ResearchPDF Available

Resolution of Trigeminal Neuralgia Following Chiropractic Care to Reduce Cervical Spine Vertebral Subluxations: A Case Study

Authors:
  • Burcon Chiropractic

Abstract

First peer reviewed paper on Trigeminal neuralgia published by an upper cervical specific chiropractor
Resolution of Trigeminal Neuralgia Following Chiropractic
Care to Reduce Cervical Spine Vertebral Subluxation
s
:
A Case Study
Michael T. Burcon, B.Ph., D.C
.
1
__________________________________________________________________________________________
A
BSTRACT
Objective:
This case study reports the improvement in quality
of life experienced by a patient undergoing cervical specific care
as an alternative to medication or surgery for the management of
Trigeminal neuralgia.
Clinical Features: A 57 year old female presented with right
sided trigeminal neuralgia (TN) of two years duration. TN pain
was helped by medication and exacerbated by exposure to cold.
Secondary complaints included high blood pressure,
hypothyroidism, diminished hearing in left ear, cervicalgia,
bilateral shoulder pain, right shin numbness and allergies.
Prescriptions include Gabapentin 900 mg 3xs/day (2700 total
with 3600 being maximum prescribed), triamterene 37.5 mg
1x/day, synthroid 75 mg 1x/day and nasacort as needed. History
included being knocked unconscious in a fall when ten years old,
significant fall while skiing thirteen years prior and recent fall
onto the sidewalk. Orthopedic and neurological examination
demonstrated the right leg one inch short relative to the left leg,
one inch bilateral cervical syndrome and positive modified Prill
tests for atlas (C1), axis (C2) and C5. Cervical x
-
ray analysis
determined listings of axis entire segment right and a posterior
C5. Diminished disc space and minor degenerative
arthritis
noted at C5/6 consistent with cervical trauma (whiplash).
Intervention and Outcomes: One week after specific
adjustments to C5 and axis, TN pain diminished dramatically in
frequency and intensity. After discussing the improvement with
her neurologist, she started cutting back on her Gabapentin
dosage. After eight weekly visits, the patient was completely off
the medication and pain free. Additionally, she reduced her high
blood pressure medication by fifty percent. After two years of
monthly maintenance care, she is still pain free without
medication, even after major dental work.
Conclusion:
This case study demonstrates the effectiveness of
cervical specific care as an alternative to medication or surgery
for the control of pain associated
with TN.
Key Words: Trigeminal neuralgia, upper cervical subluxation
complex, cervical specific adjustments, Gabapentin (Neurontin),
cervical trauma, whiplash
, chiropractic
.
_____________________________________________________________________________
_______________________________
Introduction
Trigeminal neuralgia (TN) or tic douloureux, is a
neuropathic
disorder of CN V, the Trigeminal, that causes paroxysmal
episodes of severe lancinating
pain
in the eyes, lips, nose,
scalp, forehead or jaw1 In 1756 French physician Nicolaus
Andre burned a branch of the Trigeminal nerve with a caustic
liquid. He described the disorder as tic douloureux, which
means painful spasm.2 It is estimated that 1 in 15,000 people
suffer from trigeminal neuralgia, although the actual figure
may be significantly higher due to frequent misdiagnosis and
lack of sufficient studies of incidence and prevalence.
3
TN
usually develops after the age of 50, although there have been
cases with patients being as young as three years of age.4 The
condition can bring about stabbing,
mind
-
numbing
,
electric
shock
-like pain from just a touch of the cheek. The pain of
Trigeminal neuralgia is often falsely attributed to pathology of
dental origin. "Rarely do patients come to the surgeon without
having had removed many, and not infr
e
quently all, teeth on
the affected sid
e
."5 Extractions do not help. The pain is
originating in the Trigeminal nerve its
elf, often in its roots, not
in an individual nerve of a tooth. Because of this difficulty,
many patients may go untreated for long periods of time
before a correct diagnosis is made. The Trigeminal nerve is
the fifth cranial nerve, a mixed cranial nerve responsible for
sensory data such as
tactition
(pressure),
thermoception
(temperature), and
nociception
(pain)
originating from the face
CASE STUDY
Trigeminal Neuralgia
J. Vertebral Subluxation Res
.
October
26, 2009
1
1. Private Practice
±
Grand Rapids, MI
above the jaw
line. It is also responsible for the motor function
of
the muscles of mastication (chewing), but not facial
expression. Several theories exist to explain the possible
causes of this
pain
syndrome. Leading research indicates that
it is a blood vessel, possibly the superior cerebellar artery,
compress
ing the microvasculature of the trigeminal nerve near
its connection with the pons. Such a compression can injure
the nerve's protective myelin sheath and cause erratic and
hyperactive functioning of the nerve. This can lead to pain
attacks at the slightest stimulation of any area served by the
nerve as well as hinder the nerve's ability to shut off the pain
signals after the stimulation ends. This type of injury may
rarely be caused by an
a
neurysm
(an outpouching of a
blood
vessel
), by a tumor, by an arachnoid cyst in the
cerebellopontine angle
6
; or by a traumatic event such as a car
accident, causing an upper cervical subluxation co
mplex.
