Trigeminal neuralgia in OMFS

a seminar on Trigeminal neuralgia in OMFS

1. TRIGEMINAL
NEURALGIA
Moderator –Dr. Veerendra
Presenter –Dr. Rayan

2. •Introduction
•Historical review
•Etiology
•Clinical features
•Diagnosis
•Treatment modalities
•Management
•Pathogenesis
CONTENTS

3. INTRODUCTION:
•Itisthemostdebilitatingformofneuralgiathat
affectsthebranchesofthefifthcranialnerve.
•Itisadisorderoftheperipheralorcentralfibresof
thetrigeminalnerveinwhichthedominantsymptom
ispainintheregionofdistribution.

4. Trigeminal Nerve
•Largestcranialnerve,nerveofthefirstbranchialarch.
•Trigeminalnerveiscontinuouswiththeventralsurfaceofponsbya
smallmortorrootandalargesensoaryroot.
Motorroot
•Arisesseparatelyfromsensoryroot,inmotornucleuswithinpons.
•Fibrestravelseparatelyfromsensoryroot.
•Atsemilunarganglion,fibrespassinalateralandinferiordirectionto
leaveviaforamenovale.
•ItuniteswiththesensorynervetrunkofV3toformasinglenerve
trunk
•Supply
•Musclesofmastication
•Mylohyoid
•Antbellyofdigastric
•Tensortympani
•Tensorvelipalatini

6. Sensoryroot
•Comprisethecentralprocessofganglioncells
locatedintrigeminalganglion.
•LocatedintheMeckelscave,flatcrescentshaped.
•Sensoryrootfibresentertheconcaveportion,and
thethreedivisionsexitfromtheconvexportion.
•Ophthalmicdivision(V1)–exitsfromthesuperior
orbitalfissure
•Maxillarydivision(V2)–exitsfromforamen
rotundum
•Mandibulardivision(V3)–exitsfromforamenovale

8. InternationalAssociationfortheStudyofPain(IASP)
:definedtrigeminalneuralgiaassuddenusuallyunilateralsevere
briefstabbingrecurrentpaininthedistributionofoneormore
branchesofthe5
th
cranialnerve.
Internationalheadachesociety(IHS):definedtrigeminal
neuralgiaaspainfulunilateralafflictionofthefacecharacterizedby
briefelectricshocklikepainlimitedtothedistributionofoneormore
divisionsofthetrigeminalnerve.
Nurmikko etal; trigeminal neuralgia –pathophysiology, diagnosis and current
treatment; British journal of Anesthesia; 87:1; 2001
DEFINITION:

9. Painfulunilateralafflictionoftheface,characterizedby
briefelectricshocklikepainlimitedtothedistributionof
oneormoredivisionsofthetrigeminalnerve.
Painiscommonlyevokedbytrivialstimuliincluding
washing,shaving,smoking,talkingandbrushingthe
teeth,butmayalsooccurspontaneously.
Thepainisabruptinonsetandterminationandmay
remitforvaryingperiods–Internationalheadache
society
Nurmikko etal; trigeminal neuralgia –pathophysiology, diagnosis and current
treatment; British journal of Anesthesia; 87:1; 2001

10. HISTORICALREVIEW:
JOHNLOCKEin1677gavethefirstfulldescriptionwith
itstreatment.
NICHOLASANDREin1756coinedtheterm‘Tic
Doloureux’.
JOHNFOTHERGILLin1773publisheddetailed
descriptionoftrigeminalneuralgia.
ARETAEUS-creditedwiththefirstclinicaldescriptionof
trigeminalneuralgia.
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

11. Epidemiology
•Theannualincidenceforwomenisapproximately5.9
casesper100,00women;formenitisapproximately
3.4casesper100,00men.
•Theincidenceincreaseswithage.
•Noknownracialorethnicriskfactorsexist.
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

12. Etiology
•Vascular factors
•Mechanical factors
•Anomaly of superior celebellarartery
•Dental etiology by Westrumand Black (1976)
•Infections
•Ratnersjaw bone cavities (1979)
•Multiple sclerosis by Olfson(1966)
•Petrous ridge compression by Lee (1937)

