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Diagnostic criteria and management of trigeminal neuralgia: A review

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Trigeminal neuralgia, often called tic douloreux, has been described as one of the worst painful human afflictions. It is a craniofacial pain disorder that is characterized by episodes of sharp, severe, lancinating, " electric-like " bolts of pain. Pain of trigeminal neuralgia has been compared to severe toothache or even labor pain. The International Association for the Study of Pain defines classical idiopathic trigeminal neuralgia (TN) as " a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve. " However, there are variations in presentation that are more difficult to diagnose trigeminal neuralgia. The purpose of this article is to review the recent developments, new criteria for diagnosis, medical and surgical management. The review article has been prepared doing a literature review from the World Wide Web and pubmed/medline.
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Diagnostic criteria and management of trigeminal neuralgia: A review
Rahul Srivastava
1*
, Bhuvan Jyoti
2
, Ashutosh Shukla
3
, Pankaj Priyadarshi
4
1
Senior Lecturer, Department of Oral Medicine & Radiology, Rama Dental College, Hospital & Research Centre
Kanpur (U.P), India
2
Dental Surgeon, Department of Dental Surgery, Ranchi Institute of Neuro-Psychiatry and Allied Sciences,
India
3
Senior Lecturer, Department of Oral & Maxillofacial surgery Rama Dental College, Hospital & Research
Centre Kanpur (U.P)
4
Post Graduate student, Department of Conservative and Endodontics,Rama Dental College, Hospital &
Research Centre Kanpur (U.P)
ABSTRACT
Trigeminal neuralgia, often called tic douloreux, has been described as one of the worst painful human afflictions. It is a
craniofacial pain disorder that is characterized by episodes of sharp, severe, lancinating, “electric - like” bolts of pain. Pain of
trigeminal neuralgia has been compared to severe toothache or even labor pain. The International Association for the Study of
Pain defines classical idiopathic trigeminal neuralgia (TN) as “a sudden, usually unilateral, severe, brief, stabbing, recurrent pain
in the distribution of one or more branches of the fifth cranial nerve.” However, there are variations in presentation that are more
difficult to diagnose trigeminal neuralgia. The purpose of this article is to review the recent developments, new criteria for
diagnosis, medical and surgical management. The review article has been prepared doing a literature review from the World
Wide Web and pubmed/medline.
Key
words:
Trigeminal neuralgia,cranial,fifth
Introduction
The trigeminal nerve (the fifth cranial nerve, also
called the fifth nerve, or simply CNV or CN5) is
responsible for sensation in the face. The trigeminal
nerve is the largest of the cranial nerves and it is
thought to be one of the factors involved in the cause of
migraine. Its name - “trigeminal” - is derived from the
fact that each nerve, one on each side of the pons, has
three major branches: the ophthalmic nerve (V1), the
maxillary nerve (V2) and the mandibular nerve (V3).
The ophthalmic and maxillary nerves are purely
sensory. The mandibular nerve has both sensory and
motor functions.[1] Pain, thermal, tactile and
kinaesthetic sensory stimuli are received from facial
skin, oropharynx, oral mucous membranes, sinuses,
teeth, palate, dura and masticatory muscles.
_______________________________
*Correspondence
Dr. Rahul Srivastava
Senior Lecturer, Department of Oral Medicine & Radiology,
Rama Dental College, Hospital & Research Centre Kanpur
(U.P), India
Email:
drrahul_osmf@yahoo.com
Motor fibers extend to the muscles of mastication as
well as the tensor tympani and tensor veli palatini. The
trigeminal brain stem nuclei are the spinal trigeminal
nucleus and tract, the main (or principal) sensory
nucleus, the mesencephalic nucleus, and the motor
trigeminal nucleus. The branches of trigeminal nerve
have their cell bodies in the gasserian (or semilunar)
ganglion (with the exception of jaw propioceptive
fibers). The gasserian ganglion resides in Meckel’s
cave in the temporal bone.[2]There are various other
health conditions that can cause facial pain, such as
trigeminal neuralgia.[1]International Association For
the Study of Pain (IASP) defined trigeminal neuralgia
as “sudden usually unilateral severe brief stabbing
recurrent pain in the distribution of one or more
branches of the V
th
cranial nerve”. According to the
International Headache Society (IHS) the trigeminal
neuralgia may be defined as “painful unilateral
affliction of the face characterized by brief electric
shock like pain limited to the distribution of one or
more divisions of trigeminal nerve”. Pain is commonly
evoked by trivial stimuli including washing, shaving,
smoking, talking and brushing the teeth but may also
occur spontaneously. The pain is abrupt in onset and
termination and may remit for varying periods.[3]
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Historical perspectives of TGN
Historical reviews of facial pain have attempted to
describe this severe pain over the past 2.5 millennia.