7
The Dentate Ligament-Cord Distortion Hypothesis may
provide an explanation for the efficacy of correction of upper
cervical subluxations in relieving trigeminal neuralgia.8 The
paroxysmal nature of pain indicates that it arises as a sudden
disch
arge of neurons as a result of irritation of the trigeminal
nerve, or it could occur in the gasserian ganglion or in the
spinal nucleus of the trigeminal nerve. Direct mechanical
vascular irritation of the spinal nucleus might also explain
those cases which surgical destruction of the ganglion or
sectioning of the nerve fails to provide relief.
Involvement of the mid-cervical spine in TN has been
suggested by a report in the Journal of Traditional Chinese
Medicine in which 8 of 12 subjects experienced com
plete
relief from TN symptoms as a result of mid-
cervical
adjustments.
9 A trauma case in which bilateral TN pain
developed after whiplash was reported in a British journal by
McGlone in 1988, suggesting that injury to the extra cranial
portion of the trigeminal nucleus precipitated the facial pain.10
Ten upper cervical practitioners reported complete relief from
TN symptoms in 50 of 68 cases (74%), while another 14
described partial relief.
In a case study Elster, a 38-
year
-old female experienc
ed
TN
pain for 3 years. It began with a "shock" sensation above her
lip and eventually moved throughout the right side of her face
and forehead. She was initially prescribed 200mg of Neurontin
and eventually increased up to 1800mg per day to try to
reduce the pain. Even while taking 1800mg of Neurontin per
day, she experienced excruciating pain on the right side of her
face and forehead. She also experienced dizzy spells, ear
ringing, and hearing loss on the right. Medical doctors had no
answers other than to suggest surgery to possibly impact the
involved nerves and blood vessels.
During this patient's upper cervical exam, a neck injury was
found. When questioned as to possible traumatic causes of the
injury from her medical history, she recalled experiencing a
blo
w to her head shortly before the onset of the TN pain and
her other symptoms. This blow to her head most likely caused
the upper cervical injury. After several months of upper
cervical care to correct the upper neck injury, she was pain
-
free, and gradually reduced her pain medication. The
dizziness, ear ringing, and hearing loss were also absent after
upper cervical care. Dr. Elster encourages patients that have
not had success with one upper cervical chiropractor to try
another one. ³You should not give up on the whole concept
because one technique did not work.´
Two to four percent of patients with TN, usually younger,
have evidence of multiple sclerosis, which may damage either
the Trigeminal nerve or other related parts of the brain. When
there is no structural cause, the syndrome is called
idiopathic
.
Post herpetic neuralgia, which occurs after
shingles
, may
cause similar symptoms if the trigeminal nerve is affected.
People with the condition "are begging to be killed,"
according
to
Kim Burchiel, M.D., professor and chairman of
neurological surgery at the Oregon Health & Science
University School of Medicine who sees several new TN cases
a week.11 The episodes of pain may occur
paroxysmally
. To
describe the pain sensation, patients may describe a trigger
area on the face, so sensitive that touching or even air currents
can trigger an episode of pain. It affects lifestyle as it can be
triggered by common activities in a patient's daily life, such as
eating
, talking, shaving and tooth brushing. The attacks are
said to feel like stabbing electric shocks, burning, pressing,
crushing or shooting pain that becomes intractable. Indivi
dual
attacks affect one side of the face at a time, last several
seconds, hours or longer, and repeat up to hundreds of times
throughout the day. The pain also tends to occur in cycles with
complete
remissions
lasting months or even years.
Approximately ten percent of cases are bilateral, or occurring
on both sides. This normally indicates problems with both
trigeminal nerves since one serves strictly the left side of the
face and the other serves the right side, or irritation of the
brain stem. Pain attacks typically worsen in frequency or
severity over time. A great deal of patients develop the pain in
one branch, then over years the pain will travel through the
other nerve branches.
There is often no cure for trigeminal neuralgia. Many people
however find relief from medication, upper cervical specific
chiropractic adjustment or one of the five surgical options.
Atypical trigeminal neuralgia, which involves a more constant
and burning pain, is more difficult to treat, both with
medications and surgery.
C
arbamazepine
is the most common first line treatment.12 If
patients do not find sufficient improvement some surgical
treatments may be helpful. Surgery may result in varying
degrees of numbness to the patient and lead occasionally to
anesthesia dolorosa, which is numbness with intense pain.
However, some people do find dramatic relief with minimal
side effects from the various surgeries that are now available.
Neurosurgical treatment of TN inside the cranium dates from
the 19th century, when sectioning of the sensory root between
the Gasserian ganglion and the pons was performed.
Owing to the rarity of TN, many physicians and dentists are
unfamiliar with the affliction's symptoms. As a result, TN is
often misdiagnosed. A TN sufferer will often seek the help of
numerous clinicians before a firm diagnosis is made. Those
physicians that do have experience with TN are hesitant to
treat patients under the age of 30 or patients who do not show
nerve compression on their MRIs, although nerve compression
Trigeminal Neuralgia
J. Vertebral Subluxation Res. October
26, 2009
2
is not the only cause of TN. In a recent case, a childs health
care costs totaled over $500,000.00 before the TN diagnosis
was made.13 It may also be caused by nerve trauma done
during a dental procedure such as a root canal, or trauma to the
upper body, neck or head. Patients under the age of 30 are
particularly at risk of not receiving proper medical attent
ion,
as many physicians falsely believe that one must be in the later
years of life in order for pain to strike and that the patient may
be seeking pain killing drugs.
