a seminar on Trigeminal neuralgia in OMFS

1. TRIGEMINAL
NEURALGIA
Moderator – Dr. Veerendra
Presenter – Dr. Rayan

2. • Introduction
• Historical review
• Etiology
• Clinical features
• Diagnosis
• Treatment modalities
• Management
• Pathogenesis
CONTENTS

3. INTRODUCTION:
• It is the most debilitating form of neuralgia that
affects the branches of the fifth cranial nerve.
• It is a disorder of the peripheral or central fibres of
the trigeminal nerve in which the dominant symptom
is pain in the region of distribution.

4. Trigeminal Nerve
• Largest cranial nerve,nerve of the first branchial arch.
• Trigeminal nerve is continuous with the ventral surface of pons by a
small mortor root and a large sensoary root.
Motor root
• Arises separately from sensory root, in motor nucleus within pons.
• Fibres travel separately from sensory root.
• At semilunar ganglion, fibres pass in a lateral and inferior direction to
leave via foramen ovale.
• It unites with the sensory nerve trunk of V3 to form a single nerve
trunk
• Supply
• Muscles of mastication
• Mylohyoid
• Ant belly of digastric
• Tensor tympani
• Tensor veli palatini

6. Sensory root
• Comprise the central process of ganglion cells
located in trigeminal ganglion.
• Located in the Meckels cave,flat crescent shaped.
• Sensory root fibres enter the concave portion, and
the three divisions exit from the convex portion.
• Ophthalmic division (V1) – exits from the superior
orbital fissure
• Maxillary division (V2) – exits from foramen
rotundum
• Mandibular division (V3) – exits from foramen ovale

8. International Association for the Study of Pain (IASP)
: defined trigeminal neuralgia as sudden usually unilateral severe
brief stabbing recurrent pain in the distribution of one or more
branches of the 5th cranial nerve.
International headache society (IHS) : defined trigeminal
neuralgia as painful unilateral affliction of the face characterized by
brief electric shock like pain limited to the distribution of one or more
divisions of the trigeminal nerve.
Nurmikko etal; trigeminal neuralgia – pathophysiology, diagnosis and current
treatment; British journal of Anesthesia; 87:1; 2001
DEFINITION:

9. Painful unilateral affliction of the face, characterized by
brief electric shock like pain limited to the distribution of
one or more divisions of the trigeminal nerve.
Pain is commonly evoked by trivial stimuli including
washing, shaving, smoking, talking and brushing the
teeth, but may also occur spontaneously.
The pain is abrupt in onset and termination and may
remit for varying periods – International headache
society
Nurmikko etal; trigeminal neuralgia – pathophysiology, diagnosis and current
treatment; British journal of Anesthesia; 87:1; 2001

10. HISTORICAL REVIEW :
JOHN LOCKE in 1677 gave the first full description with
its treatment.
NICHOLAS ANDRE in 1756 coined the term ‘Tic
Doloureux’.
JOHN FOTHERGILL in 1773 published detailed
description of trigeminal neuralgia.
ARETAEUS - credited with the first clinical description of
trigeminal neuralgia.
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

11. Epidemiology
•The annual incidence for women is approximately 5.9
cases per 100,00 women; for men it is approximately
3.4 cases per 100,00 men.
•The incidence increases with age.
•No known racial or ethnic risk factors exist.
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

12. Etiology
• Vascular factors
• Mechanical factors
• Anomaly of superior celebellar artery
• Dental etiology by Westrum and Black (1976)
• Infections
• Ratners jaw bone cavities (1979)
• Multiple sclerosis by Olfson (1966)
• Petrous ridge compression by Lee (1937)

13. • Intra cranial tumours
• Intra cranial vascular abnormalities
 Compession
 Distortion
• Viral etiology

14. Classification
•Based on Etiology:
Idiopathic
Secondary
Atypical
Post herpetic
•Based on clinical features:
Classical
Mixed
Wael Fouad; Management of trigeminal neuralgia by radiofrequency thermocoagulation;
Alexandria Journal of Medicine (2011) 47, 79–86

