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Trigeminal Neuralgia

Overview

Trigeminal Neuralgia also known as the suicide disease, is universally regarded as one of the most painful and unpredictable condition. It is characterised by facial pain resulting from overreaction to everyday stimuli such as talking, eating, cold breeze, smiling & light touch. These stimuli lead to intense, electric shock like one-sided head pain that bores into the forehead and often spreads down to the eye, face, mouth, gums and teeth. It is more painful than kidney stones, giving birth or a heart attack. Initially the attacks are short and mild however, with time they increase in intensity, frequency and duration Trigeminal Neuralgia is disease of elderly aged 50-70yrs with incidence being 5.2 per 1,00,000 females and 3.0 per 1,00,000 males.

Symptoms

One may feel as though the pain came out of nowhere. Some people with this condition start out thinking they have an abscessed tooth and go to a dentist. The symptoms of Trigeminal Neuralgia are:

  • Episodes of severe, shooting or jabbing pain that may feel like an electric shock
  • Spontaneous attacks of pain or attacks triggered by things such as touching the face, chewing, speaking or brushing teeth
  • Bouts of pain lasting from a few seconds to several minutes
  • Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain
  • Constant aching, burning feeling that may occur before it evolves into the spasm-like pain of trigeminal neuralgia
  • Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
  • Pain affecting one side of the face at a time, though may rarely affect both sides of the face
  • Pain focused in one spot or spread in a wider pattern
  • Attacks that become more frequent and intense over time
  • Doctors consider these sudden and intense bouts of pain be signs of classical case of trigeminal neuralgia (TN1). At times the pain could be less intense but constant, like an aching and burning sensation. This is referred to as “atypical” trigeminal neuralgia (TN2). Some people with this condition also have anxiety because they are uncertain when the pain will return.

    Causes

    Primary Trigeminal Neuralgia is caused in by tiny blood vessel impinging on the trigeminal nerve, 5th nerve – Neurovascular conflict (50%) or sometimes without any causes – Idiopathic (40%). Secondary Trigeminal Neuralgia in 10% of patients is caused by herpes infection, multiple sclerosis, tumours or nerve injuries. This condition usually surfaces when there is a contact between a blood vessel and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction. Very rarely, Trigeminal Neuralgia can be caused by a tumour compressing the trigeminal nerve. While in few cases, a cause can’t be found. The triggers for Trigeminal Neuralgia could be:

  • Shaving
  • Touching your face
  • Eating
  • Drinking
  • Brushing your teeth
  • Talking
  • Putting on makeup
  • Encountering a breeze
  • Smiling
  • Washing your face
  • Diagnosis

    The diagnosis of trigeminal neuralgia is mainly based on the description of the pain, including:

  • Type: Pain related to trigeminal neuralgia is sudden, shock-like and brief.
  • Location: The parts of your face that are affected by pain will tell your doctor if the trigeminal nerve is involved.
  • Triggers: Trigeminal neuralgia-related pain usually is brought on by light stimulation of your cheeks, such as from eating, talking or even encountering a cool breeze.
  • The doctor may recommend certain tests to diagnose trigeminal neuralgia and determine underlying causes for the condition, including:
  • A neurological examination: Touching and examining parts of the face can help the doctor determine exactly where the pain is occurring and, if you appear to have trigeminal neuralgia, which branches of the trigeminal nerve may be affected. Reflex tests also can help the doctor determine if the symptoms are caused by a compressed nerve or another condition.
  • Magnetic resonance imaging (MRI): The doctor may order an MRI scan to determine if multiple sclerosis or a tumour is causing trigeminal neuralgia. In some cases, the doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiogram).
  • It’s important to note that the facial pain may be caused by other conditions also, so an accurate diagnosis is essential. The specialists may suggest additional tests to rule out the possibilities of other conditions.

    Treatment

    The treatment for Trigeminal neuralgia usually starts with medications, and in some cases no additional treatment is required. However, over time, some people with the condition may stop responding to medications, or they may experience unpleasant/intolerable side effects. For those people, injections or surgery provide other trigeminal neuralgia treatment options. Medicinal Treatment The treatment of Trigeminal Neuralgia can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best.

  • Anticonvulsant medicines: Used to block nerve firing, are generally effective in treating TN1 but often less effective in TN2.
  • Antispasmodic agents: Muscle-relaxing agents may be used alone or in combination with anticonvulsants. Side effects may include confusion, nausea and drowsiness.
  • Botox Injections: Studies have shown that Botox injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medications. However, more research needs to be done before this treatment is widely used for this condition.
  • Surgical Treatment
  • Non-Ablative Options:
    • Open Microsurgery: This procedure is called Microvascular decompression is usually contemplated when there is abnormal vessel pressing the nerve resulting in a process called demyelination. The Surgeon would place a Teflon sponge between the vessel and the nerve and minimises the damage. The recurrence rate for the condition may be 50?ter 10 years of the procedure.
    • Neurectomy: Usually involves cutting of the superficial branches of the nerves. The effect caused by this procedure is typically temporary and pain recurs in 1-2 years.
    Ablative Options: Few of these procedures are usually done on an outpatient basis under local anaesthesia / General anaesthesia. The side-effects of the same may include – facial numbness
  • Balloon Compression: Here a hollow needle is inserted through the face and guided to a part of the trigeminal nerve that goes through the base of the skull. Then, the doctor threads a thin, flexible tube (catheter) with a balloon on the end through the needle. The balloon is inflated with enough pressure to damage the trigeminal nerve and block pain signals. This procedure is done under general anaesthesia. Usually the pain relief lasts for 1-2 years
  • Glycerol Injection: During this procedure, a sterile needle is inserted through the face and into an opening in the base of the skull. The needle is guided into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. There a small amount of sterile glycerol is injected, which damages the trigeminal nerve and blocks pain signals
  • Radiofrequency lesioning: This procedure selectively destroys nerve fibres associated with pain. An electrode is used to locate the area causing the pain. Once located, the heat is applied through the electrode to damage the nerve fibres creating an area of injury (lesion). The pain recurrence usually happens at 3-4 years.
  • Radiation Therapy
  • Stereotactic Radiosurgery: Stereotactic radiosurgery uses advanced computer and MR imaging to direct highly focused beams of radiation at the site where the trigeminal nerve exits the brain stem. This causes the slow formation of a lesion on the nerve that disrupts the transmission of sensory signals to the brain.
  • Advantages of Frameless Radiosurgery:
  • Non-invasive treatment
  • Non-invasive – No need for anaesthesia, No need for Blood, No risk of infections
  • Day-care procedure – Uses the most advanced FFF technology which enables fastest treatment delivery from 20-30mts
  • Uses Robotics which gives sub mm. Precision and accuracy in targeting the nerve
  • Allows flexi-scheduling
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