Trigeminal neuralgia is called the suicide disease. In fact, for
those who live with TN for more than 3 years, about half
commit suicide. Dentists that suspect TN should proceed in
the most conservative manner possible, and should ensure that
all tooth structures are truly compromised before performing
extractions or other procedures.
Bec
ause of the hurdles noted above, it is essential for patients
who believe they are suffering from TN to seek the advice of a
TN specialist, neurologist and/or upper cervical specific
chiropractor if they find their primary care physician to be
dismissive of their pain. Local support groups and chat rooms
on the internet with others suffering from TN may be helpful.
Diagnosis is clinical. The Trigeminal Neuralgia Association is
a good resource for clinical information.
Anticonvulsants
such as
carbamazepine
,
oxcarbazepine
,
topiramate
,
phenytoin
, or
gabapentin
are generally the most
effective medications to reduce the frequency and intensity of
attacks. No medication has been developed specifically to
target TN pain. Most of the medicines used today were
developed to treat epilepsy. They help TN because they slow
down t
he whole central nervous system.
Generally speaking, opiate based analgesics offer the best
relief from TN attacks. Anticonvulsant effects may be
potentiated with moderate to high levels of adjuvant therapies
such as
baclofen
and/or
clonazepam
.
Baclofen
may also help
some patients eat more normally if jaw movement tends to
aggravate the symptoms. The pain may be treated long-
term
with an
opioid
such as
Morphine
,
methadone
,
oxycodone
or
Duragesic
in patch form.
Botox
can be injected into the nerve
by a physician, and has been found helpful using the migraine
pattern adapted to the patient's special needs. Patients may
also find relief by having their neurologist implant a neuro-
stimulator.
Surgery may be recommended, either to relieve the pressure
on the nerve or to selectively damage it in such a way as to
disrupt pain signals from getting through to the brain.
However, some patients require follow-up procedures if a
recurrence of the pain begins. Of the five surgical options, the
microvascular decompression is the only one aimed at fixing
the presumed cause of the pain. In this procedure, the surgeon
enters the skull through a 25
mm (one-inch) hole behind the
ear. The nerve is then explored for an offending blood vessel,
and if one is found, the vessel and nerve are separated or
"decompressed" with a small pad, usually made from an inert
surgical material such as
Gore
-
Tex
. When successful, MVD
procedures can give permanent pain relief with little to no
facial numbness.
14
Three other pr
ocedures use needles or catheters that enter
through the face into the opening where the nerve first splits
into its three divisions. A cost effective
percutaneous
surgical
procedure known as balloon compression have has been
helpful in treating the elderly for whom surgery may not be an
option due to coexisting health conditions. Balloon
compression is also the best choice for patients who have
ophthalmic
nerve pain or have experienced recurrent pain after
microvascular decompression
.
15
Similar success rates have been reported with glycerol
injections and radiofrequency rhizotomies. Glycerol injections
involve injecting an alcohol
-
like substance into the cavern that
bathes the nerve near its junction. This liquid is corrosive to
the nerve fibers and can mildly injure the nerve enough to
hinder the errant pain signals. In a radiofrequency rhizotomy,
the surgeon uses an electrode to heat the selected division or
divisions of the nerve. Done well, this procedure can target the
exact regions of the errant pain triggers and disable them with
minimal numbness.
The nerve can also be damaged to prevent pain signal
transmission using
Gamma Knife
or a linear accelerator-
based
radiation therapy. No incisions are involved in this procedure.
It uses very precisely targeted radiation to bombard the nerve
root, this time targeting the selective damage at the same point
where vessel compressions are often found. This option is
used especially for those people who are medically unfit for a
long general anesthetic, or who are taking medications for
prevention of blood clotting.
16
Most sufferers of TN do not present with any outwardly
noticeable symptoms, though some will exhibit brief facial
spasms during an attack. As a result, it is often difficult for
friends and family members of TN suffers to accept that their
loved one, who was previously healthy, is now suffering from
intractable pain. That doubt can be a great hindrance to the
support of the patient, as friends and family, as well as
physicians, will often seek a psychological root cause rather
than a physiological abnormality. This is especially true of
those suffering who may not have any compression of the TN
and in whom the sole criterion of the diagnosis may be the
complaint of severe pain (constant electric-like shocks,
constant crushing or pressure sensations, or a constant severe
dull ache) and in this case Trigeminal neuralgia still exists but
is not visible to physicians because it was caused by the nerve
being damaged during a dental procedure such as root canals,
extractions, gum surgeries, or it may be a condition secondary
to multiple sclero
sis, or closer to the brain stem.