15. Theories regarding pathogenesis:
•Central – based on similarity of trigeminal neuralgia
to focal epilepsy and emphasize the role of
deafferentation in the genesis of neural hyperactivity
•Peripheral – change in peripheral axons and myelin
may lead to altered nerve sensitivity to chemical and
mechanical stimuli
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

16. Focal demyelination at the site of compression may also
allow electrical spread of excitation between adjacent
sensory axons
An emphatic short-circuit of this type within the
trigeminal nerve might explain the sudden ‘‘electric’’
jolts of pain that characterize the disorder.
Rasminsky M. Ephaptic transmission between single nerve fibres in the spinal nerve
roots of dystrophic mice. J Physiol 1980;305:151-69.

17. Bennetto etal; Trigeminal neuralgia and its management; BMJ 2007; 27:334

18. Following trauma, regenerating nerve fibers become
relatively depolarized & physiologically more excitable.
Spontaneous action potentials originate from multiple
sites and single action potentials may evoke sustained
after discharges.
Rasminsky M, Kearney RE, Aguayo AJ, Bray GM. Conduction of nervous impulses in spinal roots
and peripheral nerves of dystrophic mice. Brain Res 1978;143:71-85

19. GENERAL CHARACTERISTICS:
Incidence:
Age:
Sex:
Affliction for side:
Division of trigeminal nerve
involvement:
8 : 1,00,000
5th – 6th decade of life
Female > male ; 1.6 > 1.0
Right > left
V3 > V2 > V1
Bennetto etal; Trigeminal neuralgia and its management; BMJ 2007; 27:334

20. CLINICAL FEATURES:
Manifests as a sudden, unilateral, intermittent paroxysmal, sharp,
shooting, lancinating, shock like pain, elicited by slight touching
superficial ‘trigger points’ which radiates from that point, across
the distribution of one or more branches of the trigeminal nerve.
Pain is usually confined to one part of one division of trigeminal
nerve.
Pain rarely crosses the midline.
Attacks do not occur during sleep.

21. TIC DOULOUREUX:
Tic douloureux painful jerking
It is a truly agonizing condition, in which the patient
may clunch the hand over the face & experience
severe, lancinating pain associated with spasmodic
contractions of the facial muscles during attacks

22. Pain is of short duration, but may recur with variable
frequency.
In extreme cases, the patient will have a motionless face –
the ‘frozen or mask like face’.
Common trigger zones include:
Cutaneous
Corner of the lips
Cheek
Ala of the nose
Lateral brow
Intraoral
Teeth
Gingivae
Tongue

26. DIAGNOSIS:
Scrivani, S. J., Mathews, E. s., & Maciewicz, R. J (2005). Trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2005 Nov;100(5):527-38.

27. T1-weighted axial image showing an ectatic loop of vertebral artery (arrow)
passing anterior to the pons
Seth Love et al; Central Demyelination of the Vth Nerve Root in Trigeminal Neuralgia
Associated with Vascular Compression; Brain Pathology 8: 1-12(1998)

28. Differential diagnosis
Diagnosis Important fearures
Dental infection or
cracked tooth
Well localized to tooth,appropriate findings
on dental examination
Temporomandibular
joint pain
often bilateral,obvious findings in the joint
Persistent idiopathic
facial pain
Bilateral,extend outside the trigeminal
territory,pain is continuous & throbbing
Migrane Preceded by aura,nausea,
photophobia,phonophobia cervical
tenderness
Temporal arteritis Common in elderly,temporal arteries maybe
firm, tender and non pulsatile on
examination

29. TREATMENT MODALITIES:
MEDICAL SURGICAL

30. Dedhia et al; Trigeminal Neuralgia (TGN ) - Pathophysiology and Management;
J Anaesth Clin Pharmacol 2009; 25(1): 3-8

