Trigeminal neuralgia, microvascular decompression trigeminal nerve, neurovascular conflict, facial pain syndromes, atypical neuralgia, rhizotomy, suboccipital craniotomy, hemifacial spasm,

1. Trigeminal Neuralgia
DR DILIP KUMAR M
D N B ( N E U RO S U RG ERY)
C O N S U LTA N T N E U RO S U RG EO N
L.B NAGAR, HYDERABAD
Date: 14-07-2018

2. Also known as –
• Tic doloureux
• Suicide disease

3. What is a Trigeminal Neuralgia ?
Defined by - International Association for the Study of Pain (ISAP)
•“ A sudden and usually unilateral severe brief stabbing , recurrent pain in the
distribution of one or more branches of the fifth cranial nerve.”
•It is an excruciating, short-lasting (<2 minutes), unilateral facial pain that may be
spontaneous or triggered by gentle, innocuous stimuli and separated by pain-
free intervals of varying duration

4. Why trigeminal neuralgia is important
• One of the most excruciating, agonising pains
• Recurrent episodes
• Disturbs the quality of life significantly
• Often wrongly diagnosed as pain of “dental origin” and patient may end up
with teeth extraction before the actual diagnosis is made
• Can cause severe psychological disturbances, patients may even develop
suicidal tendencies

5. Epidemiology
• Incidence - 4.3 per 100,000
• Female > male ( male preponderance in Indian studies)
• Right side > Left side ( 3:2)
• Mostly unilateral (95%)
• Bilateral (5%) ----- 18% in pts with MS (multiple sclerosis)

6. Most common age group : 50 -70 years

7. What is the cause ?
Neuro-vascular conflict

8. VASCULAR COMPRESSION
1. Superior Cerebellar A.
2. AICA
3. Serpentine Basilar A.
4. PICA.
5. Large pontine branches of Basilar A.
6. Combination of the above.
1. Superior Petrosal V.
2. Transverse Pontine V.
3. V. of Cerebellopontine fissure.
4. V. of Middle Cerebellar Peduncle.
5. Common stem of veins draining the lateral
part of cerebellar hemisphere.
ARTERIAL VENOUS
MIXED - ARTERIAL AND VENOUS

9. Most commonly involved division is V2 ( maxillary nerve)
MC – involved
V 2 + V3
V2

10. Trigger Zones
Nasolabial fold
Upper lip
Tooth
Triggering factors
Eating, talking, smiling, exposure to cold breeze, shaving
Patient fears to eat or brush ..
* Unshaved, Halitotic, cachectic appearance

11. Clinical features

12. Not all facial pains are trigeminal neuralgias
 Taking a good history

14. Atypical Trigeminal Neuralgia – TN 2
• Pain is aching, throbbing or burning for more than 50% of the time
and there is constant background pain but strictly confined to the
anatomical distribution of the trigeminal divisions.
• Can be multiple neurovascular conflicts

15. Pathology
Idiopathic / Primary Trigeminal Neuralgia – due to NV conflict
Secondary TN

16. • Normal neurological examination
• May be decreased sensation over involving area
• Absent corneal sensation – suspect CP angle tumor
• Hypertension (Neurogenic HTN )
• d/t Vascular compression over vagal REZ / ventrolateral medulla
• After MVD surgery  reports of disappearance of hypertension

17. TN- on contralateral side of CP angle tumor due to
1. Brian stem distortion
2. Arachnoiditis
3. Contralateral vascular cross compression
** INSPITE OF PRESENCE OF CP ANGLE MASS – ACTUAL VASCULAR COMPRESSION CAN BE
A CAUSE OF TN. In such cases ONLY TUMOR EXCSION WILL Not RELIEVE PAIN . MVD is
REQUIRED

18. Imaging
3D- FIESTA MRI scan

19. MRI features

23. Management of TN
1. Management of severe pain – crisis in ER
2. Medical Management
3. Surgical Management
a) Percutaneous procedures
b) Microvascular Decompression (MVD)
4. Stereotactic radiosurgery

24. Management of acute crisis in ER
• NSAIDS and Opiates usually do not work
• No best medication yet in acute episode
• i.v infusion of Fosphenytoin – useful in some pateints ( needs ECG
monitoring)
• Local 8% spray of lidocaine

25. Medical management

27. Psychological support
• The fear, loneliness, and depression associated with TN may require
psychological, social, or other nonmedical help.
• Support groups can help to reduce feelings of isolation and despair
and can also provide high-quality information

28. 1. Radiofrequency ablation
2. Glycerol Rhizotomy
3. Balloon Rhizotomy
Percutaneous procedures

29. Percutaneous procedures

30. Percutaneous procedures are NOT first choice
Indications
1. Failed medical therapy
2. Unfit for MVD
3. Elderly > 65 years age
4. Previously failed MVD
5. TN – secondary to MS, Pontine infarction, Brain stem white matter
lesions

31. Microvascular decompression

32. Contraindications for surgery

33. complications

34. Radiosurgery
• Ablate the cisternal part of the trigeminal nerve with gamma knife
radiosurgery
• Linear accelerator based radiosurgery seems to be nearly as effective
• Takes time to show response – ( 4 weeks to 6 months)
• Recurrence rates are upto 25 %
• Radiosurgery may be indicated after a failed MVD or other measures

35. Recurrence rates
• Glycerol 54% (4 years)
• RF rhizotomy 23% (6 years)
• Balloon 21% (2 years)
• Radiosurgery 25% (3 years)
• MVD 15% (5 years)
MVD – Offers most
effective immediate
pain relief and
less recurrence

37. Microvascular decompression (MVD)

40. MVD - Video

43. Our Results
• Total no of cases: 35
• Duration : May 2014 to till date
• Follow up: No recurrence
• Complications : paradoxical csf rhinnorhea -1, improved

44. Facial nerve

45. Hemifacial spasm

46. Lower cranial nerves

47. LAKDIKAPUL & L.B NAGAR, HYDERABAD
THANK YOU

48. Questions
LAKDIKAPUL & L.B NAGAR, HYDERABAD
Dr Ramakrishna chowdary y
M.S, M.Ch (neurosurgery)
CONSULTANT Neurosurgeon