The ancient Greek physicians Hippocrates, Aretaeus,
and Galen, described kephalalgias, but their accounts
were vague and did not clearly correspond with what
we now term trigeminal neuralgia. The first adequate
description of trigeminal neuralgia was given in 1671
by German physician, Johannes Laurentius Bausch,
who suffered from a lightning like pain in the right
face. He became unable to speak or eat properly and
apparently succumbed to malnutrition. John Locke, a
physician and well-known philosopher, provided the
first full description of TN by a medical practitioner,
along with an account of its treatment. In 1677, while
in Paris, Locke was called in to evaluate the wife of the
English ambassador, the Countess of Northumberland,
who was suffering from excruciating pain in the face
and lower jaw. Locke deliberated whether to prescribe
"opening medicine" (laxative therapy), because of the
wintry weather at the time. In spite of the cold and the
inconvenience he would cause his patient, he
eventually overcame his reluctance and thoroughly
purged the Countess. Her pain improved several weeks
later. Nearly a century after that, two prominent
clinical accounts were reported, one by Nicolas André
(Fig. 1) and one by John Fothergill (Fig. 2) that further
characterized this disease’s entity. In 1756, André
reported two cases of TN, which he termed tic
douloureux. He conceptualized the disease in terms of
convulsions, and he believed that true tonic
convulsions, tetanus, and spasm clinique belonged in a
single disease spectrum. The term tic douloureux was
used to imply contortions and grimaces accompanied
by violent and unbearable pain. André believed that the
cause was "vicious nervous liquids" that distressed the
nerve and caused painful shocks. Using this reasoning,
he followed the proposal of Maréchal (a contemporary
surgeon) by applying caustic substances to the
infraorbital nerve at the infraorbital foramen over a
period of days until the nerve was destroyed. Fothergill
described trigeminal neuralgia as "a painful affection of
the face”. He presented 14 cases of a painful affliction
of the face. His description of TN has been considered
an accurate and clear account. In Fothergill's
description he made the following comments: “The
affection seems to be peculiar to persons advancing in
years, and to women more than to men....”. The pain
comes suddenly and is excruciating; it lasts but a short
time, perhaps a quarter or half a minute, and then goes
off; it returns at irregular intervals, sometimes in half
an hour, sometimes there are two or three repetitions in
a few minutes. Eating will bring it on some persons.
Talking, or the least motion of the muscles of the face
affects others; the gentlest touch of a hand or a
handkerchief will sometimes bring on the pain, whilst a
strong pressure on the part has no effect. Fothergill
asserted that TN was not within the spectrum of a
convulsive disorder. Instead, he postulated that this
disease might be the manifestation of some type of
cancer; he found a hard tumor of the breast in two of
the 14 cases he presented. Given his meticulous
description of the clinical symptoms, many thereafter
referred to this condition as "Fothergill's disease."
Fig 1: Portrait of Nicolas Andre Fig 2:
Portrait of John Fothergill
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Fig 3: Patient with typical
trigeminal neuralgia, vessels
compress the trigeminal nerve
root.
Fig 4: No vascular compression
upon the trigeminal nerve root
in patient with no TN
Fig 5: Trigger zones in facial
areas,trigger points (circles)have
greatest sensitivity
Fig 6: Important clinical features of trigeminal neuralgia
In 1779, John Hunter more clearly characterized the
entity as a form of "nervous disorder" with reference to
pain of the teeth, gums, or tongue where the disease
"does not reside." One hundred fifty years later, the
neurological surgeon Walter Dandy equated
neurovascular compression of the trigeminal nerve
with trigeminal neuralgia.[4-6]
Etiologic/predisposing factors
Trigeminal nerve is the largest of all the cranial nerves.
Trigeminal neuralgia, also called tic douloureux,
causes extreme, sporadic, sudden burning or shock-like
facial pain that lasts from few seconds to several
minutes and can be physically and mentally
incapacitating. Most cases are still referred to as
idiopathic, although many are associated with vascular
compression of the trigeminal nerve. According to the
National Institute of Neurological Disorders and
Stroke, heredity may be a cause of trigeminal
neuralgia.[7]
Compression of trigeminal nerve root is the most
common cause of trigeminal neuralgia. The
compression occurs usually within few millimeters of
entering in to the pons. The primary demyelinating
disorders can also lead to this condition. A few rare
conditions that can cause trigeminal neuralgia are:
Infiltration of nerve root (due to carcinomatous
deposit within nerve root, gasserian ganglion and
nerve )
Small infarcts or angiomas in the pons or medulla.
