Management of Trigeminal Neuralgia

MANAGEMENT OF
TRIGEMINAL
NEURALGIA
DR.WAJIHA SHEIKH
WHAT IS TRIGEMINAL NEURALGIA?
Nerve pain arising Sharp electric shock AKA TIC

from trigeminal like pain in the face DOULOUREUX
nerve. or mouth. (painful tic).
Most frequently in Lasts for seconds to

Female to male ratio
patients older than 1 minute followed by
= 1.6:1.
50 years. a refractory period.
Usually a trigger
zone is present
where mechanical
stimuli such as touch
may provoke an
attack.
TRIGGE
TYPES
RS
PRIMARY(CLASSI EATING AND

C) DRINKING
SHAVING,WASHIN
SECONDARY G FACE OR
PUTTING MAKEUP
TALKING AND
IDIOPATHIC
SMILING
APPLYING
PRESSURE TO FACE
BRUSHING,FLOSSING,MOUTHWAS
H OR ENCOUTERING LIGHT
BREEZE OR GUST OF WIND ON
FACE.
 Extraoral trigger zones: corner of the mouth, cheeks, ala of
nose, or lateral bow
 Intraoral trigger zones: teeth, gingiva or tounge.
 Clinical characterstics:
1. Severe paroxysmal pain
2. Unilateral (right>left)
3. Mild superficial stimulation provokes the pain.
4. No pain between attacks.
5. No dentoalveolar cause found.
6. No neurologic deficit.
7. LA of trigger zone temporarily arrest pain.

CAUSES AND DIAGNOSIS
 Pressure on the root entry zone of TN by a vascular loop leads to focal
demylination.
 aging, multiple sclerosis, and tumors.
 trauma, nerve impingement, and can occur after a herpes zoster
infection.
 Other nerves innervating the face and neck can also cause pain and
neuralgia, such as occipital neuralgia, glossopharyngeal neuralgia, and
auricular neuralgia.
 Diagnosis is made by history , examination and MRI.
 Patient is referred to neurosurgeon.
MANAGEMENT
Support
and
education
Medication
Surgical
SUPPORT AND EDUCATION
1)Make patient aware that it is not a life

threatening condition.
2)Educate for causes and therapies.
3)Reassurance and follow up.
MEDICATIONS
CBC and LFTs are

advised before
prescribing
medications.
SURGICAL MANAGEMENT
 The goal of surgery is to stop the blood vessel from compressing the
trigeminal nerve,.
 to cut the nerve to keep it from sending pain signals to the brain.
 Surgical procedures are performed under general anesthesia,
involve opening a hole in the skull (called a craniotomy)’
 require a 1 to 2 day hospital stay.
1. MICROVASCULAR
DECOMPRESSION (MVD)
 gently reroute the blood vessel from compressing the
trigeminal nerve by padding the vessel with a sponge.
 The major benefit of MVD is that it causes little or no
facial numbness.
 The major disadvantages are the risks of anesthesia
and of undergoing an operation near the brain.
2.SENSORY RHIZOTOMY
 irreversible cutting of the trigeminal nerve root at its
connection to the brainstem.
 The motor root, which controls the chewing muscles,
must be preserved.
 The sensory root fibers, which transmit the pain signals
to the brain, are severed.
 Cutting the nerve causes permanent facial numbness
and should only be considered for recurrent pain that has
not responded to other treatments.
3. PERIPHERAL NEURECTOMY
 performed by exposing the nerve branches on
the face through a small skin incision.
 Cutting the supraorbital nerve (branch of V1
division) may be appropriate if pain is isolated
to the area above the forehead.
 Cutting the infraorbital nerve (branch of V2
division) may be performed if pain is limited to
the area below the eye along the upper
cheekbone.
 Cutting the nerve causes complete facial
numbness in the region the nerve supplies.
4. RADIOSURGERY (GAMMA KNIFE)
 noninvasive outpatient procedure

that uses highly focused radiation
beams to destroy some of the
trigeminal nerve root fibers that
produce pain.
 Pain relief may not occur
immediately but rather gradually
over time. As a result, patients
continue to take pain medication
for a period of time.
 Complications include facial
numbness and dry eye..
OUTPATIENT NEEDLE
• Minimally PROCEDURES
invasive techniques for reaching the trigeminal nerve through
the face without a skin incision or skull opening.
• Performed with a hollow needle inserted through the skin (percutaneous)
of the cheek into the trigeminal nerve at the base of the skull.
• The goal is to damage an area of the trigeminal nerve to keep it from
sending pain signals to the brain.
• Damaging the nerve causes mild to major facial numbness in that area.
• These outpatient procedures are typically performed under local
anesthesia and light sedation.
1. RADIOFREQUENCY RHIZOTOMY
 AKA Percutaneous Stereotactic Radiofrequency Rhizotomy (PSR), uses a
heating current to selectively destroy some of the trigeminal nerve fibers
that produce pain.
 While asleep, a hollow needle and electrode are inserted through the
cheek and into the nerve. The patient is awakened and a low current is
passed through the electrode to stimulate the nerve.
 Complications aredouble vision, jaw weakness, loss of corneal reflex,
dysesthesia (troublesome numbness) and very rarely anesthesia
dolorosa. Partial facial numbness in the area where the pain existed is
expected.
 Other complications, such as blurred vision or chewing problems, are
usually temporary.
2.GLYCEROL INJECTIONS
 is similar to PSR in that a hollow needle is passed through the cheek to
the nerve. The needle is positioned in the trigeminal cistern (a fluid-filled
area in the ganglion)
 Glycerol is injected into the cistern to damage some of the trigeminal
nerve fibers that produce pain.
 As with PSR, partial facial numbness is expected and complications are
similar.
3. BALLOON COMPRESSIONS
 is similar to PSR in that a hollow needle is passed through

the cheek to the nerve. However, it is performed under
general anesthesia.
 The surgeon places a balloon in the trigeminal nerve
through a catheter. The balloon is inflated where fibers
produce pain
 The balloon compresses the nerve, injuring the pain-
causing fibers. After several minutes the balloon and
catheter are removed.
 Complications may include minor numbness, chewing
problems, or double vision
OTHER TREATMENT OPTIONS
Botulinum
toxin
Acupuncture Biofeedback
injections or
nerve blocks
Yoga and
Psychotherapy Aromatherapy
Meditation
REFRENCES
 https://mayfieldclinic.com/pe-trin.htm
 https://
www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/diagnosis-t
reatment/drc-20353347
 https://www.oaepublish.com/articles/2573-0002.2019.08
 https://my.clevelandclinic.org/health/diseases/15671-trigeminal-
neuralgia-tn
 contemporary-oral-and-maxillofacial-surgery-tucker-7th-edition/

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MANAGEMENT OF

Nerve pain arising Sharp electric shock AKA TIC

Most frequently in Lasts for seconds to

PRIMARY(CLASSI EATING AND

7. LA of trigger zone temporarily arrest pain.

1)Make patient aware that it is not a life

CBC and LFTs are

 noninvasive outpatient procedure

 is similar to PSR in that a hollow needle is passed through

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