The International Association for the Study of Pain (IASP)1 defines trigeminal neuralgia (TN) as a sudden, usually unilateral, severe brief stabbing recurrent pain in one or more branches of the fifth cranial nerve
synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
In 1677 John Locke, a American physician and philosopher, accurately identified the major clinical features of TN
In 1756 the French physician Nicolaus Andre coined the term “Tic douloureux” to the condition.
The English physician John Fothergill in 1773 published detailed description of TN, since then, it has been referred to as ‘Fothergill’s disease’.
Peripheral injections
Long acting LA
Alcohol
Glycerol
Peripheral neurectomy/ nerve avulsion
Cryotherapy
Gasserian ganglion procedures
Percutaneous stereotactic radiofrequency thermal lesioning of the trigeminal ganglion and/or root (rfl)
percutaneous glycerol gangliolysis of the trigeminal ganglion
percutaneous balloon microcompression of the trigeminal ganglion
Intracranial procedures
MVD
Partial sensory rhizotomy
Gamma knife radiation to the trigeminal root entry zone GKR
Detailed description of diagnosis and management of maxillofacial and neck space infections. Discussion of anatomy of the spaces is also done in details. Drainage of such spaces are also discussed. Medical management is also discussed. Complications are also discussed.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
Detailed description of diagnosis and management of maxillofacial and neck space infections. Discussion of anatomy of the spaces is also done in details. Drainage of such spaces are also discussed. Medical management is also discussed. Complications are also discussed.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
Trigeminal neuralgia is sudden, severe facial pain. It's often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums.
Trigeminal neuralgia
Contents
Overview
Symptoms
Causes
Diagnosis
Treatment
Bell’s palsy (facial paralysis) is due to unilateral inflammation of the ( CN VII Facial nerve) seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side.
Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation
Bell’s palsy
Trigeminal Neuralgia ( Tic Douloreux)
Cranial & spinal neuropathies
Bell’s palsy (facial paralysis) is due to unilateral inflammation of the ( CN VII Facial nerve) seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side.
Supplemental corticosteroids for dental patients with adrenal insufficiencyR...DrKamini Dadsena
Primary Adrenal Insufficiency:
It is caused by a progressive destruction of the adrenal cortex, usually of an idiopathic nature (most commonly autoimmune), but also results from hemorrhage, sepsis, infectious diseases (such as tuberculosis, human immunodeficiency virus, cytomegalovirus and fungal infection), malignancy, adrenalectomy, amyloidosis or drugs.
Clinical assessment scoring system for tracheostomy (CASST) criterion: Objec...DrKamini Dadsena
Tracheotomy has been used for many centuries as a means to bypass upper airway obstruction.
Head and neck cancers are often associated with anatomic changes which can create a potentially difficult airway.
CARNOY’S SOLUTION AS A SURGICAL MEDICAMENT IN THETREATMENT OF KERATOCYSTIC O...DrKamini Dadsena
The term keratocyst was coined by Philipsen in 1956.
Unlike the other cystic lesion KOT, has got strong tendency for recurrence.
Treatment of these lesions remains controversial and has a number of dilemmas about the choice of treatment whether to use carnoys solution as an adjunct therapy after removal of the lesion.
Temporomandibular disorders (TMDs) are considered the major cause of orofacial pain. Internal derangement (ID) of the temporomandibular joint (TMJ), which is classified as disc displacement with or without reduction, is one of the disorders of the TMJ that is frequently seen.
Displacement of the articular disc can result in decreased joint space, joint noise (clicking, popping, or crepitation), arthritis, condylar resorption, inflammation, and compression of the bilaminar tissue, all of which can cause various degrees of pain and dysfunction.
Changing Guidelines of CPR & BLS For General Dental Practitioners & O...DrKamini Dadsena
The tolerance of the heart to anoxia is relatively high, but the central nervous system will show irreversible lesions if anoxia lasts for more than 3–4 min.
Though unusual, there are reports of deaths due to CPA in dental offices during dental treatment.