Infiltration of gasserian ganglion or the nerve by a
tumour or amyloid.
Most widely accepted theory is that majority of cases
of trigeminal neuralgia are caused by atherosclerotic
blood vessel (usually the superior cerebellar artery)
pressing on and grooving the root of trigeminal nerve.
This pressure results in focal demyelinization and
hyperexcitability of nerve fibers, which will then fire in
response to light touch, resulting in brief episodes of
intense pain.[8]
Jannetta in 1967 first recognized the focal compression
of trigeminal nerve root as a major etiological factor
for the trigeminal neuralgia. Now it is considered as an
important cause of trigeminal neuralgia in 80-90% of
cases. The part of nerve root that commonly
compressed is actually within CNS tissue. There are
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following compressing lesions that can lead to TGN
are:
Vestibular schwannomas.
Meningiomas.
Epidermoid cyst etc.[8,9]
Primary demyelinating disorders
A well known complication of multiple sclerosis is
TGN. The plaque of demyelination encompasses the
root entry zone of trigeminal nerve in the pons. The
compression of blood vessel may also contribute in the
compression of root entry of trigeminal nerve in some
patient with multiple sclerosis suffering from
trigeminal neuralgia.[10-14]
Nondemyelinating lesions
Nakamura et al, Golby et al have reported some
patients with trigeminal neuralgia who were suffering
from angiomas and small infarcts within the brain
stem.[15,16]
Familial trigeminal neuralgia
In 1979 Knuckey and Gubbay reported several
individuals in three generations of family were
suffering from trigeminal / glossopharyngeal
neuralgia.[17]
Coffey et al reported a familial occurrence in Charcot-
Marie-Tooth neuropathy. He described the patients
from two different families with Charcot-Marie-Tooth
disease and medically intractable trigeminal neuralgia.
The patients were treated with percutaneous
retrogasserian glycerol rhizolysis successfully.[18]
Diabetes
Neuralgia anywhere in the body including the
trigeminal neuralgia can also cause by diabetes.
Diabetes causes the damage of tiny arteries that
provide circulation to the nerves which lead to nerve
fibers malfunctions and sometimes nerve loss.
Infectious conditions
The trigeminal neuralgia can also manifest by
infectious conditions cerebellopontine angle
cysticercosis, pons abscess and cases of bacterial
infections like Mycobacterium leprae, Secondary
syphilis, Leptospirosis, Shigella etc.
Stress
According to Beth Israel Medical Center Department
of Pain Medicine and Palliative Care the trigeminal
neuralgia can be caused by stress also. Stress leads to
inflammation of blood vessel which can compress or
irritate the trigeminal nerve. Patient having the
trigeminal neuralgia with another cause, the severity of
painful attacks can worsen by stress.[7]
Pre-trigeminal neuralgia
A typical initial manifestation that, in some patients,
precedes the classic presentation of TN, was introduced
by Symonds. He described a dull continuous, aching
pain in the upper or lower jaw that later developed in to
classic paroxysmal pain. This prodromal pain is termed
as “pre-trigeminal neuralgia” by Mitchell. Similar
prodromal sensations have also been reported in some
cases of glossopharyngeal neuralgia. Descriptions of
PTN have included pain that is mild to moderate in
intensity, dull, aching, burning, throbbing, soreness of
gums and toothache.[19,20]
Fromm GH et al reported 18 patients who subsequently
developed typical trigeminal neuralgia experienced a
prodromal pain termed “pre-trigeminal neuralgia.” The
prodromal pain was described as a toothache or
sinusitis-like pain lasting up to several hours,
sometimes triggered by jaw movements or by drinking
hot or cold liquids. Typical trigeminal neuralgia
develops a few days to 12 years later, and in all cases
affected the same division of the trigeminal nerve. Six
additional patients experiencing what appeared to be
pre-trigeminal neuralgia became pain-free when taking
carbamazepine or baclofen.[21]
Classification of trigeminal neuralgia
Based on etiology
The international headache society (IHS) has classified
trigeminal neuralgia in to two categories according to
etiology:
1. Classical trigeminal neuralgia In classical
trigeminal neuralgia there is no cause of the
symptoms can be identified other than vascular
compression.