Many TN sufferers are confined to their homes or are unable
to work because of the frequency of their attacks. It is
important for friends and family to educate themselves on the
severity of TN pain, and to be understanding of limitations
that TN can place upon the sufferer. However, at the same
time, the TN patient must be extremely proactive in furthering
his or her rehabilitative efforts. Enrolling in a chronic pain
support group, or seeking one-
on
-one counseling, can help to
teach a TN patient how to adapt to the affliction.
As with any chronic pain syndrome, clinical depression has
the potential to set in, especially in younger patients who often
are under treated for chronic pain. Friends and family, as well
as cli
nicians, must be alert to the signs of a rapid change in
Trigeminal Neuralgia
J. Vertebral Subluxation Res. October
26, 2009
3
behavior, and should take appropriate measures when
necessary. It must be constantly reinforced to the sufferer of
TN, that treatment options do exist.
Methods
The technique utilized is based on the work of BJ Palmer DC,
as developed at his Research Clinic at Palmer Chiropractic
College in Davenport, IA, from the early 1930s until his death
in 1961.17,18,19 Techniques also include the vertebral
subluxation pattern work of his clinic director, Lyle Sherman
DC, for whom Sherman College of Straight Chiropractic,
Spartanburg, SC is named.
20
A detailed case history was taken
on the first visit (45 minute discussion), followed by a spinal
examination. A report of findings was given, recommending a
minimum set of three cervical x
-
rays because evidence of an
upper cervical subluxation was discovered. X-rays and
analysis of the upper cervical vertebrae based on the work of
William G Blair DC was used to determine chiropractic
listings of subluxation.
Lateral cervical, A-P open mouth and nasium x
-
rays were
taken. Dr. Blair began to develop his distinctive method for
the analysis and correction of subluxations of the cervical
spine soon after graduating from the Palmer School of
Chiropractic. Trained in the classical upper cervical specific
³
Hole In One´ (HIO)
method, he soon became concerned with
the potential effects of osseous asymmetry or
malformation
on
the accuracy of the traditional spinographic analysis in
producing a valid adjustive listing. His
observations of skeletal
specimens also led him to conclude that the prevailing view of
misalignment of atlas in relation to the occiput was
inaccurate.
21
He found that the atlas could not move in a truly lateral
direction because the slope of the lateral masses and the
condyles created an osseous locking mechanism preventing
such motion; and atlas could not rotate in relation to occiput in
the coronal plane without causing a gapping of the atlanto-
occipital articulations due to the complementary shapes of the
articular surface of the occipital condyles and the lateral
masses.
22 Lateral cervical film was analyzed to determine
evidence of whiplash injury. Posterior atlas listing (anterior
occipital listing), along with the lack of proper cervical curve,
w
as considered evidence of a history of neck trauma in this
study. The A-P Open Mouth view was used to study lateral
deviations of the neural rings, which may cause brainstem
pressure. With the nasium x
-
ray the antero-lateral (distal)
margins of each of the articulations were clearly classified as
being juxtaposed on the left and underlapped on the right.
Overlapping is synonymous with anterior and superior atlas
listings with laterality of the side of the overlap, underlapping
indicates posterior and inferi
or C1 listings on the opposite side
of the underlap. These appositional judgments of each
articulation were combined to deduce the actual unilateral PIL
misalignment of atlas in relation to occiput. Axis (C2) was
misaligned to the right creating a variable listing in relation to
axis. An anatomically accurate adjustive formula was then
derived.
When three x-rays were not sufficient to determine upper
cervical listings, complete sets of custom Blair x
-
rays,
including individual protracto views of both atlanto-
occipital
articulations, are taken. There are only four atlas listings under
this system
²
anterior and superior on either the right or left, or
posterior and inferior on either the right or left. Using the
anterior tubercle of atlas as the reference point, considering
the rocker configuration of the atlanto-occipital articulation, if
atlas moves posterior then it must also move inferior.
Detailed leg checks were performed on each visit, utilizing the
work of J Clay Thompson DC and Clarence Prill DC.23 Dr
Thompson, with the help of Romer Derifield DC, popularized
the cervical syndrome check for the upper cervical subluxation
complex in the 1940s. Since then, no one has come up with a
reason relative leg length would change when a patient gently
turns their head from side to side, while either prone or supine,
thus not under the effects of gravity, except upper cervical
subluxation. What causes one leg to appear shorter than the
other and to change relative length when the head is turned,
taking into consideration that the patient is lying down, not
under the effects of gravity? One subluxation complex
hypothesis proposes that the mechanism of fixation involves
impingement of the atlanto-occipital intra-articular fat pad
causing reflexive guarding contraction of the suboccipital
muscles. Stimulation of the spindles in these muscles are
thought to be involved in the initiation of tonic neck reflexes
that alter global extensor muscle tone to achieve proper body
balance in response to head movement.
