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TRIGEMINAL NEURALGIA

Presented by Wita I.Septina

Supervised by Harmas Yazid Yusuf, drg. SpBM

INTRODUCTION

Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve.

Incidence 4-5 cases : 100.000


TN or Tic douloureux occur patients > 50 years. Male : Female ratio 2 : 3 Unilateral (97%). Most affected V2 and V3. The pain is intense, usually sharp, electric shocklike pain in face, lasting periods of seconds to 2 minutes ,

ANATOMY TRIGEMINAL NERVE

Cranial Nerve V

Sensoric Portio major Motoric Portio minor Sensoric + motoric Ganglion Semilunare Gasseri

Fig 1. DistributionTrigeminal nerve

CLASSIFICATION
1. Typical Trigeminal Neuralgia
(Tic Douloureux)

Most common form of TN

Caused by blood vessels compressing the


trigeminal nerve root enters the brain stem

Irritation from repeated pulsations caused


hyperactivity of the trigeminal nerve nucleus resulting TN pain

(a)

(b)

(c)

Fig 2. Anatomy Trigeminal nerve and Trigeminal neuralgia

CLASSIFICATION
2. Atypical Trigeminal Neuralgia

Unilateral Prominent constant Boring or burning pain Caused by vascular compression upon a specific part of trigeminal nerve (portio minor) A more severe from or progression of typical TN

CLASSIFICATION
3. Pre - Trigeminal Neuralgia
Symptoms : odd sensations of pain or discomfort before the first attack of TN pain

4. Multiple Sclerosis-Related Trign. Neuralgia


The symptoms & characteristics identical Typical TN 2 - 4% patients with TN have multiple sclerosis (MS)

MS formation of demyelinating plaques within the


brain First attack of pain younger patients , bilateral

CLASSIFICATION
5. Secondary Trigeminal Neuralgia

Caused by a lesion (tumor) A tumor compresses or distorts the trigeminal nerve facial numbness, weakness of chewing muscles, constant pain

6. Post-Traumatic Trigeminal Neuralgia

Develop following cranio-facial trauma, dental trauma, sinus trauma, destructive procedures (rhizotomies) Injury caused severe pain, constant ,triggers such as wind and cold, start immediately or days to years following injury

Fig. 3 MRI--- Tumor compressed trigeminal nerve

CLASSIFICATION
7. Failed Trigeminal Neuralgia
Medications, microvascular

decompression, and destructive rhizotomy


procedure ineffective in controlling TN pain

ETIOLOGY
1.

Blood vessels compression at the trigeminal nerve root Demyelination nerve A tumor compresses trigeminal nerve Injury to the trigeminal nerve Un known

2. 3. 4. 5.

Clinical Features
1. 2.

Severe paroxysmal pain

The pain intense, stabbing, electrical shock- like, one side


Frequently pain free between attacks.

3. 4. 5.

Lasting only seconds to two minutes


Each attack spontaneously or be triggered by specific light stimulation

6.

Common triggers include touch, talking, eating, drinking, chewing, tooth brushing, hair combing and
kissing.

Fig. 4 Progression of Trigeminal Neuralgia

DIAGNOSIS

Anamnesis Clinical examination CT scan and MRI MRI / A

Differential Diagnosis
1.
2.

Glossopharyngeal neuralgia
Occipital neuralgia

3.
4.

Paroxysmal hemicrania syndromes


Migraine and cluster headaches

5.

Trigeminal neuropathy

TREATMENT

Medication Surgical procedure

TREATMENT
Medication

Carbamazepin (Tegretol)

Anticonvulsants, Drug of choice for TN, effective dose 600 1200 mg/ day for 3-4 x/ day Maintenance dosage 200 mg/d to prevent recurrences Side effect : drowsiness, mental confusion, dizziness, nystagmus,ataxia

Oxycarbazepine (Trileptal)

Side effect : nausea, fatique, tremor Dose : 2 x 300mg, maximum dose : 2400-3000 mg/day

TREATMENT

Phenytoin (Dilantin)

Dose: 300-500mg/day for 3x/day Side effect : nystagmus, dysarthria, gingival hyperplasia, hypertrichosis, allergic skin rash

Gabapentin (Neurontin)

Dose : 1200 - 3600mg/d, initial dose ; 3x300mg/d.


Side effect : somnolen, ataxia, fatique

TREATMENT

Baclophen (Lioresal)
Antispasmodic agents

Initial dose : 2-3 x 5 mg/ day. Duration of action short


Side effect : nausea, fatique

TREATMENT
Surgical Procedure
For patients medical therapy has failed surgery is a viable and effective option

Microvascular decompression Nerve Injury/ Destructive Procedr (Rhizotomy)


1.

Percutaneus Glycerol Rhizotomy

2.
3. 4. 5.

Percutaneus Balloon Compression Rhizotomy


Radiofrequency Rhizotomy Stereotactic Radiosurgery (Gamma Knife) Microsurgical Rhizotomy

TREATMENT

Microvascular decompression

non-destructive technique Under general anesthesia, incising the skin behind the ear (Craniotomy) Identify an arterial loop compressing the nerve pad the vascular structure with Teflon felt Complication: CSF leaks, hearing loss, permanent anesthesia over the face

TREATMENT

Nerve Injury / Destr Proced (Rhizotomy)


1. Percutaneus Glycerol Rhizotomy
The surgeon introduces a trocar or needle lateral to the corner of the mouth into foramen ovale glycerol ganglion Gasseri nerve injury

2. Percutaneus Ballon Compression Rhizotomy


Under general anestesia operator insert a balloon catheter through the the foramen ovale the region of the ganglion

TREATMENT
3. Radiofrequency Rhizotomy
Intravena sedation electroda insert to ganglion electroda to heat thermal injury to ganglion

4. Strereotactic Radiosurgery (Gamma Knife)


Gamma Knife Radiosurgery target the nerve with stereotactic MRI, determined radiation dose to guickly relief pain without facial sensory loss

5. Microsurgical Ryzotomy

CONCLUSION

Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve. Treatment for TN medication is the initial therapy if pharmacologic treatment fails surgical procedure.

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