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Trigeminal nerve applied anatomy(part 2)
- 1. TRIGEMINAL NERVE-APPLIED ANATOMY(PART 2) DRKHADEEJA KULOOD M FIRST YEAR PG DEPT. OF PAEDODONTICS &PREVENTIVE DENTISTRY
- 2. TRIGEMINAL NEURALGIA • Chronicpain disorder that affects the trigeminal nerve. • TYPICAL (TN1) and ATYPICAL(TN2) trigeminal neuralgia. • Typical-episodes of severe, sudden, shock-like pain in one side of the face that lasts for seconds to a few minutes • Atypical - constant burning pain that is less severe • Both forms may occur in the same person. • It is one of the most painful conditions and can result in depression. Trigeminal Neuralgia Fact Sheet NINDS November 3, 2015. National Institute of Neurological Disorders and Stroke
- 3. fothergill disease • Itis estimated that 1 in 8,000 people per year develop trigeminal neuralgia • begins in people over 50 years old, but can occur at any age • Women are more commonly affected than men • first described in detail in 1773 by John Fothergill Trigeminal Neuralgia Fact Sheet NINDS November 3, 2015. National Institute of Neurological Disorders and Stroke
- 4. Trigger factors • byvibration or contact with the cheek • shaving, washing the face, or applying makeup,brushing teeth, eating, drinking, talking, or being exposed to the wind • TN is typified by attacks that stop for a period of time and then return, but the condition can be progressive. • The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. • Eventually, the pain-free intervals disappear and medication to control the pain becomes less effective.
- 5. Tic douloureux • Theexact cause is unclear, but believed to involve loss of the myelin around the trigeminal nerve This may occur due to • compression from a blood vessel as the nerve exits the brain stem. • multiple sclerosis, stroke, or trauma • Less common causes include a tumor or arteriovenous malformation Diagnosis is typically based on the symptoms, after ruling out other possible causes such as postherpetic neuralgia
- 6. Treatment • Includes Medication, Surgery & complementary approaches. Medication • Anticonvulsant —used to block nerve firing—are generally effective in treating TN1 but often less effective in TN2 • Carbamazepine Or Oxcarbazepine is usually the initial treatment • Other options include lamotrigine , baclofen , Gabapentin , pimozide , valproic acid , topiramate , pregabalin, clonazepam and phenytoin.
- 7. Surgery • Depending onthe nature of the pain; the individual’s preference, physical health, blood pressure, and previous surgeries • presence of multiple sclerosis, and the distribution of trigeminal nerve involvement (particularly when the upper/ophthalmic branch is involved)
- 8. Associated risks • Somedegree of facial numbness is expected after many of these procedures, and TN will often return even if the procedure is initially successful. • Depending on the procedure, other surgical risks include hearing loss, balance problems, leaking of the cerebrospinal fluid, infection, anesthesia dolorosa and stroke.
- 9. RHIZOTOMY ( rhizolysis) • Procedure in which nerve fibers are damaged to block pain. • A rhizotomy for TN always causes some degree of sensory loss and facial numbness. • Several forms of rhizotomy are available to treat trigeminal neuralgia : I. Balloon compression II. Glycerol injection III. Radiofrequency thermal lesioning (Radiofrequency Ablation) IV. Stereotactic radiosurgery(Gamma Knife, Cyber Knife) V. Microvascular decompression (MVD)
- 10. Balloon compression • worksby injuring the insulation on nerves that are involved with the sensation of light touch on the face. • performed under general anesthesia. • A tube called a cannula is inserted through the cheek and guided to one branch of the trigeminal nerve that passes through the base of the skull
- 11. • A softcatheter with a balloon tip is threaded through the cannula and the balloon is inflated to squeeze part of the nerve against the hard edge of the brain covering (the Dura) and the skull. • After about a minute the balloon is deflated and removed, along with the catheter and cannula. • Balloon compression is generally an outpatient procedure, although sometimes the patient may be kept in the hospital overnight • Pain relief usually lasts one to two years.
- 12. Glycerol injection • Outpatientprocedure in which the individual is sedated with intravenous medication • A thin needle is passed through the cheek, next to the mouth, and guided through the opening in the base of the skull where the third division of the trigeminal nerve (Mandibular) exits • The needle is moved into cistern that surrounds the trigeminal nerve center (or ganglion) • .
- 13. • The procedureis performed with the person sitting up, since glycerol is heavier than spinal fluid and will then remain in the spinal fluid around the ganglion • The glycerol injection bathes the ganglion and damages the insulation of trigeminal nerve fibers. • This form of rhizotomy is likely to result in recurrence of pain within a year to two years
- 14. Radiofrequency thermal lesioning •Most often performed on an outpatient basis. • The individual is anesthetized and a hollow needle is passed through the cheek • The individual is briefly awakened and a small electrical current is passed through the needle, causing tingling in the area of the nerve where the needle tips rest • When the needle is positioned so that the tingling occurs in the area of TN pain, the person is then sedated and the nerve area is gradually heated with an electrode, injuring the nerve fibers.
- 15. Stereotactic radiosurgery • usescomputer imaging to direct highly focused beams of radiation at the site where the trigeminal nerve exits the brain stem. • This causes the slow formation of a lesion on the nerve that disrupts the transmission of sensory signals to the brain. • almost half have recurrence of pain within three years.
- 16. Microvascular decompression • mostinvasive of all surgeries for TN, but better prognosis more often.-within 12 to 15 years • performed under general anesthesia, requires that a small opening be made through the mastoid bone behind the ear.
- 17. • While viewingthe trigeminal nerve through a microscope or endoscope, the surgeon moves away the vessel (usually an artery) that is compressing the nerve • places a soft cushion between the nerve and the vessel
- 18. Complementary approaches • usuallyin combination with drug treatment • low-impact exercise, yoga, creative visualization, aroma therapy, or meditation may be useful in promoting well-being • Other options include acupuncture, biofeedback, vitamin therapy, and nutritional therapy • Injections of botulinum toxin to block activity of sensory nerves
- 19. Herpes Zoster Ophthalmicus •Caused by Varicella zoster • Predilection for nasociliary branch of ophthalmic division of the trigeminal nerve. CLINICAL FEATURES:- Cutaneous lesions:- • Rash • Vesicle • Pustule crust permanent scar
- 20. Ocular lesions:- • Periorbitalpain and Oedema • Hyperasthesia • Conjunctivitis • Scleritis • Corneal scarring • Glaucoma TREATMENT:- Acyclovir 800mg 5 times /day within 4 days of onset of rash Analgesics Antibiotic ointments Systemic steroids 60mg/day Corneal grafting
- 21. Wallenberg syndrome(lateral medullary syndrome) •A stroke usually affects only one side of the body. • loss of sensation due to a stroke will be lateralized to the right or the left side of the body • In this syndrome, a stroke causes a loss of pain,temperature sensation from one side of the face and the other side of the body
- 22. • In themedulla, the ascending spinothalamic tract (which carries pain- temperature information from the opposite side of the body) is adjacent to the ascending spinal tract of the trigeminal nerve (which carries pain- temperature information from the same side of the face) • A stroke which cuts off the blood supply to this area destroys both tracts simultaneously • The result is a loss of pain-temperature sensation in a "checkerboard" pattern (ipsilateral face, contralateral body), facilitating diagnosis.
- 23. Conclusion Anatomy of trigeminalnerve and its branches plays an important role in dentistry. Application of local anaesthesia and certain surgical procedures requires a thorough knowledge of its anatomy.
- 24.