24
A conservative approach in determining evidence of
subluxation was used. That is, when in doubt no adjustment
was given. The leg checks were the main criterion used to
decide when to adjust or not. To determine whether the major
subluxation was at the level of atlas or axis, Prill modified leg
length tests were utilized. With patient prone, patient was
instructed to gently and steadily raise their feet toward the
ceiling, while the doctor resisted such movement with his
hands. The peripheral nerves were being tested, those that
innervate the postural muscles holding one upright in gravity,
so it was imperative that the patient only lift their legs slightly
and maintain this pressure for at least two seconds. This test
was for atlas, the top cervical vertebra. Instructing patients to
rotate their feet while the doctor provided resistance and
checking relative leg length was used to test axis. Some
clinicians prefer to have the toes rotate outward. I had the
patient pull their feet together. This correspon
ds to the rotation
of the head on the neck, 50% of which occurs at the level of
C2.
Although many chiropractors that utilize the Blair technique
do not adjust the lower cervicals, I did in this study. Dr Blair
died before getting below C4 in his analysis and adjusting
technique protocol. I agree with Blair that until the upper
cervical spine is cleared of subluxation, adjusting the lower
cervicals will not hold. But in my experience, when there is a
significant ³kink´ in the lower cervicals caused by a w
hiplash
injury, a specific lower cervical adjustment will help the upper
cervical adjustments hold significantly longer.
Thermographs of the cervical spine were utilized using a
Tytron C
-
300 instrument. These were used to develop a
pattern of subluxation in order to determine when to adjust. A
graph reading that is static and persistent over time is
considered to be the patient's
pattern
.26,27
When it was
J. Vertebral Subluxation Res. October
26, 2009
4
Trigeminal Neuralgia
determined that the patient was in a pattern of subluxation, a
toggle recoil adjustment was performed on axis, with the
patient in a side-posture position, or a Pierce technique
adjustment was performed on atlas, C5 or C6, with the patient
prone. Side posture was used when laterality is the main
component of the subluxation. The term used for this type of
misalignment is translation, and most often occurs with a side
impact trauma, for instance, a ³T-bone´ type of automobile
accident. When posteriority was the major component of the
subluxation, the prone position is favored. This misalignment
usu
ally is the result of the typical ³rear ended´ type of
automobile accident.
A Thuli chiropractic table, using the cervical drop piece was
utilized. For side posture adjustments the headpiece was set to
drop straight down, and with prone adjustments, it was set to
drop down and forward. The patient was then rested for fifteen
minutes and rechecked, to make sure that the pattern had been
broken.
Case Report
A 57 year old female presented with right sided trigeminal
neuralgia (TN) of two years duration. TN pain was helped by
medication and exacerbated by exposure to cold. Secondary
complaints of high blood pressure, hypothyroidism,
diminished hearing in left ear, cervicalgia, bilateral shoulder
pain, right shin numbness and allergies. The patient does not
use tobacco, exercises and eats a balanced diet.
Prescriptions include gabapentin 900mg 3xs/day (2700 total
with 3600 being maximum allowed), triamterene 37.5 mg
1x/day, synthroid 75 mg 1x/day and nasacort as needed.
History included being knocked uncon
scious in a fall when ten
years old, a significant fall while skiing thirteen years prior
and a recent fall onto the sidewalk.
Chiropractic examination showed the right leg one inch short
relative to the left leg, one inch bilateral cervical syndrome
and positive modified Prill tests for atlas (C1), axis (C2) and
C5. Cervical x
-
rays analysis determined listings of axis entire
segment right and a posterior C5. Diminished disc space and
minor degenerative arthritis noted at C5/6 consistent with
cervical tra
uma (whiplash).
One week after specific adjustments to axis and C5, TN pain
diminished dramatically in frequency and intensity. After
discussing the improvement with her neurologist, she started
cutting back on her Gabapentin dosage. After eight weekly
v
isits, the patient was completely off the medication and pain
free. Additionally, she reduced her high blood pressure
medication by fifty percent. After two years of monthly
maintenance care, she is still pain free without medication,
even after major dent
al work.
Discussion
All sensory information from the face is sent to the
trigeminal
nucleus
. On entering the brainstem, sensory fibers from V,
VII, IX, and X are sorted out and sent to the trigeminal
nucleus, which thus contains a complete sensory map of the
face and mouth. The trigeminal nucleus extends throughout
the entire brainstem, from the midbrain to the medulla, and
continues into the cervical cord, where it merges with the
dorsal horn cells of the spinal cord. The nucleus is divided
anatomically into three parts, from caudal to rostral they are
the spinal trigeminal nucleus, the main trigeminal nucleus, and
the mesencephalic trigeminal nucleus.
T
he three parts of the trigeminal nucleus receive different
types of sensory information. The spinal trigeminal nucleus
receives pain and temperature fibers. The main trigeminal
nucleus receives touch and position fibers. The mesencephalic
nucleus receives proprioceptor and mechanoreceptor fibers
from the jaws and teeth.
The spinal trigeminal nucleus contains a pain/temperature
sensory map of the face and mouth. From the spinal trigeminal
nucleus, secondary fibers cross the midline and ascend in the
trigem
inothalamic tract to the contralateral thalamus. The
trigeminothalamic tract runs parallel to the spinothalamic
tract, which carries pain/temperature information from the rest
of the body. Pain/temperature fibers are sent to multiple
thalamic nuclei. The central processing of pain/temperature
information is markedly different from the central processing
of touch/position information. Information from the neck and
the back of the head is represented in the cervical cord.