13. •Intracranialtumours
•Intracranialvascularabnormalities
Compession
Distortion
•Viraletiology

14. Classification
•Based on Etiology:
Idiopathic
Secondary
Atypical
Post herpetic
•Based on clinical features:
Classical
Mixed
Wael Fouad; Management of trigeminal neuralgia by radiofrequency thermocoagulation;
Alexandria Journal of Medicine (2011) 47, 79–86

15. Theories regarding pathogenesis:
•Central–basedonsimilarityoftrigeminalneuralgia
tofocalepilepsyandemphasizetheroleof
deafferentationinthegenesisofneuralhyperactivity
•Peripheral–changeinperipheralaxonsandmyelin
mayleadtoalterednervesensitivitytochemicaland
mechanicalstimuli
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

16. Focaldemyelinationatthesiteofcompressionmayalso
allowelectricalspreadofexcitationbetweenadjacent
sensoryaxons
Anemphaticshort-circuitofthistypewithinthe
trigeminalnervemightexplainthesudden‘‘electric’’
joltsofpainthatcharacterizethedisorder.
Rasminsky M. Ephaptic transmission between single nerve fibres in the spinal nerve
roots of dystrophic mice. J Physiol 1980;305:151-69.

17. Bennetto etal; Trigeminal neuralgia and its management; BMJ 2007; 27:334

18. Followingtrauma,regeneratingnervefibersbecome
relativelydepolarized&physiologicallymoreexcitable.
Spontaneousactionpotentialsoriginatefrommultiple
sitesandsingleactionpotentialsmayevokesustained
afterdischarges.
Rasminsky M, Kearney RE, Aguayo AJ, Bray GM. Conduction of nervous impulses in spinal roots
and peripheral nerves of dystrophic mice. Brain Res 1978;143:71-85

19. GENERAL CHARACTERISTICS:
Incidence:
Age:
Sex:
Affliction for side:
Division of trigeminal nerve
involvement:
8 : 1,00,000
5
th
–6
th
decade of life
Female > male ; 1.6 > 1.0
Right > left
V3 > V2 > V1
Bennetto etal; Trigeminal neuralgia and its management; BMJ 2007; 27:334

20. CLINICAL FEATURES:
Manifestsasasudden,unilateral,intermittentparoxysmal,sharp,
shooting,lancinating,shocklikepain,elicitedbyslighttouching
superficial‘triggerpoints’whichradiatesfromthatpoint,across
thedistributionofoneormorebranchesofthetrigeminalnerve.
Painisusuallyconfinedtoonepartofonedivisionoftrigeminal
nerve.
Painrarelycrossesthemidline.
Attacksdonotoccurduringsleep.

21. TIC DOULOUREUX:
Tic douloureux painful jerking
It is a truly agonizing condition, in which the patient
may clunchthe hand over the face & experience
severe, lancinating pain associated with spasmodic
contractions of the facial muscles during attacks

22. Pain is of short duration, but may recur with variable
frequency.
In extreme cases, the patient will have a motionless face –
the ‘frozen or mask like face’.
Common trigger zones include:
Cutaneous
Corner of the lips
Cheek
Alaof the nose
Lateral brow
Intraoral
Teeth
Gingivae
Tongue

26. DIAGNOSIS:
Scrivani, S. J., Mathews, E. s., & Maciewicz, R. J (2005). Trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod.2005 Nov;100(5):527-38.

27. T1-weighted axial image showing an ectatic loop of vertebral artery (arrow)
passing anterior to the pons
Seth Love et al; Central Demyelination of the Vth Nerve Root in Trigeminal Neuralgia
Associated with Vascular Compression; Brain Pathology 8: 1-12(1998)

28. Differential diagnosis
Diagnosis Important fearures
Dentalinfection or
cracked tooth
Well localized to tooth,appropriatefindings
on dental examination
Temporomandibular
jointpain
oftenbilateral,obviousfindings in the joint
Persistent idiopathic
facial pain
Bilateral,extendoutsidethe trigeminal
territory,painis continuous & throbbing
Migrane Precededby aura,nausea,
photophobia,phonophobiacervical
tenderness
Temporal arteritisCommon in elderly,temporalarteries maybe
firm, tender and non pulsatile on
examination