31. MEDICAL MANAGEMENT:
CARBAMAZEPINE:
Trade name: Tegretol , Carbitrol
Dosage: 100 mg BID Maintenance dose 1200-2400 mg
Mechanism of action: Slow recovery rate of voltage gated sodium
channels, modulates activated calcium channel activity and activates
descending inhibitory modulation system
Side effects: Visual blurring
Dizziness
Skin rashes
Rarely hepatic dysfunction, leukemia,
Thrombocytopenia, aplastic anemia

32. PHENYTOIN:
Trade name: Dilantin
Dosage: 200 - 600 mg/day Maintainance dose 200-400 mg/day
Mechanism of action: blockade of voltage dependent sodium
channels.
Inhibits the generation of repetitive action potentials.
Prefrentially blocks high frequency firing.
Canavaro S, Bonicalzi V. Drug therapy of trigeminal neuralgia. Expert Rev Neurother.
2006;6:429-40.
It is usually used in conjunction with carbamazepine.

33. Side effects: Slurred speech
Nystagmus
Swelling of lymph nodes
Gingival hypertrophy
Hypersensitivity
Teratogenicity

34. GABAPENTIN:
It is more expensive than other drugs but has a less side effects.
Trade name: Neurontin
Dosage:100 - 5000 mg/day Maintainance dose 1800 mg/day
Mechanism of action: mechanism unknown but possibly includes
blockage of voltage gated calcium channels by binding to α2
subunits
Side effects: dizziness, fatigue, weight gain, drowsiness,
hepatotoxicity

35. Lamotrigine:
New anticonvulsant drug
Dosage: 25 – 100mg/day BD Maintenance dose 200-400
mg/day
Mechanism of action: Decreases repetitive firing of sodium
channels by slowing the recovery rate of voltage gated channels
Also inhibits the release of the excitatory amino acids like
glutamate.
Side effects: Sleepiness
Dizziness
Headache
Vertigo
Rash

36. Topiramate:
A sulfamate-substituted monosaccharide, was first identified as an
antiepileptic drug.
Compared with other antiepileptics, this drug acts at different
neural transmission levels such as sodium channels and enhances
GABA levels, and has been termed a ‘neurostabilizer’
Dose: 200 – 300mg/day Maintenance dose: 200mg BID
Adverse effects:
Paraesthesia
Dysphasia
Fatigue
Confusion
Insomnia

37. BACLOFEN:
It is a GABA agonist
These drugs reduces the central projection of painful afferent
impulses.
Trade name: Lioresal
Dosage: 10 mg (tds) Maintenamce dose 30- 80 mg/day
Side effects: Fatigue
Vomiting
Ataxia

38. TRICYCLINE ANTIDEPRESSANTS:
Amitriptyline
Doxepin
Nortriptyline
Imipramine
10 – 300 mg/day
10 – 300 mg/day
10 – 150 mg/day
10 – 300 mg/day

39. Botulium toxin
It would limit the release of substance P, calcitonin gene-
rated peptide and glutamate from presynaptic terminals of
the primary sensory neurons, thus counteracting central
sensitization
Bao-Lin Guo et al; A closer look to botulinum neurotoxin type A-induced
Analgesia; Toxicon 71 (2013) 134–139
Injected subcutaneously into the
trigger zone (40 to 60 units)
The pain recurred five months later
and the site was again injected with
100 units

40. ACUPUNCTURE
Hüseyin Sert, Burhanettin Usta, Bünyamin Muslu, Muhammet Department of Anaesthesiology, Fatih University School of
Medicine - Ankara, Turkey CLINICS 2009;64(12):1225-6
• Adverse effects after minimal invasive approaches are paresthesia, facial
sensory loss, weakness or paralysis of masseter muscles and, rarely, loss
of the corneal reflex
• Acupuncture treatment was initiated without making any change to the
drug regime.
• Acupuncture needles (0.20 x 13 mm needles for the face and 0.25 x 25
mm needles for the other regions) were inserted on the typical areas that
are used for trigeminal neuralgia
• Every treatment session lasted about forty-five minutes, three times a
week
• By the sixth week (14 sessions), the patient was completely free of pain
• The analgesic effect of acupuncture is due to increased levels of
mediators, including endorphin, encephalin and serotonin, in the plasma
and brain tissue
• Adverse effects are minimal and include bruising or hematoma at the
needle site, metal allergy and local infection.