Cardiopulmonary resuscitation (CPR) is a vital skill which must be mastered by all health care professionals.
Therefore the thorough knowledge of CPR and Basic Life Support is of utmost importance to the dentist.
Neck Dissection: Nomenclature, Classification, and TechniqueDrKamini Dadsena
Removal of the at-risk lymphatic basins serves two important purposes.
First, it allows the removal and identification of occult metastasis in patients in whom cervical metastasis are a risk, - Elective neck dissection.
Secondly, it allows the removal of disease in patients in whom metastasis are highly suspected based on imaging, clinical examination or fine needle aspiration, - Therapeutic neck dissection.
Clinical use of botulinum toxins in oral and maxillofacial surgeryDrKamini Dadsena
Purified botulinum toxin (BTX) was the first bacterial toxin used as a medicine. Since its introduction into clinical use, over 30 years ago, it has become a versatile drug in various fields of medicine.
Its mechanism of inhibiting acetylcholine release at neuromuscular junctions following local injection is unique for the treatment of facial wrinkles.
Other dose-dependent anti-neuroinflammatory effects and vascular modulating properties have extended its spectrum of applications.
Cavernous sinus thrombosis represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. The prompt recognition and management of this problem is critical.
In 1989, Shetty and Freymiller [7] reviewed indications for removal of teeth in the line of fracture. They recommended the following indications:
1. Significant periodontal disease with gross mobility and periapical pathology
2. Partially erupted third molars with pericoronitis or cystic areas
3. Teeth preventing the reduction of fractures
4. Teeth with fractured roots
5. Teeth with exposed root apices or teeth in which the entire root surface from the apex to the gingival margin is exposed
6. Excessive delay from the time of fracture to the time of definitive treatment
In addition to these indications, another indication that requires extraction of teeth in the line of fracture is an acute, recurring abscess at the site of the fracture despite antibiotic therapy(8)
Assessment of lingual nerve injury using different surgical variables for man...DrKamini Dadsena
Assessment of lingual nerve injury using different surgical variables for mandibular third molar surgery
The objective of this study was to investigate the incidence of sensory impairment of the lingual nerves following lower third molar surgery and to compare the outcome with various operative variables.
Factors that predicted lingual nerve injury were lingual flap retraction, tooth sectioning, and buccal guttering.
Instruments in major oral and maxillofacial surgeryDrKamini Dadsena
A surgical instrument is a specially designed tool or device for performing specific actions and carrying out desired effects during surgery or operations.
Fracture is a break in the structural continuity of bone, And starts immediately after the fracture occurs.
fracture results in a well-defined progression of tissue responses that are designed to remove tissue debris, to reestablish vascular supply and to produce a new skeletal matrix.
Traditional classification were given 100 years back when RTA , assaults, sports injuries, industrial accidents were minimal.
Over the past 100 years RTA (high speed & Low speed) assaults, sports injuries (high contact/ low contact), industrial accidents have increased.
Fracture patterns which are not matching the traditional injuries pattern.
Can speed up diagnosis and treatment planning
Cohorting / clubbing of complication to Specific Fractures.
It facilitate communication between peers and assist documentation and research.
It also have prognostic value for patients and assist Surgeons in planning their management.
It serves as a basis for treatment and for evaluation of the results.
Different fractures/ Areas of fracture has different treatment plan / approaches.
Undisplaced fracture : conservative/ surgical
Displaced Fractures: Surgical/ conservative with traction
Trauma is a global problem and continues to be a leading cause of disability and death.
Approximately 25% to 30% of deaths caused by trauma can be prevented when a systematic and organized approach is used.
The main goal of the initial assessment
Recognize the patient who does have life-threatening injuries
Establish treatment priorities, and
Manage them aggressively
A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply or from a anastomised vessel.
Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue
An oroantral communication is an unnatural perforation between oral cavity and maxillary sinus.