29. TREATMENT MODALITIES:
MEDICAL SURGICAL

30. Dedhia et al; Trigeminal Neuralgia (TGN ) -Pathophysiology and Management;
J Anaesth Clin Pharmacol 2009; 25(1): 3-8

31. MEDICALMANAGEMENT:
CARBAMAZEPINE:
Tradename:Tegretol,Carbitrol
Dosage:100mgBIDMaintenancedose1200-2400mg
Mechanismofaction:Slowrecoveryrateofvoltagegatedsodium
channels,modulatesactivatedcalciumchannelactivityandactivates
descendinginhibitorymodulationsystem
Sideeffects:Visualblurring
Dizziness
Skinrashes
Rarelyhepaticdysfunction,leukemia,
Thrombocytopenia,aplasticanemia

32. PHENYTOIN:
Tradename:Dilantin
Dosage:200-600mg/dayMaintainancedose200-400mg/day
Mechanismofaction:blockadeofvoltagedependentsodium
channels.
Inhibitsthegenerationofrepetitiveactionpotentials.
Prefrentiallyblockshighfrequencyfiring.
CanavaroS,BonicalziV.Drugtherapyoftrigeminalneuralgia.ExpertRevNeurother.
2006;6:429-40.
It is usually used in conjunction with carbamazepine.

33. Sideeffects:Slurredspeech
Nystagmus
Swellingoflymphnodes
Gingivalhypertrophy
Hypersensitivity
Teratogenicity

34. GABAPENTIN:
It is more expensive than other drugs but has a less side effects.
Trade name: Neurontin
Dosage:100 -5000 mg/day Maintainancedose 1800 mg/day
Mechanism of action: mechanism unknown but possibly includes
blockage of voltage gated calcium channels by binding to α2
subunits
Side effects: dizziness, fatigue, weight gain, drowsiness,
hepatotoxicity

35. Lamotrigine:
New anticonvulsant drug
Dosage: 25 –100mg/day BD Maintenance dose 200-400
mg/day
Mechanism of action: Decreases repetitive firing of sodium
channels by slowing the recovery rate of voltage gated channels
Also inhibits the release of the excitatory amino acids like
glutamate.
Side effects: Sleepiness
Dizziness
Headache
Vertigo
Rash

36. Topiramate:
Asulfamate-substitutedmonosaccharide,wasfirstidentifiedasan
antiepilepticdrug.
Comparedwithotherantiepileptics,thisdrugactsatdifferent
neuraltransmissionlevelssuchassodiumchannelsandenhances
GABAlevels,andhasbeentermeda‘neurostabilizer’
Dose:200–300mg/day Maintenancedose:200mgBID
Adverse effects:
Paraesthesia
Dysphasia
Fatigue
Confusion
Insomnia

37. BACLOFEN:
It is a GABA agonist
These drugs reduces the central projection of painful afferent
impulses.
Trade name: Lioresal
Dosage: 10 mg (tds) Maintenamcedose 30-80 mg/day
Side effects: Fatigue
Vomiting
Ataxia

38. TRICYCLINE ANTIDEPRESSANTS:
Amitriptyline
Doxepin
Nortriptyline
Imipramine
10 –300 mg/day
10 –300 mg/day
10 –150 mg/day
10 –300 mg/day

39. Botuliumtoxin
ItwouldlimitthereleaseofsubstanceP,calcitoningene-
ratedpeptideandglutamatefrompresynapticterminalsof
theprimarysensoryneurons,thuscounteractingcentral
sensitization
Bao-Lin Guo et al; A closer look to botulinum neurotoxin type A-induced
Analgesia; Toxicon 71 (2013) 134–139
Injectedsubcutaneouslyintothe
triggerzone(40to60units)
Thepainrecurredfivemonthslater
andthesitewasagaininjectedwith
100units

