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  •  During an attack of TN, the sufferer will almost always remain still and refrain from speech or movement of the face, so as not to trigger further attacks of pain. The face may contort into a painful wince. Early descriptions of TN confused these sudden attacks with seizures, leading to the term tic doloureux or neuralgia epileptiforme. TN attacks rarely occur when the sufferer is asleep, but may be worsened or alleviated by leaning or lying in a specific position.
  • brief paroxysms of "shock-like" pain in 1 or more divisions of the trigeminal nerve (cranial nerve V). The pain most often occurs in "machine-gun-like" volleys, lasting a few seconds to a minute, and recurring frequently for weeks at a time. The pain can be so intense that it may precipitate facial spasms or wincing; hence the term "tic douloureux." It typically occurs unilaterally, but in 4% of patients -- of whom, most have underlying multiple sclerosis -- it is bilateral. Patients may also experience a dull ache between the paroxysms of pain.
  • The pain is provoked by touching certain trigger zones or by other stimuli such as cold wind, talking, brushing the teeth, chewing, shaving or washing the face. Trigger zones most commonly are located on the cheek, lip, nose, or buccal mucosa
  • 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.
  • Atypical TN is characterized by a unilateral, prominent constant and severe aching, boring or burning pain superimposed upon otherwise typical TN symptoms.
  • D. Pre-Trigeminal Neuralgia
         Days to years before the first attack of TN pain, some sufferers experience odd sensations in the trigeminal distributions destined to become affected by TN. These odd sensations of pain, (such as a toothache) or discomfort (like "pins and needles", parasthesia),
    G. Trigeminal Neuropathy or Post-Traumatic Trigeminal Neuralgia
    The pain of trigeminal neuropathy or post-traumatic TN is usually constant, aching or burning, but may be worsened by exposure to triggers such as wind and cold. Such deafferentation pain can start immediately or days to years following injury to the trigeminal nerve. In the most extreme form, called anesthesia dolorosa, there is continuous severe pain in areas of complete numbness.
  • Image: CT, MRI, MRA
    Try and error: carbamazepine
  • Block of the gasserian ganglion is performed with the patient in the supine position.6 Location of the foramen ovale is facilitated by the use of fluoroscopic guidance.When fluoroscopy is used, the C-armis angled so that the axis of the x-raybeamis aligned to reveal the foramen ovale (oblique and caudal angulation). Askin wheal of local anesthetic is raised 2–3 cmlateral to the corner of the mouth and a 22-gauge, 10-cm spinal needle is advanced upward toward the mandibular condyle in a plane in line with the pupil (Figure 18–5). The surface of the greater wing of the sphenoid bone is typically contacted at a depth of 4 to 6 cm, and the needle is withdrawn and redirected in amore posterior direction until the foramen ovale is entered. Once the needle enters the foramen, it is advanced an additional 1–1.5 cm. As the foramen is entered, a paresthesia in the mandible is usually elicited. As the advancement continues, paresthesia in the maxilla and orbit are also typically reported. Injection volume of 1.0 mL is usually sufficient to produce dense analgesia. Paresthesia in the effected division is sought to guide needle placement prior to neurolysis.