Information from the face and mouth is represented in the
spinal trigeminal nucleus.
Within the spinal trigeminal nucleus, information is
represented in an onion skin fashion. The lowest levels of the
nucleus (in the upper cervical cord and lower medulla)
represent peripheral areas of the face (the scalp, ears and
chin). Higher levels (in the upper medulla) represent more
central areas (nose, cheeks, lips). The highest levels (in the
pons) represent the mouth, teeth, and pharyngeal cavity.
The trigeminal nerve is the largest of the cranial nerves. Its
name derives from the fact that it 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.
The ophthalmic, maxillary and mandibular branches leave the
skull through three separate
foramina
: the superior orbital
fissure
, the foramen rotundum and the foramen ovale. The
ophthalmic nerve carries sensory information from the scalp
and forehead, the upper eyelid, the conjunctiva and cornea of
the eye, the nose, the nasal mucosa, the frontal sinuses, and
parts of the
meninges
. The maxillary nerve carries sensory
information from the lower eyelid and cheek, the nares and
upper lip, the upper teeth and gums, the nasal mucosa, the
palate and roof of the pharynx, the maxillary, ethmoid and
sphenoid sinuses, and parts of the meninges. The mandibular
nerve carries sensory informat
ion from the lower lip, the lower
teeth and gums, the chin and jaw (except the angle of the jaw,
which is supplied by C2-C3), parts of the external ear, and
parts of the meninges. The mandibular nerve carries
touch/position and pain/temperature sensation f
rom the mouth.
It does not carry taste sensation, but one of its branches, the
lingual nerve
carries multiple types of nerve fibers that do not
originate in the
mandibular nerve
.
It is imperative that physicians diagnosing and treating
J. Vertebral Subluxation Res. October
26, 2009
5
Trigeminal Neuralgia
Trigeminal
neuralgia understand that the lesion causing the
facial pain can originate anywhere adjacent to the nerve, all
the way from the lower cervical spine to the face.
Conclusion
Although a case study is limited in its ability to provide
conclusions, this study is a typical representation of over three
hundred cases researched at Burcon Chiropractic over the past
ten years, where the same protocol is used for all one sided
brain stem disorders, including Bells palsy, migraine
headaches, Menieres syndrome, Trigeminal neuralgia,
multiple sclerosis and Parkinsons disease.
28,29,30,31
Although this patient was satisfied with pain control benefits
provided by medication, she was concerned about possible
side effects, especially impairment while driving from
so
mnolence and dizziness. She was not interested in surgery
because of the possible negative side effects. She reported that
not only did cervical specific care provide more relief than
medication, positive side effects included lowered high blood
pressure a
nd an improved state of over all well being.
Physicians should consider recommending cervical specific
care to those patients not satisfied with a medicinal and/or
surgical approach to the control of their Trigeminal neuralgia.
References
1.
Bayer DB, Stenger TG. Trigeminal neuralgia: an
overview. Oral Surg. Oral Med. Oral Pathol. 1979
Nov;48 (5): 393
±9.
2.
Brown J, Coursaget C, Preul M, Sangvai D. Mercury
water and cauterizing stones: Nicolas Andre and tic
douloureux. J Neurosurg 1999;977
-
981.
3.
Zakrzewska JM
, Hamlyn PJ. Facial pain.
In: Crombie
IK, Croft PR, Linton SJ, et al, eds. Epidemiology of
pain.
Seattle: IAS Press, 1999:171
±
202.
4.
Bloom R. ³Emily Garland: A young girl's painful
problem took more than a year to diagnose."
Arizona
Daily Star, 11.18.2004
.
5.
Dandy, Sir Walter. The Brain. The Classics of
Neurology and Neurosurgery (Special ed.).
Birmingham: Gryphon editions. 1987. pp.
179.
6.
Babu R, Murali R. Arachnoid cyst of the
cere
bellopontine angle manifesting as contralateral
trigeminal neuralgia: case report. Neurosurgery.
1991; 28 (6): 886
±7.
7.
Hinson R. Upper Cervical Neurology and Trigeminal
Neuralgia. Abstracts from the 16th Annual Upper
Cervical Spine Conference, Nov 20-21, 19
99.
Marietta, GA.
8.
Grostic JD. Dentate Ligament-Cord Distortion
Hypothesis. Chiropr Res J, 1988; 1(1):47
-
55.
9.
Eriksen K. Upper Cervical Subluxation Complex: A
Review of the Chiropractic and Medical Literature.
Lippincott Williams & Wilkins, 2003.
10.
McGlone R, Morton RJ, Sloan JP. Trigeminal pain
due to whiplash injury. Injury 1988 Sep; 19(5): 366
.
11.
Burchiel KJ. "A new classification for facial pain
".
Neurosurgery 2003;53 (5): 1164
±7.
12.
Gronseth G, Cruccu G, Alksne J, et al (October
2008
). "Practice parameter: the diagnostic evaluation
and treatment of trigeminal neuralgia (an evidence-
based review): report of the Quality Standards
Subcommittee of the American Academy of
Neurology and the European Federation of
Neurological Societies". Neurology 71 (15): 1183
±
90.