40. ACUPUNCTURE
HüseyinSert, BurhanettinUsta, BünyaminMuslu, MuhammetDepartment of Anaesthesiology, FatihUniversity School of
Medicine -Ankara, TurkeyCLINICS 2009;64(12):1225-6
•Adverseeffectsafterminimalinvasiveapproachesareparesthesia,facial
sensoryloss,weaknessorparalysisofmassetermusclesand,rarely,loss
ofthecornealreflex
•Acupuncturetreatmentwasinitiatedwithoutmakinganychangetothe
drugregime.
•Acupunctureneedles(0.20x13mmneedlesforthefaceand0.25x25
mmneedlesfortheotherregions)wereinsertedonthetypicalareasthat
areusedfortrigeminalneuralgia
•Everytreatmentsessionlastedaboutforty-fiveminutes,threetimesa
week
•Bythesixthweek(14sessions),thepatientwascompletelyfreeofpain
•Theanalgesiceffectofacupunctureisduetoincreasedlevelsof
mediators,includingendorphin,encephalinandserotonin,intheplasma
andbraintissue
•Adverseeffectsareminimalandincludebruisingorhematomaatthe
needlesite,metalallergyandlocalinfection.

41. Treatment resistant trigeminal neuralgia
relieved with oral sumatriptan
•Sumatriptanisaserotoninagonist,specificallydevelopedtorelieve
migraineheadaches.
•Althoughthecauseofmigraineisnotfullyunderstood,itisthoughtthat
awideningofbloodvesselsinthebraincausesthethrobbingpainof
migraineheadaches.
•Sumatriptanworksbycausingvasoconstrictionofthesevesselsviathe
•stimulationofserotonin(or5-HT)receptors.
•Sumatriptanmimicsthisactionofserotoninbydirectlystimulatingthe
serotoninreceptorsinthebrain.
•Thisresultsinnarrowingofthebloodvesselsandineffectivereliefof
themigraineheadachepain
JA Moran and A Neligan Treatment resistant trigeminal neuralgia relieved with oral sumatriptan: a case report Department of General
Practice, Brookfield Health Sciences Centre, University College Cork, Cork, Ireland and 2UCL Institute of Neurology

42. Multiple drug therapies
•Whenapatientonlypartiallyrespondstoasingledrug
therapyatdosagesthatevokesideeffects,addingasecond
drugmayenhancethetherapeuticresponse

43. Peripheral procedures
Ganglionic procedure
Open procedures
SURGICAL MANAGEMENT:

44. PERIPHERALINJECTION:
Ithasbeenknownthatinjectionofdestructive
substanceintoperipheralbranchesofthetrigeminal
nerve,producesanaesthesiainthetriggerzonesorin
areasofdistributionofspontaneouspain.
(A)LONGACTINGANAESTHETICAGENTS:
Bupivacainewithorwithoutcorticosteroidsmaybe
injectedatthemostproximalpossiblenervesite.

45. (B)ALCOHOLINJECTION:
0.5–2mlof95%absolutealcoholcanbeusedtoblock
theperipheralbranchesofthetrigeminalnerve.
Aimistodestroythenervefibres.
Itproducestotalnumbnessintheregionofdistribution
ofthenervethatwasanaesthetized.
Complication:
Necrosisoftheadjacenttissue
Fibrosis
Alcoholinducedneuritis

46. (C) Transcutaneous electric nerve
stimulation
Itreferstoapplyingalowvoltage
electricalimpulsetothenerve
systemviaelectrodesplacedonthe
skin,onebeingoverpainfulareaand
theotherelsewhere.
Thestimulusintensity,frequencyand
durationareadjustedbythepatients
toobtainrelieffrompain
Frequency–10–50Hzfor4to6sec
Varadarajan; Transcutaneous electric nerve stimulation in trigeminal neuralgia: A
review of literature; J Res Dent Sci 2014 ;5:36-41