2. Symptomatic trigeminal neuralgia -
Symptomatic trigeminal neuralgia has the same
clinical criteria, but another underlying cause is
responsible for the symptoms.[22]
Based upon the specific objective and reproducible
criteria a classification scheme for trigeminal neuralgia
was proposed by Eller JL. The classification was based
on information provided in the patient’s history and
incorporates seven diagnostic criteria, as follows:
1 and 2- Trigeminal neuralgia Types 1 and
2(TN1andTN2) refer to idiopathic, spontaneous facial
pain that is predominantly episodic (as in TN1) or
constant (as in TN2) as in nature.
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3- Trigeminal neuropathic pain results from
unintentional injury to the trigeminal nerve from
trauma or surgery.
4- Trigeminal deafferentation pain results from
intentional injury to the nerve by peripheral nerve
ablation, gangliolysis or rhizotomy in attempt to treat
either TN or other related facial pain.
5- Symptomatic TN results from multiple sclerosis.
6- Post-herpetic TN follows a cutaneous herpes zoster
outbreak in the trigeminal distribution.
7- The category of atypical facial pain is reversed for
facial pain secondary to somatoform pain disorder and
requires psychological testing for diagnostic
confirmation.
Based on symptoms
From symptomatic point of view the trigeminal
neuralgia is classified in to following:
1-Typical Trigeminal Neuralgia (Tic Douloureux)
This is the most common form of TN, which has
previously been termed Classical, Idiopathic and
Essential TN. Nearly all cases of typical TN are
caused by blood vessels compressing the trigeminal
nerve root as it enters the brain stem. This
neurovascular or microvascular compression at the
trigeminal nerve root entry zone may be caused by
arteries of veins, large or small, that may simply
contact or indent the trigeminal nerve. (Fig 3) In people
without TN, blood vessels are usually not in contact
with the trigeminal nerve root entry zone. (Fig 4)
Pulsation of vessels upon the trigeminal nerve root do
not visibly damage the nerve. However, irritation from
repeated pulsations may lead to changes of nerve
function, and delivery of abnormal signals to the
trigeminal nerve nucleus. Over time, this is thought to
cause hyperactivity of the trigeminal nerve nucleus,
resulting in the generation of TN pain. The superior
cerebellar artery is the vessel most often responsible
for neurovascular compression upon the trigeminal
nerve root, although other arteries or veins may be the
culprit vessels.
2 - Atypical trigeminal neuralgia
Atypical TN is characterized by a unilateral, prominent
constant and severe aching, boring or burning pain
superimposed upon otherwise typical TN symptoms.
This should be differentiated from cases of typical
TN that develop a minor aching or burning pain within
the affected distribution of the trigeminal nerve. As in
typical TN vascular compression, is thought to be the
cause of many cases of atypical TN. Some authors also
believe that atypical TN is due to vascular compression
upon a specific part of the trigeminal nerve (the portio
minor); while others theorize that atypical TN
represents a more severe form or progression of typical
TN.[23] The disorder is sometimes broken down into
type 1 and type 2. TN type 1 (TN1) is characterized by
attacks of intense, stabbing pain affecting the mouth,
cheek, nose, and/or other areas on one side of the face.
TN type 2 (TN2) is characterized by less intense pain,
but a constant dull aching or burning pain. Both types
of pain can occur in the same individual, even at the
same time. In some cases, the pain can be excruciating
and incapacitating. TN1 develops due to a blood vessel
pressing against the trigeminal nerve, but sometimes no
underlying cause can be identified (idiopathic). TN2
can be idiopathic, due to compression of the trigeminal
nerve, or can occur due to a known underlying cause
such as a tumor or multiple sclerosis. There is no
consensus or agreed upon classification system for TN.
TN1 is also known as classical trigeminal neuralgia.
TN2 was once known as atypical or symptomatic
TN.[24]
Clinical presentaion
Recurring episodes of intense, short-lived spasms
of pain of the lower portion of the face and the
jaw.
In most cases, pain is limited to one side of the
face (unilateral).
The pain has been compared to a series of
"electrical shocks" followed by a steady dull ache.
The pain often starts and stops rapidly.
Intense pain usually lessens rapidly (usually within
several seconds), but the following dull aching
pain may persist for as much as one to two
minutes. For many individuals, pain is completely
gone in between episodes. However, for some
individuals, even some individuals with TN1,
some degree of pain may persist.
