TRIGEMINAL NEURALGIAAlso known as…

TIC DOULOUREUXPROSOPALGIASUICIDE DISEASENEURALGIA EPILEPTIFORME By: Aleshba Saba Roll # 17 BDS 1st Year A neuropathic disorder of trigeminal

nerve

Contents…

IntroductionCauses, risk factors & triggersSymptomsTypes of Trigeminal neuralgiaTests & diagnosisTreatmentPreventionReferences

(INTRODUCTION)

TRIGEMINAL NEURALGIA

Excruciating

current-like

intense pain

Jabbing in nature

Pain is limited to the sensory distribution of trigeminal nerve that includes middle face (maxillary division V2)– being most frequently involved, lower (mandibular division V3) & upper (ophthalmic division V1)– being least frequently involved

Trigeminal neuralgia (TN) is amongst the most painful conditions known. It produces brief but severe attacks of intense pain that lasts from seconds to minutes

Trigeminal neuralgia pain is characterized by episodes of excruciating, stabbing or electric shock-like pains, that may occur in one or more of the distributions of CN V

Attacks may come on without warning (spontaneously) or be triggered by activities such as talking, eating, drinking, tooth brushing, shaving, etc

Pain of TN may occur many times per day during period of flare up (exacerbations)

There are also the periods when pain disappears (remissions)

That are commonly experienced early in the course of the disease

However, virtually all patients develop

progressively more severe and frequent pain attacks as well as reduced periods of remission

Therefore the need for more aggressive medical or surgical treatments increases as the disease invariably progress

If nerve's function is disrupted: Usually, the problem is contact between a normal artery or vein and the trigeminal nerve, at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction

As a result of aging

Causes

Multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves

tumor compressing the trigeminal nerve

Shingles

In most cases the cause is unknown

Causes

Tumor affecting CN V

Risk factorsUsually develops after the age of 50, although there have been cases with patients being as young as three years of age

1 in 15,000 (estimated) people suffer from TN

Women are 3 times more likely to be affected than men

Triggers that may set off the pain of TN

Shaving Stroking your face Eating Drinking Brushing your teeth Talking Putting on makeup Encountering a breeze Smiling

SYMPTOMS

Symptoms:Occasional twinges of mild pain Episodes of severe, shooting or jabbing pain

that may feel like an electric shock Spontaneous attacks of pain or attacks

triggered by things like touching the face, chewing, speaking, and brushing teeth

Bouts of pain lasting from a few seconds to several seconds

Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain

Symptoms:Pain in areas supplied by the trigeminal

nerve (nerve branches), including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead

Pain affecting one side of your face at a time Pain focused in one spot or spread in a wider

pattern Attacks becoming more frequent and intense

over time

TYPES OF TRIGEMINAL NEURALGIA

PRE-TN

POST-TRAUMIC

TN

2ndary TN FAILED

TN

MULTIPLESCLEROSIS RELATED

TN

ATYPICAL TN

TYPICAL

TN

7 TYPES

1. Typical TN…Most common form of TN Minor aching or burning pain Previously been termed Classical, 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

Caused by arteries or veins, large or small, that may simply contact or indent the trigeminal nerve

…Typical TNPulsation of vessels upon the trigeminal

nerve root do not visibly damage the nerve. However, irritation from repeated pulsations may lead to changes of nerve function, and delivery of abnormal signals to the trigeminal nerve nucleus. Over time, this is thought to cause hyperactivity of the trigeminal nerve nucleus, resulting in the generation of TN pain.

Normal

Neurovascular compression

…Typical TNsuperior cerebellar artery is the vessel most

often responsible for neurovascular compression upon the trigeminal nerve root

It may be cured by medicines or micro vascular decompression (MVD surgery)

2. Atypical TNCharacterized by a unilateral, prominent,

constant and severe aching or burning pain Vascular compression is thought to be the

cause of many cases of atypical TN Can be at least partially relieved with

medications MVD surgery is curative for many patients

with atypical TNRhizotomy procedures might be effective in

treating

MVD

3. Pre-trigeminal neuralgia

Odd sensations of pain, (such as a toothache) or discomfort (like “pins and needles”), may be symptoms of pre-trigeminal neuralgia

Pre-TN is most effectively treated with medical therapy used for typical TN

4. Multiple Sclerosis-Related TN1% of patients suffering from multiple

sclerosis develop TN TN is more commonly seen in people with

multiple sclerosis MS involves the formation of

demyelinating plaques within the brain For treatment, Trigeminal rhizotomy is

employed when medications fail to control the pain

For some individuals with MS-TN, neurovascular compression of the trigeminal nerve root may be a rare cause and is demonstrated with special MRI or CT scans