47. TheanalgesicmechanismofTENSinvolves:
Gatecontroltheory:substantiagelatinosaofspinalcordactsasa
gatecontrolsystem.Activationoflargemyelinatingfibressubserving
touch,pressure,vibrationisthoughttofacilitatepresynaptic
inhibitionofsubstantiagelatinosacellsinthedorsalhorn,thus,
reducingpaintransmission.
Physiologicalblock:Asthefrequencyofstimulationincreases,
conductiondecreasesresultinginphysiologicalblock.
Endogenouspaininhibitorysystems:Presynapticinhibitioninthe
dorsalhornofthespinalcord,endogenouspaincontrol(via
endorphins,enkephalinsanddynorphins),directinhibitionofan
abnormallyexcitednerveandrestorationofafferentinput.
Varadarajan; Transcutaneous electric nerve stimulation in trigeminal neuralgia: A review of
literature; J Res Dent Sci2014 ;5:36-41

48. Advantages:
Noprostaglandinsinhibition,sinceTENScontrolspainby
gatecontrolmechanism.
Rapidandtimelyinhibitionofpainatpeakprogression.
Noadverseeffectsofdrugs
Noninvasive
Shorttermtreatmentfor20-40daysascomparedwithlong
termmedicinaltreatment.
Noneedforsurgicalintervention.
Canbeusedathomewithportablemachine.
Equallyeffectiveinpostneurectomyandpostinjection
alcoholneuralgia.
Singlaetal;Roleoftranscutaneouselectricnervestimulationinthemanagementof
trigeminalneuralgia;JNeurosciRuralPract.2011Jul-Dec;2(2):150–152.

49. PERIPHERAL NEURECTOMY (NERVE AVULSION):
Oldest & most effective peripheral nerve destructive method
Can be repeated & relatively reliable technique.
It acts by interrupting the flow of a significant number of afferent
impulses to central trigeminal apparatus.
Performed commonly on infraorbital, inferior alveolar, mental and
rarely lingual.
Disadvantage:
May produce
Full anaesthesia
Deep hypoesthesia
Mukrametal;Peripheralneurectomies:Atreatmentoptionfortrigeminalneuralgiainrural
practice;JNeurosciRuralPract.2012May-Aug;3(2):152–157.

50. INFRAORBITALNEURECTOMY:
(i)Conventionalintraoralapproach
(ii)Braun’stransantralapproach
Conventionalintraoralapproach:
A‘U’-shapedCaldwell–Lucincisionismadeintheupper
buccalvestibuleinthecaninefossaregion.
Mucoperiostealflapisreflectedsuperiorlytolocatethe
infraorbitalforamen.
Oncethenerveisexposed,alltheperipheralbranchesareheld
withthehemostat&avulsedfromtheskinsurfaceintraorally.

51. Theentiretrunkisseparatedfromtheskinsurfaceisheldwith
thehemostatattheexitpointfromtheforamen&isremovedby
windingitaroundhemostat&pullingitoutfromtheforamen.
Thenitmaybepluggedwithpolyethyleneplug.

52. Braun’stransantralapproach:
Anintraoralincisionismadefromthemaxillarytuberosity
tothemidlineinthemaxillaryvestibule.

53. Thedescendingpalatinebranchofthetrigeminalnerveisidentified
&tracedtothesphenopalatineganglion.
Themaxillarynerveissectionedfromtheforamenrotundumtothe
inferiororbitalfissure.
Theantralmucoperiostealflapinthevestibuleisrepositioned&
suturedback.
A3cmwindowismadeintheantero–lateralwallofthemaxillary
sinus.
Posterosuperiorportionofantrumisexcisedtocreateaposterior
window

54. INFERIORALVEOLARNEURECTOMY:
(i)Extraoralapproach
(ii)Intraoralapproach
Theextraoralapproach:
DonethroughRidson’sincision
Afterreflectionofmasseter,abonywindowis
drilledinoutercortex&nerveisliftedwithnerve
hook&avulsedfromitssuperiorattachment&
mentalnerveisavulsedanteriorlythroughthesame
approach.

55. Theintraoralapproach:
DoneviaDrGinwalla’sincision
Incisionismadealongwiththeanteriorborderof
asescendingramus,extendinglingually&buccally
endinginaforklikeinvertedY.
Incisionisthendeepenedonthemedialaspectof
ramus.
Thetemporalis&medialpterygoidmusclesaresplitat
theirinsertion&inferioralveolarnerveislocated.