41. Treatment resistant trigeminal neuralgia
relieved with oral sumatriptan
• Sumatriptan is a serotonin agonist, specifically developed to relieve
migraine headaches.
• Although thecause of migraine is not fully understood, it is thought that
a widening of blood vessels in the brain causes the throbbing pain of
migraine headaches.
• Sumatriptan worksby causing vasoconstriction of these vessels via the
• stimulation of serotonin (or 5-HT) receptors.
• Sumatriptan mimics this action of serotonin by directly stimulating the
serotonin receptors in the brain.
• This results in narrowing of the blood vessels and in effective relief of
the migraine headache pain
JA Moran and A Neligan Treatment resistant trigeminal neuralgia relieved with oral sumatriptan: a case report Department of General
Practice, Brookfield Health Sciences Centre, University College Cork, Cork, Ireland and 2UCL Institute of Neurology

42. Multiple drug therapies
• When a patient only partially responds to a single drug
therapy at dosages that evoke side effects, adding a second
drug may enhance the therapeutic response

43. Peripheral procedures
Ganglionic procedure
Open procedures
SURGICAL MANAGEMENT:

44. PERIPHERAL INJECTION:
It has been known that injection of destructive
substance into peripheral branches of the trigeminal
nerve, produces anaesthesia in the trigger zones or in
areas of distribution of spontaneous pain.
(A) LONG ACTING ANAESTHETIC AGENTS:
Bupivacaine with or without corticosteroids may be
injected at the most proximal possible nerve site.

45. (B) ALCOHOL INJECTION:
0.5 – 2 ml of 95 % absolute alcohol can be used to block
the peripheral branches of the trigeminal nerve.
Aim is to destroy the nerve fibres.
It produces total numbness in the region of distribution
of the nerve that was anaesthetized.
Complication:
Necrosis of the adjacent tissue
Fibrosis
Alcohol induced neuritis

46. (C) Transcutaneous electric nerve
stimulation
It refers to applying a low voltage
electrical impulse to the nerve
system via electrodes placed on the
skin, one being over painful area and
the other elsewhere.
The stimulus intensity, frequency and
duration are adjusted by the patients
to obtain relief from pain
Frequency – 10 – 50Hz for 4 to 6 sec
Varadarajan; Transcutaneous electric nerve stimulation in trigeminal neuralgia: A
review of literature; J Res Dent Sci 2014 ;5:36-41

47. The analgesic mechanism of TENS involves:
Gate control theory: substantia gelatinosa of spinal cord acts as a
gate control system. Activation of large myelinating fibres subserving
touch, pressure, vibration is thought to facilitate pre synaptic
inhibition of substantia gelatinosa cells in the dorsal horn, thus,
reducing pain transmission.
Physiological block: As the frequency of stimulation increases,
conduction decreases resulting in physiological block.
Endogenous pain inhibitory systems: Presynaptic inhibition in the
dorsal horn of the spinal cord, endogenous pain control (via
endorphins, enkephalins and dynorphins), direct inhibition of an
abnormally excited nerve and restoration of afferent input.
Varadarajan; Transcutaneous electric nerve stimulation in trigeminal neuralgia: A review of
literature; J Res Dent Sci 2014 ;5:36-41

48. Advantages:
 No prostaglandins inhibition, since TENS controls pain by
gate control mechanism.
 Rapid and timely inhibition of pain at peak progression.
 No adverse effects of drugs
 Non invasive
 Short term treatment for 20-40 days as compared with long
term medicinal treatment.
 No need for surgical intervention.
 Can be used at home with portable machine.
 Equally effective in post neurectomy and post injection
alcohol neuralgia.
Singla et al; Role of transcutaneous electric nerve stimulation in the management of
trigeminal neuralgia; J Neurosci Rural Pract. 2011 Jul-Dec; 2(2): 150–152.

