Trigeminal neuralgia


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Trigeminal neuralgia

  2. 2. NEURALGIA Pain of severe throbbing or stabbing character in the course of distribution of a nerve.
  4. 4. TRIGEMINAL NEURALGIA Trigeminal neuralgia (TN) is sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve.
  5. 5. SYNONYMS • Trifacial neuralgia • Fothergill’s disease • Tic-doloureux (painful jerking)
  6. 6. ETOIOLOGY • INTRACRANIAL CAUSES 1. Petrous ridge compression-internal carotid artey pulsations 2. Multiple sclerosis 3. Intracranial tumors- at the cerebellopontine angle 4. Intracranial vascular abnormalities-basilar artery aneurysm, superior cerebellar artery abnormality
  7. 7. • EXTRACRANIAL CAUSES 1. 2. 3. 4. 5. Vascular factors Dental etiology Post traumatic neuralgia Infections Viral etiology
  8. 8. Other disorders that may affect the trigeminal nerve include : • • • • • • Neuralgias and neuritis Syphilis Tuberculosis Tumor of the brain Basilar meningitis Pontine diseases . • Skull fracture • Aneurysm of the carotid artery or circle of willis • Psychoneuroses,and • Cavernous sinus thrombosis
  9. 9. PATHOPHYSIOLOGY Atherosclerotic blood vessel pressing on the root of Trigeminal nerve Focal demyelination Hyperexcitability of nerve fibres Episodes of intense pain
  10. 10. TYPES OF TRIGEMINAL NEURALGIA • Pre Trigeminal neuralgia • Idiopathic Trigeminal neuralgia • Symptomatic neuralgia
  11. 11. • Pre trigeminal neuralgia: dull aching pain usually observed before appearance of trigeminal neuralgia • Idopathic neuralgia: where the etiology remains unknown • Symptomatic neuralgia: the type in which the etiology is known
  12. 12. CLINICAL FEATURES • • • • Incidence : 4 in 1,00,000 Age : 4th to 5th decade Sex : F>M 60% on the right side, 3% bilateral. • Mean age of onset-52-58yrs
  13. 13. Involvement : maxillary-60% mandibular-49% ophthalmic-16% all 3 divisions-1%
  14. 14. • Manifests as sudden, unilateral, intermittent, paroxysmal, sharp, shooting, lancinating pain, elicited by slight touch. • Patient usually complains of electric shock/lightening like pain • Usually confined to one part. • Lasts for few seconds to minutes. • Motionless or mask like face.
  15. 15. • Rarely crosses the midline. • Trigger points - Spontaneous attack or triggered by trigger zone or movement of the face as in chewing, talking, brushing or yawning • This leads patient frequently go unshaven or unwashed • Paroxysms occur in cycles. • Depression and weight loss
  16. 16. Trigger zones are usually located on vermillion border of lip, ala of the nose, cheek, chin, and around the eye.
  17. 17. • There is generally no evidence of sensory or motor impairment • Apart from pain the other features are itching & sensitivity of the face • Rarely trigeminal neuralgia is associated with hemi facial spasm- a condition called TIC CONVULSIF that involves both V & VII cranial nerves
  18. 18. DIAGNOSIS • • • • • • History Trigeminal nerve examination Diagnostic nerve blocking MRI (brain) EEG Microneurography
  19. 19. DIFFERENTIAL DIAGNOSIS • • • • • • • Post herpetic neuralgia Dental pain Post traumatic neuralgia Multiple sclerosis Glossopharyngeal neuralgia Migraine SUNCT syndrome (sudden unilateral neuralgia type of pain with conjunctival involvement) • Migraine • Tumors of nasopharynx( trotter`s syndrome)
  21. 21. PHARMACOLOGICAL • FIRST LINE OF APPROACH Carbamazepine 100, 200mg.. • SECOND LINE OF APPROACH Phenytoin 100mg Baclofen 5-80 mg/day Lamotrigine 25 mg/day • THIRD LINE OF APPROACH Clonazepam 4-8 mg Valproic acid 250-500 mg Oxcarbazepine 1200mg/day
  22. 22. Other methods used are • Trichloro ethylene inhalation • Topical capsaicin cream application • Proparacaine 0.5% anaesthetic drops in eye • Anti inflammatory drug-Indomethacin & short courses of steroids are found useful in some cases
  23. 23. Review of Treatments – Medical • Carbamazepine (Tegretol) • Gabapentin (Neurontin) • Baclofen • Clonozepam • Lamotrigin • Oxcarbamazepine • Phenytoin • • • • Amitriptyline Nortriptyline (Pamelor) Protriptyline Sumatriptan (cluster headaches) • NSAIDS / Opoids • Capsaisin (topical)
  24. 24. SURGICAL • Stereo tactically controlled thermo coagulation of V cranial nerve • Vascular decompression( through posterior fossa craniotomy) • Repositioning of the basilar artery( compressing the V nerve) • Micro vascular decompression • Gamma knife radio surgery • Cryotherapy
  25. 25. • • • • Injection of the nerve with alcohol Local anaesthetic injection of the nerve Nerve sectioning & avulsion Percutaneous radiofrequency trigeminal neurolysis • Bulbar trigeminal tractotomy • Glycerol rhizotomy
  28. 28. Review of Treatments – Surgical • MVD • Radio Frequency Rhizotomy • Balloon Compression • Glycerol Rhizotomy • Gamma Knife Radiosurgery • Nerve Blocks • Neurotomy • NICO Surgery • DREZ (Dorsal Root Entry Zone)
  29. 29. OTHERS • TENS – Transcutaneous Electric Nerve Stimulation • Acupuncher • Psychological approach
  30. 30. Review of Treatments - Alternative • • • • • • • • Acupuncture • Ayurvedic Medicine Botulinum Toxin (Botox)• Cervical Chiropractic • • Exercise / Running • Homeopathy Hot / Cold Compresses • • Hypnosis Low Intensity Laser Lidocaine Cream / Patch Myotherapy Osteopathy TENS (Postherpetic N.) Vitamin B12 Yoga / Biofeedback
  31. 31. PARATRIGEMINAL NEURALGIA • Also called as raeder’s syndrome • Characaterised by severe headache or pain in the distribution of trigeminal nerve with signs of ocular sympathetic paralysis • Homolateral pain in the head or eye • Sudden appearance of signs and symptoms
  32. 32. • Most common in males • Generally occurs in middle aged people • It can be differentiated from horners syndrome by presence of pain and no change in sweating activity
  33. 33. SPHENOPALATINE NEURALGIA • Also called as vidian nerve neuralgia or hortons’s syndrome • An idiopathic sydrome consisiting of recurrent brief attack of sudden severe unilateral periorbital pain. • Typical periodicity has been attributed to hypothalamic harmonal influences
  34. 34. • Pain is thought to be generated at the level of pericarotid/ cavernous sinus complex • Characterized by unilateral paroxysms of intense pain in the region of the eyes, maxilla, ear , mastoid, base of the nose, and beneath the zygoma. • Sometimes the pain extends intothe occipital area as well.