57. Thenerveisligatedattwopointsinthemostsuperior
partvisible&dividedbetweentheligature.
Thesuperiorendiscauterized&thelowerendisheld
securelyusingahemostat.
Thementalnerveisalsosimilarlyligatedintwopoints
closetothementalforamen&dividedbetweentwo.
Theremainingnerveisheldattheinferioralveolarend
&woundaroundthehemostat&excisedfromthe
canal.

58. LINGUALNEURECTOMY:
Anincisionismadeintheanteriorborderoftheramus
slightlytowardsthelingualside.
Thelingualaspectisexposed&thelingualnerve
identifiedinthethirdmolarregionjustbelowthe
periosteum.
Thenervecanbeeither
avulsedorligated,cut
andtheendsmay
becauterized.

59. CRYOTHERAPHY:
Barnardfirstusedcryotheraphyin1981forthetreatmentof
thetrigeminalneuralgia.
Afteridentifyingtheaffectednerve,itisthenexposedto
thecryoprobeintraorally.
Directapplicationofcryotheraphyprobeattemperatures
colderthan-60CareknowntoproduceWallerian
degenerationwithoutdestroyingthenervesheathitself.
Nerveisexposedfor2minfreezefollowedby5minthaw
cycle.
Thefreeze–thawcycleisrepeatedatleast3times.
Zakrzewska JM, Cryotherapy for trigeminal neuralgia: a 10 year audit, Br J Oral
Maxillofac Surg. 1991 Feb;29(1):1-4

60. GASSERIANGANGLIONPROCEDURES:
PERCUTANEOUSRHIZOTOMY:
Thisisdoneonthe
Gasserianganglion
whichinvolveseither
mechanically or
chemicallydamaging
partsofthetrigeminal
nerve.

61. •1910 –Harris, Tapatas and Hartel introduced
percutaneous approaches via foramen ovale
•1931-Kirschner introduced percutaneous
electrocoagulation of gasserian ganglion
•Three procedures used with variable success rate
are
•Glycerol injections
•Thermocoagulation
•Balloon compression

62. Techniqueofneedlepenetration:
Theforamenovaleisbest
visualizewiththex–raytube
placedforasubmentovertex
position.
Infiltrationoftheskin&cheekis
donewithlocalanaesthetic
agentontheaffectedside.
ThreepointsofHartelaremarked
onthesideofthefaceusing
markingink.

63. Firstpoint–aperpendicularlineisdrawnfromthelateral
orbitalrimtotheinferiorborderofthemandible.
Secondpoint–markedat15mmlateraltotheangleofthe
mouthontheperpendicularfirstline
Thirdpoint–markedatthelevelofTMJ2.5cmfromthe
centreoftheexternalauditorymeatus.

64. •Thislineisthelineofelevation.
•Whenpatientissupine,planeofelevationwillbe
perpendiculartofloor
•Needleispassedthroughthesecondpoint.
•Needleispassedtillanteriorborderoframusof
mandible,thenturntheneedlemedialandupwardsto
baseofskull
•Positionisconfirmed.
•Needleisthenpushedforhalfcentim
eter,finalposition.

65. (A)Controlledradiofrequencythermocoagulation:
ItwasfirstintroducedbyKirschner(1931)&latermodifiedby
Sweet(1970).
Technique:
Thepatientissedatedwithashortacting
sedativeandvitalsignsaremonitored.
Theelectrodeisinsertedthroughthecheek
underfluoroscopyintoforamenovale.
Thepatientisawakenedbrieflytoaccurately
locatethepositionoftheelectrode.