13.
Weigel, G; Casey, K. Striking Back: The Trigeminal
Neuralgia and Face Pain Handbook. Gainesville:
Trigeminal Neuralgia Association, 2004.
14.
Solth A, Veelken N, Gottschalk J. Successful
vascular decompression in an 11-
year
-old patient
with trigeminal neuralgia. Childs Nervous System.
2008 June;24(6):763
-
766.
15.
Natarajan, M. Percutaneous trigeminal ganglion
balloon compression: experience in 40 patients.
Neurology (Neurological Society of India) 200;48
(4): 330.
16.
Rosenburg M, Zerris, Borden J. On the Cutting
Edge« gamma knife radiosurgery for the treatment
of trigeminal neuralgia, Departments of Oral and
Maxillofacial Surgery, Anesthesia and Neurosurgery,
Tufts University Schools of Medicine and Dental
Medicine.
17.
Palmer, BJ. The Subluxation Specific, The
Adjustment Specific. Davenport, Iowa: Palmer
School of Chiropractic, 1934.
18.
Palmer, BJ. Chiropractic Clinical controlled
Research. Volume XXV. Davenport, IA: The BJ
Palmer Chiropractic Clinic, 1951.
19.
Palmer, BJ. History in the Making. Volume XXXV.
Davenport, Iowa: Palmer School of Chiropractic,
1957.
20.
Sherman L. Neurocalometer
-
neurocalographneurotempometer Research. Eight BJ
Palmer Chiropractic Clinic Cases. Davenport, IA:
Palmer School of Chiropractic; 1951.
21.
Addington E. Blair Cervical Spinographic Analysis.
Conference of Research and Education, Monterey,
CA June 21
-
23, 1991.
22.
Blair W. Blair upper Cervical Spinographic
Research; primary and adaptive malformations;
procedures for solving malformation problems; Blair
principle of
occ
ipito-atlanto misalignment.
Davenport, IA: Palmer College of Chiropractic;
1968.
23.
Prill, C. The Prill Chiropractic Spinal Analysis
Technique. 2001.
24.
Knutson G. Tonic Neck Reflexes, Leg Length
Inequality and Atlanto-occipital Fat Pad
Impingement: An Atlas Subluxation Complex
Hypothesis. Chiropr Res J 1997; 4(2):64
-
76.
25.
Burcon M, Olsen E. Modified Prill Leg Check
Protocol. 11th Annual Vertebral Subluxation
Research Conference, Sherman College of Straight
Chiropractic, Spartanburg, SC 2003.
26.
Hart J, Boone R. Pattern Analysis of Paraspinal
Temperatures: A Descriptive Report. J Vert Sublux
Res 1999
-
2000:3(4).
27.
Burcon M. BJs $50,000 µTimpograph still captures
our imagination after more than fifty years.
Chiropractic Economics, Nov/Dec 1995.
28.
Burcon M. Parkinsons di
sease, Menieres syndrome,
Trigeminal neuralgia and Bells palsy: One cause,
J. Vertebral Subluxation Res. October
26, 2009
6
Trigeminal Neuralgia
One Correction, Dynamic Chiropractor. 2003; Vol
21, Issue 11.
29.
Burcon M. Cervical Specific Protocol and Results for
100 Menieres Patients. The 26th Politzer Society
Meeting, Oct 13-16 2007; Cleveland Clinic,
Cleveland, OH. .
30.
Burcon M. Upper Cervical Protocol and Results for
139 Menieres Patients. The 13th International
Symposium and Workshops on Inner Ear Surgery
and Medicine, 2008;Zell am Zimmer, Austria.
31.
Elster E. Upper Cervical Protocol for Five Multiple
Sclerosis Patients. Today's Chiropractic November
2000.
J. Vertebral Subluxation Res. October
26, 2009
7
Trigeminal Neuralgia
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Article
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Trigeminal neuralgia (TN) is a common cause of facial pain. To answer the following questions: 1) In patients with TN, how often does routine neuroimaging (CT, MRI) identify a cause? 2) Which features identify patients at increased risk for symptomatic TN (STN; i.e., a structural cause such as a tumor)? 3) Does high-resolution MRI accurately identify patients with neurovascular compression? 4) Which drugs effectively treat classic and symptomatic trigeminal neuralgia? 5) When should surgery be offered? 6) Which surgical technique gives the longest pain-free period with the fewest complications and good quality of life? Systematic review of the literature by a panel of experts. In patients with trigeminal neuralgia (TN), routine head imaging identifies structural causes in up to 15% of patients and may be considered useful (Level C). Trigeminal sensory deficits, bilateral involvement of the trigeminal nerve, and abnormal trigeminal reflexes are associated with an increased risk of symptomatic TN (STN) and should be considered useful in distinguishing STN from classic trigeminal neuralgia (Level B). There is insufficient evidence to support or refute the usefulness of MRI to identify neurovascular compression of the trigeminal nerve (Level U). Carbamazepine (Level A) or oxcarbazepine (Level B) should be offered for pain control while baclofen and lamotrigine (Level C) may be considered useful. For patients with TN refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife, and microvascular decompression may be considered (Level C). The role of surgery vs pharmacotherapy in the management of TN in patients with MS remains uncertain.