49. PERIPHERAL NEURECTOMY (NERVE AVULSION):
Oldest & most effective peripheral nerve destructive method
Can be repeated & relatively reliable technique.
It acts by interrupting the flow of a significant number of afferent
impulses to central trigeminal apparatus.
Performed commonly on infraorbital, inferior alveolar, mental and
rarely lingual.
Disadvantage:
May produce
Full anaesthesia
Deep hypoesthesia
Mukram et al; Peripheral neurectomies: A treatment option for trigeminal neuralgia in rural
practice; J Neurosci Rural Pract. 2012 May-Aug; 3(2): 152–157.

50. INFRAORBITAL NEURECTOMY:
(i) Conventional intraoral approach
(ii) Braun’s transantral approach
Conventional intraoral approach:
A ‘U’ - shaped Caldwell – Luc incision is made in the upper
buccal vestibule in the canine fossa region.
Mucoperiosteal flap is reflected superiorly to locate the
infraorbital foramen.
Once the nerve is exposed, all the peripheral branches are held
with the hemostat & avulsed from the skin surface intra orally.

51. The entire trunk is separated from the skin surface is held with
the hemostat at the exit point from the foramen & is removed by
winding it around hemostat & pulling it out from the foramen.
Then it may be plugged with polyethylene plug.

52. Braun’s trans antral approach:
An intra oral incision is made from the maxillary tuberosity
to the midline in the maxillary vestibule.

53. The descending palatine branch of the trigeminal nerve is identified
& traced to the sphenopalatine ganglion.
The maxillary nerve is sectioned from the foramen rotundum to the
inferior orbital fissure.
The antral mucoperiosteal flap in the vestibule is repositioned &
sutured back.
A 3 cm window is made in the antero – lateral wall of the maxillary
sinus.
Posterosuperior portion of antrum is excised to create a posterior
window

54. INFERIOR ALVEOLAR NEURECTOMY:
(i) Extra oral approach
(ii)Intra oral approach
The extra oral approach:
Done through Ridson’s incision
After reflection of masseter, a bony window is
drilled in outer cortex & nerve is lifted with nerve
hook & avulsed from its superior attachment &
mental nerve is avulsed anteriorly through the same
approach.

55. The intra oral approach:
Done via Dr Ginwalla’s incision
Incision is made along with the anterior border of
asescending ramus, extending lingually & buccally
ending in a fork like inverted Y.
Incision is then deepened on the medial aspect of
ramus.
The temporalis & medial pterygoid muscles are split at
their insertion & inferior alveolar nerve is located.

57. The nerve is ligated at two points in the most superior
part visible & divided between the ligature.
The superior end is cauterized & the lower end is held
securely using a hemostat.
The mental nerve is also similarly ligated in two points
close to the mental foramen & divided between two.
The remaining nerve is held at the inferior alveolar end
& wound around the hemostat & excised from the
canal.

58. LINGUAL NEURECTOMY:
An incision is made in the anterior border of the ramus
slightly towards the lingual side.
The lingual aspect is exposed & the lingual nerve
identified in the third molar region just below the
periosteum.
The nerve can be either
avulsed or ligated, cut
and the ends may
be cauterized.

59. CRYOTHERAPHY:
Barnard first used cryotheraphy in 1981 for the treatment of
the trigeminal neuralgia.
After identifying the affected nerve , it is then exposed to
the cryoprobe intraorally.
Direct application of cryotheraphy probe at temperatures
colder than -60 C are known to produce Wallerian
degeneration without destroying the nerve sheath itself.
Nerve is exposed for 2 min freeze followed by 5 min thaw
cycle.
The freeze – thaw cycle is repeated at least 3 times.
Zakrzewska JM, Cryotherapy for trigeminal neuralgia: a 10 year audit, Br J Oral
Maxillofac Surg. 1991 Feb;29(1):1-4

60. GASSERIAN GANGLION PROCEDURES:
PERCUTANEOUS RHIZOTOMY:
This is done on the
Gasserian ganglion
which involves either
mechanically or
chemically damaging
parts of the trigeminal
nerve.

