TRIGEMINAL NEURALGIA (Tic Douloureux)

Definition;
Trigeminal neuralgia (TN) is defined as sudden,usually unilateral, severe, brief, stabbing, lancinating, recurring pain in the distribution of one or more branches of 5th cranial nerve.

TRIGEMINAL NEURALGIA
Types of Trigeminal Neuralgia and Their Causes:
1. 2. 3. 4. 5. 6. 7. Typical Trigeminal Neuralgia (Tic Douloureux) Atypical Trigeminal Neuralgia Pre-Trigeminal Neuralgia Multiple Sclerosis-Related Trigeminal Neuralgia Secondary or Tumor Related Trigeminal Neuralgia Trigeminal Neuropathy or Post-Traumatic Trigeminal Neuralgia "Failed" Trigeminal Neuralgia

 V3 commonly involved than V2.

CAUSES:
PRIMARY
Idiopathic

SECONDARY.
TUMORS (acoustic neuroma,cerebellopontine angle tumors)

VASCULAR Pulsatile compression of adjacent artery . INFLAMMATORY; multiple sclerosis POST TRAUMATIC. Viral Accident Dental trauma Sinus trauma

Age
Average age of onset - typically sixth decade may present at any age. Symptomatic or secondary trigeminal neuralgia tends to occur in younger patients.

Sex

Male : Female 2:3

 KCD.

242 CASES jan 01 to jan 2000 in PODJ 25 (2) Dec 2005. Mean age; 43.88 with peak inci. 5&6th deca. M:F----1.068:1 Rt63.22%, Lt35.95%,Bil; o.82% (2. F) Branch; Max & Man almost equal.40.08% & 39.667%.Opth.2.08%(5 cases in combi.)

Relation with diet

A. Elite class with v luxurious socio ecnomic status.-----------------------NIL. B. Good socio ecnomic status.2.47% C. Moderate s e status-------------36.77% D. V V poor. Labour class---------60.74%
IT SHOWS THAT THERE MIGHT BE SOME DEFICIENCY OF IMPORTANT INGREDIENTS IN THE DIET.

Clinical Features
Sudden, Sharp, Shooting, lancinating, unilateral paroxysmal, intermittent, shock like pain. trigger zones ; V1;over the supraorbital ridge V2; Skin of the upper lip, ala nasi , cheek,gums. V3; lower lip,teeth, gums, tongue Rarely crosses the midline. short duration-seconds During attack, hands over the affected side, stop activities, hold or rub the face which may redden or the eyes water until the attack subs.

Paroxysms----weeks / months cycles Electric shock like like electric light in rain Bad oral hygiene Paroxysms----weeks / months cycles No attacks during sleep History of extractions Loss of weight Depressed

Trigeminal Neuralgia

Nature of pain
tic douloureux - pain attack is accompanied by tic-like cramps or involuntary spasms of the facial muscles

DIAGNOSTIC CRITERIA paroxysmal attacks of pain lasting a second to 2mins and

affect one or more division of trigeminal nerve .

CHARACTERISTICS
Sharp Intense Stabbing Superficial Precipitated by trigger zone.

No Neurological disorder.

Differential Diagnosis:
1. 2. 3.
4.

Odontogenic Sinusitis. Atypical facial pain.

Cluster Headache (but last for 20-45 minutes) not along course of nerve.

5. Post herpetic neuralgia. 6. Opthalmoparesis (Reader Syndrome). 7. TMJD. 8.Temporal arteritis. 9 Acoustic neurilemoma, Multiple sclerosis, Post herpetic neuroma, post traumatic neural.

DIAGNOSIS
History. Clinical Features. Local Anaesthetics. Carbamezapine response Age less than 35 years, suspect space occupying lesions or arteriovenous malformations intracranially. MRI,CT SCAN

Management It has 3 aspects 1. Support and Education. 2. Medical. 3. Surgical.

Management
No treatment modality to permanently eliminate Managed initially with medication Surgical if refractory to medical management or develops serious side effects

Support and Education:

Make patient aware that it is not life threatening. Realize the severity of condition. Educate for:
Causes Therapies

Reassurance and Follow up.

Medical Management

Medical Management
Do not respond to conventional analgesic drugs Controlling drugs exert their effect by depressing excitatory afferent transmission or through facilitation of segmental inhibition Although mechanisms not fully clear, treatment for TN is still quite successful. slowly discontinue the medications when the patient is asymptomatic to see if the patient is in a pain-free remission period.

 ANTICONVULSANTS
Carbamazepine Gabapentin Phenytoin Divalproex Sodium Lamotrigine

SKELETAL MUSCLE RELAXANTS

Baclofen

ANTIANXIETY DRUGS
Clonazepam

Carbamazepine
still the drug of choice for the initial management stabilization of neuronal membranes by blocking sodium channels thus preventing the generation of an action potential. selective for hyperactive sodium channels.

Carbamazepine
Started with a dose of 100 mg twice daily. increased by 100 mg/day until either a decrease in pain is noted or signs of toxicity appear. suggested maximum dose is 1500 mg. sustained-release form of carbamazepine is also available for a more sustained effect. bioavailability can be assessed through blood levels

Carbamazepine Side Effects

most common side effects - rash, sedation, vertigo, blurred vision, and ataxia. Other reactions although low - aplastic anemia, leukopenia and thrombocytopenia. complete blood count (CBC) before prescribing Also potential for inducing serious liver toxicity liver function tests. CBC and liver function tests should be repeated every few weeks at the start of therapy and then once or twice a year thereafter.

Surgical Management

SURGERY
Peripheral neurectomy
Supraorbital Infraorbital lingual Inferior alveolar Long buccal neurectomy

Neurosurgical interventions
when medical therapy proves ineffective in controlling TN pain. potential benefits as well as risks of complications or long-term side effects. None of the surgical interventions are effective in every case. no accurate way to predict.

 Nerve Injury / Destructive Procedures (Rhizotomies) Non-nerve injury procedures

Rhizotomies
Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions Percutaneous Rhizotomies Stereotactic Radiosurgery (Gamma Knife) Microsurgical Rhizotomy

Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions

Increased susceptibility to surgical complications. Very elderly, frail or medically infirm. A relatively simple means to injure any branch of the trigeminal nerve.

Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions

By injection of alcohol, cutting (sectioning) or avulsion of the nerve branch. Effective immediately Also cause severe or complete numbness at least temporarily. Often recurs Other interventions for long-term disease control.

Rhizotomies

Percutaneous Rhizotomies
Percutaneous Glycerol Rhizotomy Percutaneous Balloon Compression Rhizotomy Radiofrequency Rhizotomy

Percutaneous Glycerol Rhizotomy

Percutaneous Balloon Compression Rhizotomy

Radiofrequency Rhizotomy

Stereotactic Radiosurgery (Gamma Knife)

focused radiation to the trigeminal nerve root Frame applied to the patients head and then MRI positioned in the Gamma Knife (up to 201 focused beams of cobalt radiation) delayed injury & pain reduction within a few weeks

Microsurgical Rhizotomy

Nerve Decompression

alleviates neurovascular compression by placing inert shredded Teflon felt implants between offending vessels and the trigeminal nerve root