Trigeminal neuralgia (tic douloureux) painful twitch

CT guided interventional treatment

Jalal Jalal Shokouhi- MD ISR IranShahyar Pashaie-MD Tehran. Uni. IranMohammad hossein Herischi Baku Republic Azerbaijan

jalaljalalshokouhi@hotmail.comwww.medimage.ir

www.neurocongress.com

TRIGEMINAL NEURLAGIA

Trigeminal NeuralgiaWhat is it?

Fifth cranial nerve pain in the cheek, lips, gums or chin on the one side

Function:ChewingSalivaTearsFacial sensations

Topogram:

Ophtalmic branch: around eyes and forhead

Maxillary branch: lips, nose, cheek

Mandibular branch: tongue, lower lip

TGN-Historical perspective

• Fallopius : documented the trigeminal nerve in the 16th

century in an anatomical study

• John Locke : American physician in Paris – gave a full detailed

description of TGN. The patient was the Countess of

Northumberland, wife of British Ambassador to the

French Court.

• Nicolas Andre : called the clinical entity ‘Tic douloureaux’ in 1756

describing 5 patients who suffered from a :

‘cruel and obscure illness which causes in the face some violent motions, some

hideous grimaces, which are an insurmountable obstacle to the reception of

food, which put off sleep’

• Fothergill’s disease : after eponymous London Physician in 1776.

• Trousseau : 1853 suggested that the paroxysmal nature of TGN was due to

abnormal conduction and called it ‘neuralgia epileptiform’

TGN : Clinical features• Female > Male• Incidence : 4.3 / 100,000• Age group : 50 - 60 years• Paroxysmal recurrent pain of short duration• Trigger point(s), allodynia• Periods of remission• Recurrent episodes of pain with progressively shorter

periods ofremission• Distribution of pain :– localised to Trigeminal nerve– 80% Maxillary / Mandibular combination– Right side > Left side• Clinical examination : Usually normal

TGN-Differential diagnosis• Dental / Sinus related pain• Cluster headache / Migrainous neuralgia• Atypical facial pain• Post - herpetic neuropathy• TM joint dysfunction– Degenerative , Rheumatoid arthritis• Trigeminal neuropathy– Demyelination : Multiple sclerosis• Facial myalgia

Trigeminal NeuralgiaWhat causes it

Pathophysiology• Compression at root exit zone : at junction of central myelin(oligodendroglial cells) and peripheral myelin (Schwann

cells) : theObersteiner-Redlich line– Vascular cross compression of Root Exit Zone• Atherosclerotic degeneration causing elongation and

tortuosity– Neoplastic compression• Meningioma, Schwannoma, Neuroma, Epidermoid• Focal segmental axonal demyelination with abberantsynaptogenesis resulting in transaxonal ephaptic transmission• Spontaneous discharge occur at site of compression• Evoked potentials studies demonstrate increased latency &

thresholdconsistent with nerve compression

Pathophysiology• Association between multiple sclerosis anddemyelination– 4% of patients with MS have TGN• Harris 1950 Rare forms of paroxysmal

trigeminal neuralgiaand their relation to disseminated sclerosis BMJ

2 1015 - 1019– 2% of patients with TGN have MS

Treatments:1. Drug: antiepileptic: carbamazepine or

tegretol,phenytoin or dilantin

Treatments:1. Drug: antiepileptic: carbamazepine or

tegretol,phenytoin or dilantin2. Surgery of tumor or vascular decompression,

microendoscopy (2.7mm)

Treatments:1. Drug: antiepileptic: carbamazepine or

tegretol,phenytoin or dilantin2. Surgery of tumor or vascular decompression,

microendoscopy (2.7mm)3. Radio surgery(γ-knife,RF)

Treatments:1. Drug: antiepileptic: carbamazepine or

tegretol,phenytoin or dilantin2. Surgery of tumor or vascular decompression,

microendoscopy (2.7mm)3. Radio surgery(γ-knife,RF)4. Interventional radiology: glycerol, ethanol,

RFA

63 patients13 Female50 Male

33 Idiopathic (dental operations)??16 M.S14 ?

Techniques and drugs:Needle G22Spiral CT guidanceLocal anesthesia (marcaine, pubivicaine 6-8-10cc)Iodine 0.5 ccEthanol 65-95% 2-3cc

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Nerve blockage, if there is no organic lesion in meckle cave, cavernous sinus and parasellar, also mandibular nerve branch

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M.S and Pain:

53 to 82%

Acute: Neuropathic in acute phase

Chronic: 90% Neuropathic or musculoskeletal

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Site of lesions:

Trigeminal entry zone in brain stem: Tri. G. Neuralgia

Brain stem, spinal cord: muscle spasm, pain full cramp

Corticospinal, Corticobulbar, Spasticity, LBP, extremity

pain

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Results:All patients: pain free immediately after

injection• Repeat injection: 2-3

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Take home message:

M.S. has diplopia, parestesia, paralysis, vertigo,... Also MS has pain.

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Thank youAny Question?