5. Secondary or tumor related TN

Caused by a lesion, such as a tumor May cause facial numbness, weakness of

chewing muscles, and constant aching pain Medications usually help control secondary

TN pain Surgically removing the tumor usually

alleviates pain and trigeminal function may return

After the removal of the tumor, the trigeminal nerve may be found to also be compressed by an artery or vein. Then MVD technique is used

Tumor

6. Post-Traumatic TN or Trigeminal neuropathy…

Caused by injury to CN VMay develop following cranio facial trauma

(such as from a car accident), dental trauma, sinus trauma (such as following Caldwell Luc procedures)

Numbness may become associated with sensations or pain, sometimes called phantom pain

…Post-Traumatic TN or Trigeminal neuropathy

Constant, aching or burning pain, but may be worsened by exposure to triggers such as wind and cold

Pain may not be controlled with medications There are some reports of pain relief

associated with the use of trigeminal nerve stimulation procedures

7. Failed TN

Unfortunately, in a very small proportion of sufferers, all medications, MVD and destructive rhizotomy procedures prove ineffective in controlling TN pain. This condition is called “failed” trigeminal neuralgia

When to seek medical advice? If you experience facial pain, particularly

prolonged or recurring pain or pain unrelieved by over-the-counter pain relievers, see your doctor.

TESTS AND DIAGNOSIS

What should a doctor do?Review medical history of the patientAsk patient to describe the pain

(a) How severe it is? (b) What part of face is affected (c) How long it lasts (d) What triggers it

Touches parts of face to try to determine exactly where the pain is occurring May need MRI or CT Scan

TREATMENT

There are some things that a patient can do to minimize the frequency and intensity of TN attacks:

1.Apply ice packs. Cold often numbs the area and will reduce the pain

2.Warming packs provide relief as they stimulate blood flow to the area they are placed upon

3.Get adequate rest in normal rest cycles 4.Manage your stress well and keep stress levels

low 5. Avoid foods that may act as nerve stimulants,

such as coffee, tea, and foods that are high in sugar

6. Maintain adequate hydration and electrolyte levels at all time

7. Practice healthy living principles such as diet and exercise

1st step of treatment- Medications Trigeminal neuralgia is usually treated

with drugs called anti- convulsants which include:

Carbamazepine (most commonly used)PhenytoinOxycarbazepineGabapentin Baclophen Half of TN sufferers eventually become

dissatisfied with medical therapy, because of incomplete control of pain or drug-related side effects that are almost always experienced. Surgical treatments are then considered

Alternative treatment methods Complementary and alternative treatments

for trigeminal neuralgia include:

Acupuncture Biofeedback Vitamin therapy Nutritional therapy Electrical stimulation of nerves

2nd step of treatment- SurgeryThe goal of surgery is either to stop the blood

vessel from compressing the trigeminal nerve, or to damage the trigeminal nerve to keep it from malfunctioning

Damaging the nerve often causes temporary or permanent facial numbness, and with any of the surgical procedures, the pain can return months or years later

Surgical options include:

Microvascular decompression (MVD Glycerol injection Balloon compression Electric current Severing the nerve called partial sensory

rhizotomy (PSR)Stereotactic Radiation Therapy

Microvascular Decompression Surgery alleviates neurovascular compression by placing inert shredded Teflon® felt implants between compressing vessels and the trigeminal

nerve root

Percutaneous Rhizotomies involve inserting a needle through the cheek and into an opening at skull base (foramen ovale). There, a controlled injury to the trigeminal nerve and Gasserion ganglion may be produced in one of three ways:

1) Percutaneous Glycerol Injection - glycerol is injected into the space around the Gasserion ganglion, and chemically damages the nervous tissue.

2) Percutaneous Balloon Compression Rhizotomy - 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, and heated to thermally damage the nervous tissue.

Gamma Knife Radio surgery focuses cobalt radiation upon the trigeminal nerve root, producing a delayed injury to nervous tissue that is similar to that produced by other percutaneous rhizotomy techniques.

Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions involve injuring the peripheral portions of the trigeminal nerve external to the skull.

Microsurgical Rhizotomy involves surgical exposure and cutting of the trigeminal nerve root near its entry into the brain stem.

MVD

In one case of trigeminal neuralgia associated with tongue-piercing, the condition resolved after the jewelry was removed

Some patients have reported a correlation between dental work and the onset of their trigeminal nerve pain

FACTS

Prevention There are no guidelines for preventing

trigeminal neuralgia. However, once you have it, steps that may help prevent attacks include:

Eating soft foods Eating food and drinking beverages that

are at room temperature Washing your face with cotton pads and

warm water If tooth brushing triggers attacks, rinsing

your mouth with warm water after eating Avoiding or minimizing known triggers

such as heat, cold, touch, or air

THANK YOU !