Some patients are sensitive in certain areas of face
called trigger zone, which when touched cause an
attack. These zones are usually near the nose, lips,
eyes, ears or inside the mouth. (Fig. 5)
Pain may be triggered by mild tactile stimuli
including brushing one’s teeth, washing one’s
face, shaving, drinking hot or cold drinks,
chewing, talking, blowing one’s nose, a cool
breeze, or a light touch to the face.
Some episodes may occur without an apparent
trigger (spontaneously). Consequently, episodes
can occur repeatedly throughout the day.
Episodes rarely occur during sleep.
Attacks typically stop for a period of time and then
return.
Over time, the pain tends to grow worse with
fewer pain-free periods.
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Major clinical features are summarized in
Fig.6[24-27]
Diagnosis
The diagnostic criteria of the International Headache
Society (IHS) (1988) are as follows:
1- Paroxysmal attacks of facial pain which last a few
seconds to less than two minutes.
2- Pain has at least 4 of the following characteristics:
Distribution along one or more divisions of
the trigeminal nerve.
Sudden, intense, sharp, superficial, stabbing or
burning in quality.
Pain intensity is severe.
Precipitation from trigger areas, or by certain
activities such as eating, talking, washing the
teeth or cleaning the face.
Between paroxysms the patient is entirely
asymptomatic.
3- Attacks are stereotyped in the individual patient.
4- No neurological deficit and exclusion of other
causes.[28]
The IHS describes TN as unilateral disorder
characterized by brief electric shock like pain, abrupt in
onset and termination limited to the distribution of one
or more division of the trigeminal nerve in the second
edition. In the second edition the diagnostic criteria for
classical trigeminal neuralgia are as follows:
A- Paroxysmal attacks of pain lasting from fraction of
a second to two minutes, affecting one or more division
of trigeminal nerve and fulfilling criteria B&C.
B. Pain has at least one of the following characteristics:
1- Intense, sharp, superficial or stabbing.
1- Precipitated from trigger area or by trigger factor.
C- Attacks are stereotype in the individual patients.
D- There is no clinically evident neurological defect.
E- Not attributed to another disorder.
The IHS description states that between paroxysms the
patient is usually asymptomatic, but a dull background
pain may present in some longstanding cases and that
many, possibly most, patient with this condition have
compression of the trigeminal root by tortuous or
aberrant vessels.[29]
The trigeminal neuralgia association, UK has given the
following clues that point to a correct diagnosis of
trigeminal neuralgia:
1- The degree of pain exceeds the evidence.
2- Painkillers do not kill the pain.
3- The pain cannot be pinned down to one specific
tooth.[30]
The diagnosis of TN is purely clinical. Haematological
investigations at regular intervals are important in
patient on drug therapy. Radiologic investigations are
important. Secondary TN (e.g. multiple sclerosis, cysts,
vascular pathologies etc.) can be rule out with help of
MRI. Sensory testing is not done routinely, but
quantitative sensory testing (QST) and evoked
potentials may play an important role in differentiating
between symptomatic and idiopathic TN.[27]Nurmikko
and Edridge have proposed their own diagnostic
criteria for the trigeminal neuralgia (Table:1)
Management of pain
Administration of anticonvulsant drug was first
treatment of choice initially, but nowadays varieties of
effective treatments are available in both forms
pharmacological as well as surgery. Drugs used as
pharmacological treatment for trigeminal neuralgia is
summarized in Table 2.[33-36]
Surgical management
When trigeminal neuralgia cases become refractory
then they are referred to a neurosurgeon with special
interest and experience with trigeminal neuralgia.
There are following surgical options for the treatment
of trigeminal neuralgia:
1. Microvascular decompression
Target area in microvascular decompression lies at the
nerve-pons junction. The posterior fossa approached
through a suboccipital craniotomy. After aspiration of
cerebrospinal fluid, the operator advances toward the
nerve by gently retracting the superolateral margin of
the cerebellum. The most common finding is a segment
of the superior cerebellar artery compressing the nerve
at the root entry zone. Anterior inferior cerebellar
artery or the superior petrosal veins are the less
frequent cause of the compression. After the arachnoid
is dissected and the vessel freed, the operator places a
piece of shredded Teflon left between the vessel and
the nerve to separate them.[37]
2. Glycerol gangliolysis
The procedure can be done under local anesthesia in
fully awake patients although mild sedation is usually
used. The needle is inserted into the trigeminal cistern
through the foramen ovale using similar trajectors as in
radio-frequency lesioning and balloon compression.