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    1. 1. Trigeminal neuralgia Speaker: R2 楊芝琳 Supervisor: Dr. 林嘉祥 1. The clinical journal of pain, 18(1), 2002 2. Surgical Neurology 66 (2006), 350–356 3. JADA, Vol. 135, 2004,1713-1717 4. 2007;334;201-205 BMJ
    2. 2. IntroductionIntroduction Neuralgia  Unexplained peripheral nerve pain  The most common site: head and neck  The most frequently diagnosed form: trigeminal neuralgia (TN)trigeminal neuralgia (TN)  Fothergill’s disease  Tic douloureux (painful jerking)  Mean age: 50 y/o  Female predominance (male : female = 1:2 ~2:3)
    3. 3. Characteristics of trigeminal neuralgiaCharacteristics of trigeminal neuralgia  paroxysms of severe, lancinating, electric shock-like bouts of pain restricted to the distribution of the trigeminal nerve  Unilaterally (right side)  The mandibular (V3) and/or maxillary (V2) branch or, rarely, the ophthalmic (V1) branch  Spontaneously attack or triggered by trigger zone & movement of the face  Seconds to minutes
    4. 4. AnatomyAnatomy
    5. 5. Pathogenesis of trigeminal neuralgiaPathogenesis of trigeminal neuralgia Uncertain  Traumatic compression of the trigeminal nerve by neoplastic (cerebellopontine angle tumor) or vascular anomalies  Infectious agents Human herpes simplex virus (HSV)  Demyelinating conditions Multiple sclerosis (MS)
    6. 6. Types of Trigeminal Neuralgia Typical TN Atypical TN Pre-TN Multiple sclerosis-related TN Tumor-related TN Post-traumatic TN (trigeminal neuropathy) Failed TN
    7. 7. DiagnosisDiagnosis Classic TNClassic TN Atypical or mixed TNAtypical or mixed TN A persistent and dull ache between paroxysms or mild sensory loss
    8. 8. TreatmentTreatment  Medical treatment  Carbamazepine (Tegretol) – first line  Oxcarbazepine  Gabapentin (Neurontin)  Lamotrigine  Baclofen  Phenytoin  Clonazepam  Valproate  Mexiletine  Topiramate Second line Others
    9. 9. Mechanism of medical therapy
    10. 10. Surgical treatment  Gasserian ganglion-level procedures  Microvascular decompression (MVD)  Ablative treatments • Radiofrequency thermocoagulation (RFT) • Glycerol rhizolysis (GR) • Balloon compression (BC) • Stereotactic radiosurgery (SRS)  Peripheral procedures  Peripheral neurectomy  Cryotherapy (cryonanlgesia)  Alcohol block Neuro- destructive procedure Surgical decompress
    11. 11. Microvascular decompressionMicrovascular decompression (MVD)(MVD)
    12. 12. Mechanism of ablationMechanism of ablation treatmenttreatment
    13. 13. RadiofrequencyRadiofrequency thermocoagulation (RFT)thermocoagulation (RFT)
    14. 14.  CSF flow when entry Mechel’s cave  45~90 sec. cycles of 60~90℃  Perceiving a sharp pinprick as a light touch (hypalgesia)  Divisional cutaneous facial flushing
    15. 15. Glycerol rhizolysis (GR)Glycerol rhizolysis (GR)
    16. 16.  Test dose: 0.1-0.15 ml  0.05~0.1 ml at 3~5 min. intervals  Total dose: 0.1~0.4 ml  Sensory changes: pain, burning or paresthesia
    17. 17. Balloon compressionBalloon compression (BC)(BC)
    18. 18.  0.5~1 ml of contrast  Pear-shape balloon  Compression time: 1~7 min.
    19. 19. Stereotactic radiosurgeryStereotactic radiosurgery (SRS)(SRS)
    20. 20. Peripheral proceduresPeripheral procedures
    21. 21.  Peripheral neurectomy  Alcohol block  0.5~1.5 ml of 80~100% alcohol  Whole branch & smaller peripheral nerve branches  External approach & intraoral method  Cryotherapy  Exposed surgically and direct application of a cryoprobe  -50~-140℃  3 cycles of 2 min. with a 5 min. thawing period in between
    22. 22. Ganglion-level proceduresGanglion-level procedures vs. Peripheral proceduresPeripheral procedures Ganglion-level ablative procedures  Similar long-term success rate  Varying degrees of sensory loss  Balloon compression: least likely to impair corneal sensation or to cause anesthesia dolorosa Peripheral procedures  High recurrence rates  No benefit over ganglion-level procedures  Reserved for emergency use
    23. 23. Flow chart of the current practice of surgery for TN at UCLA.
    24. 24. ThanksThanks for yourfor your attention!!attention!!
    25. 25. (a) Thermal lesion of trigeminal nerve.(a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode.(b) Mislocation of the electrode. (c) Expansion of thermal energy to neighboring neural structures.(c) Expansion of thermal energy to neighboring neural structures.
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