luc1. intraoral – vestibular – caldwell –luc

approach or transantral approachapproach or transantral approachMental nerve:Mental nerve:Intraoral -vestibularIntraoral -vestibular

DisadvantagesDisadvantages

Complete anesthesia or deep Complete anesthesia or deep hypoesthesia related dysfunctionhypoesthesia related dysfunction

There is also the expected eventual return There is also the expected eventual return of pain with proliferation of amputated of pain with proliferation of amputated nerve stump neuromasnerve stump neuromas

The duration of pain remission after The duration of pain remission after neurectomy can be prolonged if the cut neurectomy can be prolonged if the cut end nerve is cauterized or redirected and end nerve is cauterized or redirected and sutured into viable muscle or periosteum sutured into viable muscle or periosteum or bone tissue to prevent active neuroma or bone tissue to prevent active neuroma formation.formation.

The bony foramen can be plugged with The bony foramen can be plugged with nonresorbable material or by the bone nonresorbable material or by the bone piece itself.piece itself.

CRYOTHERAPYCRYOTHERAPY

Direct Application Of Temperatures Below Direct Application Of Temperatures Below -60-6000C.C.

Nitrous oxide probe – for a period of 1-2 Nitrous oxide probe – for a period of 1-2 min followed by 3 minutes thaw, to be min followed by 3 minutes thaw, to be repeated 3 times.repeated 3 times.

Other modalitiesOther modalities

Peripheral radiofrequency neurolysis Peripheral radiofrequency neurolysis (thermocoagulation)(thermocoagulation)

Gasserian ganglion proceduresGasserian ganglion procedures1. glycerol injection1. glycerol injection2. controlled radiofrequency 2. controlled radiofrequency

thermocoagulationthermocoagulation3. balloon compression3. balloon compression

Intracranial proceduresIntracranial procedures

1. microvascular decompression1. microvascular decompression2. trigeminal root section2. trigeminal root section

a. extradural sensory root sectiona. extradural sensory root sectionb. intradural root sectionb. intradural root sectionc. trigeminal tractotomyc. trigeminal tractotomy

Newer approachesNewer approaches

Physical inhibition of pain by Physical inhibition of pain by transcutaneous neural stimulationtranscutaneous neural stimulation

acupunctureacupuncture

Psychological approachesPsychological approaches

BiofeedbackBiofeedback Psychiatric counselingPsychiatric counseling Hypnosis / autosuggestion.Hypnosis / autosuggestion.