Needle positioning must be precise to ensure the tip
lies in ganglion and not the subarachnoid space beneath
the temporal lobe. Free CSF flow is the norm, except in
previously treated cases. Fluoroscopic control is
mandatory but use of radio opaque contrast to visualise
the cistern varies from centre –to- centre. Once needle
is optimally placed, the patient is brought in to a sitting
position and a small test of sterile anhydrous glycerol
injected. This is followed by small dose increments up
to a total of 0.1-0.4 ml depending upon the divisions
involved. Patient is usually able to perceive the effect
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of injection as tingling or burning sensation in the
affected divisions. Patient remains in the sitting
position for 2 hour after injections.
3. Radiofrequency gangiolysis
This procedure is carried out under fluoroscopic
control in intermittently anaesthetized patient. A
radiofrequency needle is inserted through the foramen
ovale into Meckel’s cave using bony landmarks. The
relationship of trigeminal rootlets to the foramen ovale
is such that by stepwise advancement of the needle the
third, second and first divisions will be in succession
stimulated, the closer to the clival line the needle tip is.
As soon as the needle has entered Meckel’s cave,
aspiration will usually yield CSF. Once the needle has
travelled the pre-planned distance, the patient is
allowed to awake, the stylet replaced by the electrode
and stimulation of the nerve root carried out. The
paraesthesia elicited must confirm to the location of the
neuralgia, otherwise the needle must be repositioned.
Once appropriate siting has taken place, the patient is
anaesthetized again for thermal lesioning. This is
performed in cycles of 45 to 90 s at temperatures of 60-
90
0
.
After each lesioning the patient is awakened and
manual sensory testing of the face carried out.
Additional thermal lesions are performed until clear
hypalgesia has ensued.[31]
Balloon compression
This procedure is performed under general anesthesia.
Using fluoroscopic control, a guide needle is inserted
in to foramen ovale, but not beyond it. Through the
needle, the fogarty catheter is advanced until its tip lies
in Meckel’s cave and balloon is slowly inflated with
0.5 1.0 ml of contrast dye until it occupies the cave,
ensuring adequate compression. Total compression
times vary from 1-6 min. This produces only a mild
sensory loss with immediate pain relief in practically
all patients. There is complete recovery in a matter of
weeks. The patient usually only requires an overnight
stay.[31]
Stereotactic radiosurgery
Several reports have documented the efficacy of
Gamma Knife® stereotactic radiosurgery for TN.
Because radiosurgery is the least invasive procedure
for TN, it is a good treatment option for patients with
co-morbidities, high-risk medical illness, or pain
refractory to prior surgical procedures. Radiosurgery is
a good alternative for most patients with medically
refractory trigeminal neuralgia, especially those who
do not want to accept the greater risk of an MVD for a
greater chance of pain relief[32].
Gamma Knife treatment is a simple, relatively painless
and quite straight- forward process that consists of four
steps:
1. Attaching the head frame;
2. Imaging with MRI or CT scan (for patients with
pacemakers)
3. Treatment planning
4. Treatment
The head frame
Placement of the frame on the head of the patient is a
very important part of the procedure. This frame allows
the doctor to pinpoint the target area with extremely
high accuracy. For trigeminal neuralgia patients, the
target is usually in the vicinity of the root entry zone of
the fifth cranial nerve.
Imaging
During this part of the procedure, most patients are
awake and alert; however, patients who experience
anxiety about the MRI or CT scan can be given further
sedation so that the imaging can be carried out.
Treatment planning
During treatment planning, data from the images is
transferred to a special, highly sophisticated computer.
Unlike gamma knife treatment for brain tumors in
which the tumor is outlined, trigeminal neuralgia
patients will have the nerve outlined in multiple
imaging sequences. Neurosurgeon and the rest of the
team will go through a quality assurance process and
everyone will review and confirm the plan before
embarking on the actual treatment.
Treatment
Patient will then be taken to the actual Gamma Knife
Suite where patient will be allowed to lie down in a
comfortable position. The head frame is now attached
to the automatic position system (APS). This is a very
sophisticated computerized robotic system with high
accuracy. At this point, patient may move his arms and
legs, but head will actually be fixed. All of this will be
explained by the nurses and doctors once inside the
unit.[38,39]
Cyber knife in trigeminal neuralgia
Because of the intrinsic limitations of current
stereotactic radiosurgical devices, image-guided
robotic radiosurgery was developed, and these
principles are embodied in the CyberKnife® System.
For patients who had undergone balloon nerve
compression, glycerol rhizotomy, or percutaneous
thermorhizotomy, one complication is facial
paresthesia and/or numbness of varying magnitude.