  35. 35. • The paroxysms of pain hava a rapid onset, persist for about 15 min, and to several hours, and then disappears asrapidly as they begin • There is no trigger zone • The attacks develop regularly, usually atleast once a aday, over a prolonged period of time
  36. 36. • The onset of paroxysm occur exactly in the same time of the day, and for this reason, the disease is referred to as “alarm clock headache” • Aftersome weaks or months, the trauma disappears completely and this period of freedom and may persist for month or even for years
  37. 37. • Sneezing , swelling of nasal mucosa and severe nasal discharge often appears simultaneously with the painful attacks as epiphohra or wattereing of eyes and blood shoot eyes • Paraesthestic senstation over the skin of lower half of the face also are reported • Men are more effected more commonly than women (5:1)
  38. 38. • Treatment: • Cocainization of sphenopalatine ganglion or alcohol injection of this structure • Resection of ganglion • Surgical corrections of septal defects
  39. 39. GLOSSOPHARYNGEAL NEURALGIA • It is a pain similar to trigeminal neuralgia • Not as common as trigeminal neuralgia, but when it occurs, the pain may be as severe • The pain is sharp, shooting pain in the ear, commonly in the nasopharynx, tonsils, posterior portion of the tongue • Etiology is unknown
  40. 40. • It occurs at any age period without age predilection • Numerous mild attacks may be interspreaded by occassional severe one • The patient usually has trigger zone in the posterior oropharynx or tonsillar fossa
  41. 41. • Treatment: • Resection of extra carnial portion of nerve or intra cranial portion • Injection of alcohol is not widely accepted
  42. 42. GENICULATE NEURALGIA • Also called as nervous intermedius neuralgia • It is uncommon paroxysmal neuralgia of cranial nerve VII • Characeterized by the pain in ear, anterior part of tongue and soft palate • This type of pain has a trigger zone
  43. 43. • The location of pain runs alsong the distribution of neve(external auditory canal, small area of soft palate, posterior auricular region) • The pain is not as sharp and intense as trigeminal neuralgia and often sometimes facial paralysis, indicating the involvement of motor root
  44. 44. • This pain results commonly from herpes zoster of geniculate ganglion and nervus intermedius of cranial nerve vii • This condition is also referred to as ramsay hunt syndrome • Virus vesicles may be observed in the ear canal or tympanic membrane • Acyclovir significantly reduces the duration of pain
  45. 45. • Symptoms result from nflammatory neural degeneration and short course(2 to 3 weks) of high steroid therapy • Patient may also be treated with carbamazepine and antidepressants • Patient may also undergo surgery of nervous intermidius if he doesn’t respond to the above medication
  46. 46. OCCIPITAL NEURALGIA • Rare neuralgia in the distribution of the sensory branches of cervical plexus • The most common cause are trauma, neoplasms, infections and aneurysms of effected nerves • Palpation below the superior nuchal line may reveal an exquisitely tender spot
  47. 47. • Treatment has included corticosteroids, neurolysis, avulsion and blocking the nerve with local anesthetic solution
  48. 48. POST HERPETIC NEURALGIA It is caused by reactivation of varicellazoster virus infection 15-20% of cases of herpes zoster invoule trigeminal nerve Majority cases affect ofhthalamic division of 5th nerve
  49. 49. Characterized by pain and lesions in the region of eyes and forehead Infection of maxiilary and mandibilar divisions cause facial and oral pain Pain resolves within month after the lesions heal Mostly affects elderly people.
  50. 50. Pathogenesis • The vz virus injures the periphral nerve by demyelination, wallerian degeneration and sclerosis • Atrophy of dorsal horn cells in the spinal cord • Patient exhibits painfull response to non painfull stimuli
  51. 51. Clinical features • Pain paresthesia. Hyperesthasia and alodynia persists months to years after zoster lesions have healed • Pain is accompanied by a sensory deficit in the region of nerve distrubtion
  52. 52. TREATMENT • Topical therapy: lidocaine, capsaicin,EMLA cream. • Tricyclic antidepressants: amitriptyline, nor triptyline, doxepin, desiprimine • Others: gabapentin, carbamazepine, phenytoin
  53. 53. • Surgery: nerve blocks peripheral nerve sresection, dorsal root surgery • Prevention:antiviral drug (famciclovir) and corticosteroids
  54. 54. THANK YOU