Facial pain is a perplexing problem confronting all who practice the healing arts. The purpose of this article is to concentrate on one aspect of facial pain--trigeminal neuralgia. An overview of this entity is presented by demonstrating current concepts in its etiology, diagnosis, and treatment. Classically, trigeminal neuralgia has been described as a paroxysmal, lancinating, knifelike pain which is limited to the anatomic pathways of the fifth cranial nerve. It is a chronic facial pain that is amenable to medical and surgical treatment when correctly diagnosed. A knowledge of the anatomy of the fifth cranial nerve is essential for a correct diagnosis of trigeminal neuralgia. A description of the anatomy is not within the scope of this article, and the reader is referred to any of the standard anatomy textbooks for review.
Article
A case of an arachnoid cyst in the cerebellopontine angle manifesting as contralateral trigeminal neuralgia is presented. Decompression and excision of the lesion resulted in total relief of symptoms. The possible causes of contralateral trigeminal neuralgia are briefly reviewed, and the surgical treatment of this entity is discussed.
Article
In his 1756 text, Observations pratiques sur les maladies de l'urèthre et sur plusiers faits convulsifs, Nicolas André coined the term "tic douloureux." He believed that this pain originated from compression of facial sensory peripheral nerves. Using scientific observation and experimentation to confirm this hypothesis, he reproduced the tic pain and treated it by using careful efforts to remove adhesions from the nerve with a caustic solution of mercury water. Believing that recurrence of the pain was a result of early closure of the wound, with recompression of the nerve being the direct cause, André prevented recompression by ensuring open wound drainage. André's surgical technique of using cauterizing stones ensured that there was minimal blood loss and little danger of rebleeding and recompression of the nerve by an accumulated blood clot. His case reports include lengthy follow-up periods that documented the benefits of his procedures, which were confirmed by testimonials from uninvolved colleagues. Although remembered for the two words, "tic douloureux," Nicolas André has long been ignored for his prescient treatment and scientific analysis of a disease for which the modern standard of care has only been defined during the last generation.
Article
Forty patients of trigeminal neuralgia were treated with percutaneous trigeminal ganglion balloon compression. Symptoms had been present since six months to twenty years. The age ranged between 23 years and 73 years. All the patients had immediate relief from pain. Two had already undergone trigeminal cistern rhizolysis. One patient had foramen ovale stenosis. After the procedure, all the patients had mild to moderate degree of ipsilateral facial sensory loss which included buccal mucosa and anterior 2/3rd of the tongue. Facial dysaesthesia (anaesthesia dolorosa) was seen in only one case, who had mild involvement lasting one week. Thirty patients had altered taste sensation, probably due to general somatic sensory loss. Five patients had herpes perioralis. In this study group, two patients had already undergone microvascular decompression. All the patients were followed for a period ranging from one to eighteen months. Balloon compression technique seems to be better than injection of alcohol, glycerol or radio frequency lesion. Recurrence of pain was noted in 3 patients after one year.
Article
A patient-oriented classification scheme for facial pains commonly encountered in neurosurgical practice is proposed. This classification is driven principally by the patient's history. The scheme incorporates descriptions for so-called "atypical" trigeminal neuralgias and facial pains but minimizes the pejorative, accepting that the physiology of neuropathic pains could reasonably encompass a variety of pain sensations, both episodic and constant. Seven diagnostic labels result: trigeminal neuralgia Types 1 and 2 refer to patients with the spontaneous onset of facial pain and either predominant episodic or constant pain, respectively. Trigeminal neuropathic pain results from unintentional injury to the trigeminal nerve from trauma or surgery, whereas trigeminal deafferentation pain results from injury to the nerve by peripheral nerve ablation, gangliolysis, or rhizotomy in an intentional attempt to treat either trigeminal neuralgia or other facial pain. Postherpetic neuralgia follows a cutaneous herpes zoster outbreak (shingles) in the trigeminal distribution, and symptomatic trigeminal neuralgia results from multiple sclerosis. The final category, atypical facial pain, is synonymous with facial pain secondary to a somatoform pain disorder. Atypical facial pain can be suspected but not diagnosed by history and can be diagnosed only with detailed and objective psychological testing. This diagnostic classification would allow more rigorous and objective natural history and outcome studies of facial pain in the future.
Article
Case report We present the case of an 11-year-old boy who was suffering distinct trigeminal neuralgia. At the age of 3 years, the patient had contracted a severe Epstein–Barr virus infection and developed mild meningoencephalitis. Magnetic resonance imaging scans showed a slight enhancement in the pontomesencephalic cistern as well as a neurovascular conflict at the right trigeminal nerve. Intraoperatively, thickened fibrous tissue was found that was attached to both the trigeminal nerve and the superior cerebellar artery. Microvascular decompression using Gore Tex as tissue implant brought immediate relief. Discussion Trigeminal neuralgia in pediatric patients is very rare. We present a case of typical trigeminal neuralgia in a child, demonstrating the pathogenesis of the neurovascular conflict due to subarachnoidal adhesions after meningoencephalitis.