This adverse effect may result from injury of the
trigeminal nerve, causing impairment of sensory nerve
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transmission. In a recent Stanford CyberKnife
radiosurgery study, no patient with prior surgery
developed facial paresthesia following radiosurgery
treatment. The reduced rate of facial sensory
disturbance indicates that the effects of radiosurgery
are both physiologic and histologic due to lesser
irritation on nerve tissue than other ablative surgeries.
Cyber Knife technology allows conformal treatment
along the nerve and permits highly collimator radiation
beams near the dorsal root entry zone.
Conclusion
Trigeminal neuralgia has an enormous psychological
effect that can affect the quality and lifestyle of a
person. A definitive diagnosis of trigeminal neuralgia
is one of the greatest problems among clinician and
patients. Trigeminal neuralgia is a rare condition and
clinician may only see a few cases in their dental
practice career. Diagnosis of trigeminal neuralgia is
made clinically with the help of characteristic signs and
symptoms. Certain imaging modalities such as MRI
can be used to rule out the underlying cause of
trigeminal neuralgia including tumour and multiple
sclerosis. A clinician must be aware of proper
diagnosis and management of this type of craniofacial
pain disorder.
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Source of Support: NIL
Conflict of Interest: None
Table 1: Diagnostic criteria for the trigeminal neuralgia proposed by Nurmikko and Edridge
Typical
TGN(Liverpool
criteria)
Atypical TGN(Liverpool
criteria) TGN(IASP and
IHS definition) Trigeminal
neuropathy
(Liverpool criteria)
Site Unilateral Unilateral Unilateral Unilateral or bilateral
Quality of pain Sharp, shooting,
stabbing, lingering
aftersensations
Sharp, shooting, stabbing,
lingering aftersensations,
burning, smarting
Sharp, stabbing,
burning, superficial Dull or sharp,
smarting, steady pain
with shooting
sensations
superimposed.
Duration of pain
A few seconds at
most Several seconds Brief Any duration, usually
hours
Duration of
paroxysms
Seconds to minutes Seconds to minutes Seconds to two
minutes Continuous with pain-
free spells.
Refractory
period
yes yes yes No
Continuous pain
No Yes, not severe No Dominant feature
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Allodynia
Small trigger zones. Small trigger zones Limited trigger
zones Large allodynic areas
Associated
features Vasodialation,
swelling seen with
severe pain
Vasodilatation, swelling
seen with severe pain. Slight flush Variable
vasodilatation and
swelling, may be
constantly present
Radiation None outside
affected division None outside affected
division None outside
affected division May extend outside
trigeminal territory
Provoking
factors Touching, speaking,
eating, drinking,
cold, not heat,
movement
Touching, speaking, eating,
drinking, cold, occasionally
heat, movement
Eating, talking,
washing face,
brushing teeth and
smoking.
Same as atypical TGN
Variability of
pain
Some Variation Definite variation stereotyped Definite variation
Sensory loss Not detectable with
bedside test QST
may be abnormal
May be detectable with
bedside tests QST usually
abnormal
None Prominent, easily
detected with bedside
tests confirmed by
QST
Pain behaviour Aversion to touch
guarded speech Aversion to touch guarded
speech Not discussed Tolerates touching
speech not affected
Course of pain Early remissions
pre- TGN Early remissions
previously typical TGN Spontaneous
remissions No remission; slow
progression
Table 2: Drugs used as pharmacological treatment for trigeminal neuralgia
Drugs Mechanism of action Dosage Adverse effect
Carbamazepine Slow the recovery rate of voltage
gated sodium channels, modulates
activated calcium channel activity
and activates descending inhibitory
modulation system
200-1200 mg daily in 2
divided doses Memory problems,
diplopia, drowsiness,
fatigue, nausea,
nystagmus liver
dysfunction,
hematosupression
Baclofen Act by facilitating segmental
inhibition of the trigeminal complex. Initial dose is 5mg TID for
3 days and dose may be
increase d up to10 to 20
mg/day every 3 days and
maximum tolerated dose is
50 to 60 mg/day
Drowsiness, Dizziness,
weakness, Fatigue and
nausea
Oxcarbazepine Act by blocking voltage-gated
sodium channel and it modulates
voltage activated Ca++ currents.
300 to 1800 mg daily in
two divided doses Dizziness, fatigue, ataxia,
fatigue, tremors, diplopia,
diminished concentration.
