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Trigeminal neuralgia 2_


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Trigeminal neuralgia 2_

  1. 1. TRIGEMINAL NEURALGIA Presented by Wita I.Septina Supervised by Harmas Yazid Yusuf, drg. SpBM
  2. 2. INTRODUCTION• Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve.• Incidence 4-5 cases : 100.000• TN or Tic douloureux occur patients > 50 years.• Male : Female ratio 2 : 3• Unilateral (97%). Most affected V2 and V3.• The pain is intense, usually sharp, electric shocklike pain in face, lasting periods of seconds to 2 minutes ,
  3. 3. ANATOMY TRIGEMINAL NERVE• Cranial Nerve V o Sensoric e Portio major o Motoric Portio minor o Sensoric + motoric n Gasseri
  4. 4. Fig 1. DistributionTrigeminal nerve
  5. 5. CLASSIFICATION1.Typical Trigeminal Neuralgia(Tic Douloureux)• Most common form of TN• Caused by blood vessels compressing the trigeminal nerve root enters the brain stem• Irritation from repeated pulsations t caused hyperactivity of the trigeminal nerve nucleus p resulting TN pain• Fig 2
  6. 6. (a) (b) (c)Fig 2. Anatomy Trigeminal nerve and Trigeminal neuralgia
  7. 7. CLASSIFICATION2. Atypical Trigeminal Neuralgia• Unilateral• Prominent constant• Boring or burning pain• Caused by vascular compression upon a specific part of trigeminal nerve (portio minor)• A more severe from or progression of typical TN
  8. 8. CLASSIFICATION3. Pre - Trigeminal Neuralgia Symptoms : odd sensations of pain or discomfort before the first attack of TN pain4. Multiple Sclerosis-Related TrigeminalNeuralgia• The symptoms & characteristics identical o• 2 - 4% patients with TN have multiple sclerosis (MS)• MS formation of demyelinating plaques within the brain• First attack of pain y younger patients , bilateral
  9. 9. CLASSIFICATION5. Secondary Trigeminal Neuralgia• Caused by a lesion (tumor)• A tumor y compresses or distorts the trigeminal nerve facial numbness, weakness of chewing muscles, constant pain• Fig 3.6. Post-Traumatic Trigeminal Neuralgia• Develop following cranio-facial trauma, dental trauma, sinus trauma, destructive procedures (rhizotomies)• Injury t cold, start immediately or days to years following injury
  10. 10. Fig. 3 MRI--- Tumor compressed trigeminal nerve
  11. 11. CLASSIFICATION7. Failed Trigeminal Neuralgia Medications, microvascular decompression, and destructive rhizotomy procedure ineffective in controlling TN pain
  12. 12. ETIOLOGY1.Blood vessels compression at the trigeminal nerve root– Demyelination nerve– A tumor compresses trigeminal nerve– Injury to the trigeminal nerve– Un known
  13. 13. Clinical Features1. Severe paroxysmal pain– The pain intense, stabbing, electrical shock- like, one side– Frequently pain free between attacks.– Lasting only seconds to two minutes– Each attack spontaneously or be triggered by specific light stimulation– Common triggers include touch, talking, eating, drinking, chewing, tooth brushing, hair combing and kissing.
  14. 14. Fig. 4 Progression of Trigeminal Neuralgia
  15. 15. DIAGNOSIS• Anamnesis• Clinical examination• CT scan and MRI• MRIA
  16. 16. Differential Diagnosis1.Glossopharyngeal neuralgia– Occipital neuralgia– Paroxysmal hemicrania syndromes– Migraine and cluster headaches– Trigeminal neuropathy
  17. 17. TREATMENT• Medication• Surgical procedure
  18. 18. TREATMENTMedication• Carbamazepin (Tegretol) o Anticonvulsants, Drug of choice for TN, effective dose 600 -1200 mg/ day for 3-4 x/ day o Maintenance dosage 200 mg/d to prevent recurrences o Side effect : drowsiness, mental confusion, dizziness, nystagmus,ataxia• Oxycarbazepine (Trileptal) o Side effect : nausea, fatique, tremor o Dose : 2 x 300mg, maximum dose : 2400-3000 mg/day
  19. 19. TREATMENT• Phenytoin (Dilantin) o Dose: 300-500mg/day for 3x/day• Side effect : nystagmus, dysarthria, gingival hyperplasia, hypertrichosis, allergic skin rash• Gabapentin (Neurontin) o Dose : 1200 - 3600mg/d, initial dose ; 3x300mg/d. o Side effect : somnolen, ataxia, fatique
  20. 20. TREATMENT• Baclophen (Lioresal) Antispasmodic agents Initial dose : 2-3 x 5 mg/ day. Duration of action x Side effect : nausea, fatique
  21. 21. TREATMENTSurgical Procedure For patients e medical therapy has failed surgery is a viable and effective option• Microvascular decompression• Nerve Injury/ Destructive Procedure (Rhizotomy) 1. Percutaneus Glycerol Rhizotomy • Percutaneus Balloon Compression Rhizotomy • Radiofrequency Rhizotomy • Stereotactic Radiosurgery (Gamma Knife) • Microsurgical Rhizotomy
  22. 22. TREATMENT• Microvascular decompression o non-destructive technique o Under general anesthesia, incising the skin behind the ear (Craniotomy) o Identify an arterial loop compressing the nerve n pad the vascular structure with Teflon felt o Complication: CSF leaks, hearing loss, permanent anesthesia over the face
  23. 23. TREATMENT• Nerve Injury/ DestructiveProcedure (Rhizotomy) 1. Percutaneus Glycerol Rhizotomy The surgeon introduces a trocar or needle lateral to the corner of the mouth into foramen ovale l glycerol–ganglion Gasseri f nerve injury 2. Percutaneus Ballon Compression Rhizotomy Under general anestesia – operator insert a balloon catheter through the the foramen ovale r the region of the ganglion
  24. 24. TREATMENT3. Radiofrequency Rhizotomy Intravena sedation h electroda insert to ganglion electroda to heat thermal injury r to ganglion4. Strereotactic Radiosurgery (Gamma Knife) Gamma Knife Radiosurgery g stereotactic MRI, determined radiation dose to guickly relief pain without facial sensory loss5. Microsurgical Ryzotomy
  25. 25. CONCLUSION• Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve.• Treatment for TN n initial therapy if pharmacologic treatment fails l surgical procedure.