1. Trigeminal Neuralgia Clinical Observation from Latin American Experience Mauro Segura,. M.D., Ph.D. Neurosurgery MEXICOinfo@neurologiasegura.net

2. Functional Anatomy and CE Clinical examination Eyes movements Dermatoma afected Facial expresion Audicin & equilibrio Nasopharinge Cervical and occipital nerve territory Skin and EAC Depresion scores Hamiltons GSA general sensation fromhead and facial structures Main sensory nucleus Descending tract of V to spinaltrigeminal nucleus Functional equivalent of substantiagelatinosa of spinal cord GSE muscles of mastication SVE branchial arch muscles Tensor veli palatini Tensor tympani 3. The enemy to beat is at home... and it is not the pain 4. Transnational Experience Geography & Demography Arriving by Countryusa peru ecua guat colomb venezchileMexico 63%el salv arg costa nica espaa mexico 5. TN Natural CourseTime living with TN Pharmacological phase 6y17%24%YEARS1529% 6. Analysis male 34%Jul 2010-Jun 2013 Fem 66%Our population distribution by age groups n=257 403035253020 1525 10205150 2nd3rd4th5th6thDecade10 5 0 20-3031-4041-5051-6061-7071-8081-907th8th9th 7. Utility of Imaging TN1 and TN2 one can identify Presence and degree of NVC Mostly MRI does predict the Nature and number of the NVCsymptomatic surgical side Mostly MRI does demonstrate a higher degree of NVC on the symptomatic In general, MRI can differentiate arterial and venous compression Location of NVC along the nerve Findings can be confirmed duringMVD Small tumor finding 8. Non truely functional diagnostic support Case 1 9. Trigeminal Vascular Compression (TVS) and MS 10. Non truely functional diagnostic support Case 2 11. Truely functional diagnostic support 12. Our Surgical Procedures n=116 Microvascular decompression (39%) Percutaneous ablative procedures Radiofrequency gangliolysis (10%) Glycerol rhizolysis (3%) Ganglion balloon compression3% 10%Medical Treatment2%n=141Stereotactic radiosurgery (2%) GK/CK LINAC-based45% 39%Peripheral ablative procedures (V1 & V2 pain) Peripheral branch neurectomy Alcohol neurolysisOpen destructive procedures Partial sensory rhizotomy Subtemporal ganglionectomy (Frazier-Spiller procedure) Trigeminal bulbar nucleus thermoablation (1%)1% 13. Complications of MVD AuthorYearn=CSFVVIIVIII Death HemBreeze1982522%17%15%11%Van Loveren 198223Apfelbaum 1983406Kolluri198472Piatt19841032%Zorman19841254%Bederson19891664%Klun19922200Sun199461Barker19961204Kondo1997281Revuelta2006668ndndndndnd0,2%Segura *20131162%3%1%2%01,7%13%09% 1%3%1%19%01%8%1%2%3%05%5%011% 1%3%0.5% 0.5% 4.5% 7%0.2%3%6%01%0.5%1%0.2%7% 14. New Surgical TechniquesChronic Stimulation of the Gasserian Ganglion in patients with Trigeminal Neuropathy: A Case Series Jean-Pierre Van Buyten & Caroline Hens Abstract: Between 2009 and 2011 we implanted 8 patients with refractory Trigeminal Neuropathic Pain (TNP) with a custom, tined, percutaneous, tripolar electrode to stimulate the Gasserian Ganglion (TGS). The electrode was positioned with the help of a three dimensional (3D), real-time, tip-tracked, electromagnetic (EM) guidance system. This technique reduced operating time, and augmented electrode targeting and procedural safety. Six of the eight patients had pain relief of at least 30%, all significantly tapered medication-intake (4 stopped opiods completely), two had minor dislocations, and none suffered any major complication. This EM stimulation technique is a valuable, reversible, minimally invasive method to treat refractory TNP. 15. Findings can or can not be confirmed during MVD 16. Opinions from Latin American Experience From the last decade experience, by working face to face with TN complicated cases, we resume our current data interpretation from clinical course, imaging and therapeutic options from Latin American population that is not the same than previously publicated. From a personal point of view, the TN, always must be analyzed as a syndromatic entity but not only as typical neurological state. The successful treatment of any patient with facial pain in general and TN in particular depends on right diagnosis at the outset. In our clinical practice, we concentrate a high number of difficult and complex cases but by employing a multimodal therapeutic approach; we are able to reach up to 97% successful treatment free of facial pain for the time of following 17. Opinions from Latin American Experience Our higher and younger incidence rates could be related to Asian or ancestry (Mayan) genetic factors The age is not a contraindication to achieve a successful MVD, but the comorbidity must be considerated To be a MS case does not excluded to be a TVC Of course, there is not a single one better surgical technique but a multimodal surgical and medical approaches If you offer an earlier personalized surgical procedure, the earliest your patient will live free of facial pain and better QOL Thank you 18. Mauro Segura MD, PhD. Neurosurgery info@neurologiasegura.net www.neurologiasegura.net www.facebook.com/neurologia.segura http://www.youtube.com/user/neurologiasegura Mauro Segura (neurologiasegura)