66. Thestraighttemperature
monitoringelectrodewas
usedtoperformaninitial
lesionat60Cfor120s
Thepatientisawakenedfor
sensorytesting
Thelesionmayberepeated
atthesametemperatureand
durationifsensorydeficit
wasnotevident
Facial hyperemia in the distribution of right V2
during RFT.
WaelFouad; Management of trigeminal neuralgia by radiofrequency thermocoagulation;
Alexandria Journal of Medicine (2011) 47, 79–86

67. Indication:
Toxicity of drugs
Failure of response to the other
modalities
Dependence on the drugs for life time
Elderly patients
Medically compromised patients

68. Advantages:
Comparativelowrateofrecurrence
Zeromortality
Thermocoagulationpreservesthemotorfunctionofthe
trigeminalnerve
Canavoidmajorsurgicalprocedure
Disadvantage:
Maycause
Anaesthesiadolorosa
Lossofcornealreflex
Meningitis(rarely)

69. (B)Percutaneousglycerolrhizotomy:
Glycerolisaneurolyticalcoholwhichcanbeusedtochemically
destroythenerveroot.
Theinjectionof0.1–0.4mlofglycerolintothetrigeminal
cisterniscarriedoutunderfluoroscopiccontrol

70. Advantages:
Simple technique
Lower incidence of
anaesthesia dolorosa
Complication:
Post operative headache, nausea, vomiting
Meningitis
Post operative herpes simplex perioralis

71. (C)Percutaneousballooncompression:
Thisisamechanicalmeansofdestructionofthetrigeminal
nerveintroducedbyMullan&Lichtorin1980.
Technique:
Ano.4Fogarthy’scatheterisintroducedwith
fluoroscopicguidance.
A0.5-1mmballoonisinflatedfor1–6minutes.

73. OPEN PROCEDURES ( INTRACRANIAL PROCEDURES):
(A) Microvasculardecompression of the trigeminal
nerve sensory root:
Procedure popularized in 1967 –1976 by Jannetta.
Most commonly performed intra cranial open
procedure.
The root is examined under the
microscope

74. A compressing branch of the
superior cerebellar artery will be
seen medial to the nerve at the
root entry zone.
Incision is made over the mastoid area

75. Thenthetrigeminalnerveisfreed
fromthecompressing/pulsating
artery.
Afterfreeingthenerve,thenerveis
separatedfromthearterybyplacing
apieceofTeflonbetweenthem.

76. Non absorbable insulating
sponge may also be placed.

77. (B)Trigeminalrootsection:
(a)Extraduralsensoryrootsection:
Itisalsoknownasthesubtemporal
extraduralretrogasserianrhizotomy.
Itisnolongerusednow.
Inthis,sensoryrootisdivided,sparing
themotorroot,asclosetothebrainstem
aspossible.
Disadvantage:
Profoundsensoryloss
Highincidenceofanesthesiadolorosa

78. (b)Intraduralrhizotomy:
Thisisanintraduralprocedurethatisdonewhenthepain
recursafterMVD.
Thisisusuallydoneintheposteriorcranialfossa.
Itcanbeselectiveorcomplete.
(c)Trigeminaltractotomy:
Itisalsoknownasthemedullarytractotomy.
Thisisnotusuallydone.
Thedescendingtractofthetrigeminalnerveissectionedat
thejunctionofthecervicomedullaryregion.

79. STEREOTACTICRADIOSURGERY(GAMMAKNIFE):
Theradiationisaimedattheproximalnerveandrootentryzonein
thepons
Thegammaknifeprojects201veryfinebeamsofgammaraysat
doseof70–90Gy(generatedbyradioactivecobalt)throughskull
andbrain
Ithasbeenshowntoaffect
abnormalephatictransmissionbut
notnormalaxonalconduction
Siddiquietal;Painmanagementtrigeminalneuralgia;Hospitalphysician2003

80. Conclusion
•Trigeminalneuralgiahaslongbeenrecognizedby
themedicalprofessionals
•Howeveritisstillanenigmaticdisorder,andits
managementremainscontroversial.

81. References
•HolguinJetal;Suprameatalextensionofretrosigmoidapproachfor
microvasculardecompressionofTN;IJOS2015:13-16
•YasushiLetal;NeuronavigationassisteddecompressionofTN:
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•KoopmanJetal;Nationalwidestudyof3invasivetreatmentforTN;IASP
2011:507-513
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•Nurmikkoetal;TN-pathophysiology,diagnosisandcurrenttreatment;
BJA2001:117-32
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