Oroantral fistula is an epithelized, pathological, communication between these two cavities. A fistulous tract present more than 14 days should be considered as chronic fistula.
The practice of surgery rests on certain fundamental principles which remain unchanged, though to apply them the surgeon may have to modify techniques to suit the anatomical field, the type of operation and the conditions obtaining at the time.
Obstructive sleep apnea (OSA) is a prevalent chronic disease characterized by pharyngeal collapse during sleep.
Sleep disorder that involves cessation or significant decrease in airflow through the upper airway in the presence of breathing effort.
Obstructive sleep apnea is the second most common sleep disorder, insomnia being the most common.
Associated with recurrent oxyhemoglobin desaturations and arousals from sleep
Apnea index- no. of apneas /hr of total sleep time.
AHI (APNEA-HYPOPNEA INDEX)- No of apneas and hypoapneas/hr of total sleep time.
RDI (Respiratory Disturbance Index) – no. of apneas, hypoapneas and respiratory effort related arousals(RERA)/hr of total sleep time.
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
4. Introduction
• The International Association for the Study of Pain
(IASP)1 defines trigeminal neuralgia (TN) as a
sudden, usually unilateral, severe brief stabbing
recurrent pain in one or more branches of the fifth
cranial nerve
• synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
5. History
• In 1677 John Locke, a American physician and philosopher,
accurately identified the major clinical features of TN
• In 1756 the French physician Nicolaus Andre coined the term
“Tic douloureux” to the condition.
• The English physician John Fothergill in 1773 published detailed
description of TN, since then, it has been referred to as
‘Fothergill’s disease’.
6. Etiology and Pathogenesis
• Condition known for centuries, but pathogenesis has remained
ENIGMA
• Vascular factors
• transient ischemia,
• autoimmune hypersensitivity
• Mechanical factors: pressure from aneurysms of ICA →erode
intra cranial fossa → pulsatile irritation of trigeminal ganglion
→ demyelenation → pain
7. Etiology
• Anomaly of superior cerebellar artery: lies in contact with
sensory root of trigeminal ganglion → anomaly →
demyelenation
• Dental etiology: Westrum and Black ,1976 differentiation from
loss of teeth & degeneration of nerve → proceeds proximally to
involve nucleus
• Infections: various granulomatous & nongranulomatous
infections invoving 5th nr
8. Etiology
• Ratner’s jaw bone cavities (1979): Cavities in the alveolar and
jaw bones are the causative factor.
• Multiple sclerosis: Olfson (1966), sclerotic plaque located at root
entry zone of TNr
• Petrous ridge compression: Lee (1937),compression of nerve at
dural foramen
• Post traumatic neuralgia: traumatic neuromas following injury
9. ‘Ignition Hypothesis’
proposed by Devor et al
• In this model, a trigeminal injury induces physiologic changes that
result in a population of hyper excitable and functionally linked primary
sensory neurons.
• The discharge of any individual neuron in this group can quickly spread
to activate the entire population.
• Such a sudden synchronous discharge could underlie the sudden jolt
of pain characteristic of a TN pain attack.
10. Etiology
• Intracranial tumours: epidermoid tumors, meningiomas of
cerebellopontine angle & meckel’s cave, arteriovenous
malformations, aneurysms, vascular compressions & trigeminal
neuromas may impinge on the nerve
• Intracranial vascular abnormality:
• Viral etiology: post herpetic neuralgia is seen in elderly patients.
Viral lesions of the ganglion can be etiologic factor
11. General characteristics
• Incidence: 4:1,00,000
• Occurs at middle age or later (5th or 6th decade)
• Female predisposition (58%)
• Predilection for RT side
• V3 > V2 > V1
12. Clinical features
Sudden, unilateral, intermittent paroxysmal, sharp, shooting,
stabbing, lancinating, recurring pain, elicited by slight touching
superficial “trigger points”. Pain radiates from that point, across
the distribution of one more branches
Pain usually confined to 1 branch
13. Clinical features
• Rarely crosses the mid line
• Pain is of short duration, lasts for few seconds
• "tic douloureux" because of a characteristic muscle spasm that
accompanies the pain.