61. • 1910 – Harris, Tapatas and Hartel introduced
percutaneous approaches via foramen ovale
• 1931- Kirschner introduced percutaneous
electrocoagulation of gasserian ganglion
• Three procedures used with variable success rate
are
• Glycerol injections
• Thermocoagulation
• Balloon compression

62. Technique of needle penetration:
The foramen ovale is best
visualize with the x – ray tube
placed for a submentovertex
position.
Infiltration of the skin & cheek is
done with local anaesthetic
agent on the affected side.
Three points of Hartel are marked
on the side of the face using
marking ink.

63. First point – a perpendicular line is drawn from the lateral
orbital rim to the inferior border of the mandible.
Second point – marked at 15 mm lateral to the angle of the
mouth on the perpendicular first line
Third point – marked at the level of TMJ 2.5 cm from the
centre of the external auditory meatus.

64. • This line is the line of elevation.
• When patient is supine, plane of elevation will be
perpendicular to floor
• Needle is passed through the second point.
• Needle is passed till anterior border of ramus of
mandible,then turn the needle medial and upwards to
base of skull
• Position is confirmed.
• Needle is then pushed for half centim
eter, final position.

65. (A)Controlled radiofrequency thermocoagulation:
It was first introduced by Kirschner (1931) & later modified by
Sweet (1970).
Technique:
The patient is sedated with a short acting
sedative and vital signs are monitored.
The electrode is inserted through the cheek
under fluoroscopy into foramen ovale.
The patient is awakened briefly to accurately
locate the position of the electrode.

66. The straight temperature
monitoring electrode was
used to perform an initial
lesion at 60 C for 120 s
The patient is awakened for
sensory testing
The lesion may be repeated
at the same temperature and
duration if sensory deficit
was not evident
Facial hyperemia in the distribution of right V2
during RFT.
Wael Fouad; Management of trigeminal neuralgia by radiofrequency thermocoagulation;
Alexandria Journal of Medicine (2011) 47, 79–86

67. Indication:
Toxicity of drugs
Failure of response to the other
modalities
Dependence on the drugs for life time
Elderly patients
Medically compromised patients

68. Advantages:
Comparative low rate of recurrence
Zero mortality
Thermocoagulation preserves the motor function of the
trigeminal nerve
Can avoid major surgical procedure
Disadvantage:
May cause
Anaesthesia dolorosa
Loss of corneal reflex
Meningitis (rarely)

69. (B) Percutaneous glycerol rhizotomy:
Glycerol is a neurolytic alcohol which can be used to chemically
destroy the nerve root.
The injection of 0.1–0.4 ml of glycerol into the trigeminal
cistern is carried out under fluoroscopic control

70. Advantages:
Simple technique
Lower incidence of
anaesthesia dolorosa
Complication:
Post operative headache, nausea, vomiting
Meningitis
Post operative herpes simplex perioralis

71. (C) Percutaneous balloon compression:
This is a mechanical means of destruction of the trigeminal
nerve introduced by Mullan & Lichtor in 1980.
Technique:
A no. 4 Fogarthy’s catheter is introduced with
fluoroscopic guidance.
A 0.5 - 1 mm balloon is inflated for 1 – 6 minutes.

73. OPEN PROCEDURES ( INTRACRANIAL PROCEDURES):
(A) Microvascular decompression of the trigeminal
nerve sensory root:
Procedure popularized in 1967 – 1976 by Jannetta.
Most commonly performed intra cranial open
procedure.
The root is examined under the
microscope

74. A compressing branch of the
superior cerebellar artery will be
seen medial to the nerve at the
root entry zone.
Incision is made over the mastoid area

75. Then the trigeminal nerve is freed
from the compressing / pulsating
artery.
After freeing the nerve, the nerve is
separated from the artery by placing
a piece of Teflon between them.