Phenytoin Promotes sodium reflux from
neurons. 300 to 500 mg/day Nystagmus, ataxia, slurred
speech, mental confusion
Lamotrigine It acts as a voltage sensitive sodium Starting dose is 25 mg Ataxia, constipation,
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channel
and stabilizes neural membranes.
twice daily and it can be
increased
gradually to a maintenance
dose of 200-400mg/day in
two divided doses.
vomiting and rash
Levetiracetam mechanism of action is thought to
involve binding to the high voltage
N type calcium channels
as well as the synaptic vesicle
protein 2A (SV2A).
effective dose range is
1000 - 4000
mg/day
sleepiness, fatigue,
weakness, headache, pain,
double vision, dizziness,
coordination difficulties,
runny nose or cough,
increased infections,
memory difficulties,
anxiety, and behavioral
problems
Gabapentin Mechanism of action is not known
but possibly includes blockage of
voltage – gated calcium channels by
binding to α2/ subunit
1200 to 3600 mg daily in
3 or 4 divided doses dizziness,
coordination problems,
nausea, vomiting
Pregabalin drug binds to the a2d subunit of the
voltage gated calcium channels
causing decreased presynaptic
calcium entry leading to decreased
synpatic
release of glutamate.
150-600 mg/day Ataxia
Topiramate Acts by sodium channel blockade,
enhancing GABA
A
activity by
binding to a non-benzodiazepine site
on GABAA receptors, and
selectively blocking AMPA/kainite
glutamate receptors.
50 to 100 mg a day Dizziness, sedation,
cognitive impairment,
fatigue, nausea, blurred
vision and
weight loss.
... Symonds stated that trigeminal neuralgia proceeds with prodromal symptoms and it was named as "Pre-trigeminal neuralgia" by Mitchell [3,11]. The prodromal symptoms present with dull, aching, and continuous pain in the maxilla and mandible and later develop into the classical paroxysmal pain. ...
... It also decreases the severity of the disease [10]. Classical trigeminal neuralgia symptoms presents with pain attacks that last for few seconds or it may occur in "volleys" -that is multiple bursts of pain in quick intervals -lasting minutes [3] (Table 2 and 3). ...
... International Association for the Study of Pain (IASP) defined trigeminal neuralgia as "sudden usually unilateral severe brief stabbing recurrent pain in the distribution of one or more branches of the 5th cranial nerve". Similarly International Headache Society (IHS) defined it as "painful unilateral affliction of the face characterized by brief electric shock like pain limited to the distribution of one or more divisions of trigeminal nerve" [3,4]. ...
... Literature reveals that pain assessment plays a significant role in studies related to clinical management, in conducting clinical trials which might help identify effective pain and epidemiology and health related policies that have a great impact on the patient's quality of life (QoL) [10]. TN is defined by the IASP as "a sudden usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve" and is prevalent in 2-3% of the population [7,11]. According to American academy of orofacial pain, TMD is defined as "a collective term embracing a number of clinical problems that involve the masticatory muscles, the temoromandibular joint and associated structures or both". ...
... Most of the trigeminal neuralgia patients in our study chose "sharp, stabbing, shooting, burning, numb and unbearable" to describe their pain and they were highly statistically significant (p < 0.001). These findings were similar to the typical description of pain in TN [11]. Among TMD patients statistically significant words were "aching, nagging" (p < 0.001) and these findings were mostly similar to the study done by Mongini F et al [23]. ...
... • Posterior fossa at the root entry zone. 4 Different surgical approaches have been proposed for the treatment of drug-resistant TN. 4,5,11,14,[30][31][32][33][34][35][36][37][38][39][40] ...
... Symptomatic TN is related to specific causes including tumors, infarctions, multiple sclerosis, and others [31]. The pathophysiological mechanism is suspected to be the same as in classical TN; however, it is dependent on the interaction of these pathologies with the trigeminal nerve [32,33]. Approximately 2-4% of multiple sclerosis patients have shown to also develop TN as result of plaques affecting the trigeminal root [3]. ...
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Trigeminal neuralgia (TN), the most common of the facial neuralgias, is an extremely debilitating disorder that is characterized by severe electric shock-like neuropathic pain that is localized to one or more branches of the trigeminal nerve. It can have a serious impact on an individual’s life and is often first encountered by dentists and general practitioners. Although a treatable and usually manageable condition, appropriate diagnosis remains a factor that plagues this disease. The objective of this article is to summarize the current literature surrounding the classification, epidemiology, presentation, and pathophysiology of TN while also including the current and evidence-based knowledge on the diagnosis and treatment options. It provides a baseline from which dental and medical colleagues alike can help manage patients suffering from this devastating neuralgia.
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