trigeminal neuralgia

The favourite topic of my late teacher professor dr umarkhitab which he presented in international conference in Lahore.

1. TRIGEMINAL NEURALGIA (Tic Douloureux)

2. International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

3. "if it isn't unpleasant, it isn't pain."

4. categories: Somatic from the noxious stimulation of normal structures that innervate the affected area Normal or Physiologic

5. Neuropathic arises in the absence of any noxious stimulation. a functional or structural abnormality within the nervous system itself. episodic (paroxysmal) and continuous Pathophysiologic

6. psychogenic arises from psychological causes. Neither elicited by noxious stimuli nor an abnormality within the neural system

7. General characteristics of neuropathic pain Pain in the absence of obvious nociception Pain that can be intense and out of proportion to the degree of stimulation Pain quality that is bright, stimulating and burning Pain that is relatively unresponsive to low doses of narcotic analgesics.

8. TRIGEMINAL NEURALGIA (Tic Douloureux)

9. HISTORY John lock------------1677 (1 st description) Nicolous Andre-----1756 (Tic douloreux) John Fother Gills---1773 (Full description) Other Names----- (Prosopalgia, Face Palsy, Suicide disease)

10. Trigeminal – Cranial nerve V Neur – Nerve related Algia - Pain

11. 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 5 th cranial nerve.

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

13. Sex F more than M 5.9 : 3.4 In 100000

14. KCD . 242 CASES in 3 years (PODJ 25 (2) Dec 2005) Mean age ; 43.88 with peak inci.age.50 - 60 M:F ----1.068:1 Rt —63.22%, Lt —35.95%, Bil; o.82% (2. F) Branch ; Max & Mand almost equal.40.08% & 39.667%.Opth.2.08%(5 cases in combi.)

15. Relation with diet A . Elite class with v luxurious socio economic status.-----------------------NIL. B . Good socio economic status.—2.49% C . Moderate s e status-------------36.77% D. V V poor Labor class---------60.74%

16. IT SHOWS THAT THERE MIGHT BE SOME DEFICIENCY OF IMPORTANT INGREDIENTS IN THE DIET.

17. V3 commonly involved than V2.

18. Types of Trigeminal Neuralgia and Their Causes: 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 TRIGEMINAL NEURALGIA

19. CAUSES : PRIMARY Idiopathic SECONDARY . TUMORS (acoustic neuroma,cerebellopontine angle tumors, Schwanoma. Pituitary gland tumor)

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

21. Clinical Features Sudden, Sharp, Shooting, lancinating, unilateral paroxysmal, intermittent, shock like pain. trigger zones ; V1; 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.

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

23. Trigeminal Neuralgia

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

25. DIAGNOSTIC CRITERIA(IHS) 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 Doesn’t cross the midline No Neurological deficit's Attacks are stereotyped.

26. Differential Diagnosis : Odontogenic Sinusitis. Atypical facial pain. Cluster Headache (but last for 20-45 minutes) not along course of nerve. Post herpetic neuralgia. 6. Opthalmoparesis (Reader Syndrome). TMJD. 8.Temporal arteritis. Acoustic neurilemoma, Multiple sclerosis, Post herpetic neuroma, post traumatic neuroma.

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

28. Management 3 aspects 1. Support and Education. 2. Medical. 3. Surgical.

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

30. 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.

31. Medical Management

32. 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.

33. ANTICONVULSANTS Carbamazepine Gabapentin Cap Xaar (Pregabalin) Phenytoin Divalproex Sodium Lamotrigine SKELETAL MUSCLE RELAXANTS Baclofen ANTIANXIETY DRUGS Clonazepam

34. 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.

35. 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

36. 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. Blood smear and liver function tests should be repeated every few weeks at the start of therapy and then once or twice a year thereafter.

37. Surgical Management

38. 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.

39. SURGERY Peripheral neurectomy Supraorbital Infraorbital lingual Inferior alveolar Long buccal neurectomy

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

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

42. Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions Increased susceptibility to surgical complications. Very elderly, frail or medically unfit. A relatively simple means to injure any branch of the trigeminal nerve.

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

44. Rhizotomies

45. Percutaneous Rhizotomies Percutaneous Glycerol Rhizotomy Percutaneous Balloon Compression Rhizotomy Radiofrequency Rhizotomy

46. Percutaneous Glycerol Rhizotomy

47. Percutaneous Balloon Compression Rhizotomy

48. Radiofrequency Rhizotomy

49. Stereotactic Radiosurgery (Gamma Knife) focused radiation to the trigeminal nerve root Frame applied to the patient’s 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

50. Microsurgical Rhizotomy

51. Nerve Decompression alleviates neurovascular compression by placing inert shredded Teflon® felt implants between offending vessels and the trigeminal nerve root

52. CONCLUSION Proper diagnosis is the key Peripheral neurectomy needs to be encouraged Psychological support. Role of the Dentist TN a Medical Dilemma

53. Patients who are fit for surgery now but might not be in 10 years should be referred now, not in 10 years when the drugs no longer work and the surgery is more likely to be dangerous.

54. SURGICAL MANAGEMENT Peripheral procedure Ganglion procedure Open procedure

55. PERIPHERAL PROCEDURE Neurectomy Cryotherapy Alcohol injection Radiofrequency

56. GANGLION PROCEDURE Radiofrequency thermocoagulation (Temperature 60-80c) Glycerol injection (glycerol rhizotomy, 16g needle, 0.5-0.75ml) Balloon compression (4 FG Catheter, 1minute) Stereotactic Radiosurgery (70-90 grays)

57. OPEN OPERATIONS Microvascular decompression (by Retromastoid incision 5-6cm) Trigeminal root sectioning (sensory rhizotomy)