76. Non absorbable insulating
sponge may also be placed.

77. (B) Trigeminal root section:
(a) Extradural sensory root section:
It is also known as the subtemporal
extradural retrogasserian rhizotomy.
It is no longer used now.
In this, sensory root is divided, sparing
the motor root, as close to the brainstem
as possible.
Disadvantage:
Profound sensory loss
High incidence of anesthesia dolorosa

78. (b) Intradural rhizotomy:
This is an intradural procedure that is done when the pain
recurs after MVD.
This is usually done in the posterior cranial fossa.
It can be selective or complete.
(c) Trigeminal tractotomy:
It is also known as the medullary tractotomy.
This is not usually done.
The descending tract of the trigeminal nerve is sectioned at
the junction of the cervicomedullary region.

79. STEREOTACTIC RADIOSURGERY (GAMMA KNIFE):
The radiation is aimed at the proximal nerve and root entry zone in
the pons
The gamma knife projects 201 very fine beams of gamma rays at
dose of 70 – 90Gy( generated by radioactive cobalt) through skull
and brain
It has been shown to affect
abnormal ephatic transmission but
not normal axonal conduction
Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003

80. Conclusion
•Trigeminal neuralgia has long been recognized by
the medical professionals
•However it is still an enigmatic disorder, and its
management remains controversial.

81. References
• Holguin J et al; Suprameatal extension of retrosigmoid approach for
microvascular decompression of TN; IJOS 2015: 13-16
• Yasushi L etal; Neuronavigation assisted decompression of TN:
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• Bennetto L et al; TN and its management; BMJ 2008:334
• Chole R et al; Drug treatment of TN: JOMS 2007:40-45
• Nurmikko et al; TN- pathophysiology, diagnosis and current treatment;
BJA 2001: 117-32
•Textbook of Maxillofacial Surgery- by Peter Ward Booth, 2nd Edition, Vol 2
Principles of Neurological surgery- by Richard G. Ellenbogen, 3rd Edition.
Principles of Maxillofacial Surgery- by Larry J. Peterson
Textbook of pharmacology- by Goodman & Gillman

82. • Rasminsky M, Kearney RE, Aguayo AJ, Bray GM. Conduction of nervous impulses in
spinal roots and peripheral nerves of dystrophic mice. Brain Res 1978;143:71-85
• Rasminsky M. Ephaptic transmission between single nerve fibres in the spinal nerve
roots of dystrophic mice. J Physiol 1980;305:151-69.
• Wael Fouad; Management of trigeminal neuralgia by radiofrequency
thermocoagulation; Alexandria Journal of Medicine (2011) 47, 79–86
• Siddiqui etal; Pain management trigeminal neuralgia; Hospital physician 2003
• Joffroy A et al; Trigeminal neuralgia pathophysiology and treatment; Acta neurol
beig 101: 20-25: 2001
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science international; 2011: 8:17-19
• Elsotouhy A et al; Tic douloureux in patients with incidental intracranial
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83. Dedhia et al; Trigeminal Neuralgia (TGN ) - Pathophysiology and Management;
J Anaesth Clin Pharmacol 2009; 25(1): 3-8
Qiang-ping et al; Topiramate versus Carbamazepine for the Treatment of
Classical Trigeminal Neuralgia; CNS Drugs 2011; 25 (10): 847-857
Jørgen Degn : Surgical treatment of trigeminal neuralgia. Results
from the use of glycerol injection, microvasculardecompression, and rhizotomia
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Giorgio Cruccu; Refractory Trigeminal Neuralgia; CNS Drugs (2013) 27:91–96
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for trigeminal neuralgia: A multi-factor analysis; Neurology India |
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84. Wenyao Hong et al; Clinical features and surgical treatment of trigeminal
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