14. Clinical features
• Male patients avoid shaving, poor oral hygiene
• Occasionally a cold breeze blowing on the face can be enough
to initiate an attack.
• Paroxysms occur in cycles, each cycle lasting for weeks or
months
• No attacks during sleep
• Patients lead poor quality of life due to pain
15. Clinical features
• The condition can lead to
• Irritability
• Severe anticipatory anxiety and Depression
• Life-threatening malnutrition.
• Suicidal depression is not uncommon
17. Diagnosis
White and Sweet - ‘‘Sweet criteria’’
• 1. The pain is paroxysmal.
• 2. The pain may be provoked by light touch to the
face (trigger zones).
• 3. The pain is confined to the trigeminal distribution.
• 4. The pain is unilateral.
• 5. The clinical sensory examination is normal.
18. • International Classification of Headache Disorders II (ICHD-II)
subdivides TN into
• 1. Classic TN and
2. Symptomatic TN.
19. Classical trigeminal neuralgia:
A. Paroxysmal attacks of pain lasting from a fraction of a second to 2
minutes, affecting one or more divisions of the trigeminal nerve and
fulfilling criteria B and C:
B. Pain has at least one of the following characteristics:
1. intense, sharp, superficial or stabbing
2. Precipitated from trigger areas or by trigger factors
C. Attacks are stereotyped in the individual patient.
D. There is no clinically evident neurological deficit.
E. Not attributed to another disorder.
20. Symptomatic trigeminal neuralgia:
A. Paroxysmal attacks of pain lasting from a fraction of a second to 2
minutes, with or without persistence of aching between paroxysms,
affecting one or more divisions of the trigeminal nerve and fulfilling
criteria B and C
B. Pain has at least one of the following characteristics:
1. Intense, sharp, superficial or stabbing
2. Precipitated from trigger areas or by trigger factors
C. Attacks are stereotyped in the individual patient
D. A causative lesion, other than vascular compression, has been
demonstrated by special investigations and/or posterior fossa
exploration.
21. Steps in Diagnosis
• History
• Diagnostic nerve block Material Required
• 3–1 cc syringes
• 3–25 gauge needles
• Sterile normal saline
• Two percent lignocaine without adr
• Several alcohol wipes
22. Inject 0.5 cc of
normal saline
•psychogenic pain
inject 0.5 ml of 2
percent
lignocaine without
adrenaline at
surface site
•Direct therapy at
small nociceptor
fibers.
persists–inject little
deeper
•Musculoskeletal
origin of pain.
more proximal
portionof nerve
•direct therapy at
site, when relief
occurred.
selective inferior
alveolar, lingual,
buccal, infraor bital,
posterior superior
alveolar blocks
23. Steps in Diagnosis
• History
• Diagnostic nerve block
• Carbamazepine
• MRI
Material Required
• 3–1 cc syringes
• 3–25 gauge needles
• Sterile normal saline
• Two percent lignocaine without adr
• Several alcohol wipes
27. Medicinal
• Phenytoin was first introduced in 1942, and in 1962
carbamazepine became the most commonly used
drug.
• Baclophen may add to the effectiveness of these
drugs.
• Recently - Neurontin has been widely used because of
reduced side effects, although is more expensive.
29. Carbamazepine (Tegretol)
• Dose- initial- 100mg bid
Maintainance- 1200 -2400mg
• Drug dosage should be taken at night, so that adequate serum
concentration can be present in early morning, when pain most occurs.
• Side effects: Visual blurring, dizziness, somnolence, skin rashes and ataxia
and in rare cases hepatic dysfunction, leukopenia, thrombocytopenia—
aplastic anemia (It is known to suppress the bone marrow. Patients should
be monitored to avoid agranulocytosis). Whenever the side effects appear, a
reduction of 200 mg of drug will often eliminate them. Once the pain
remission has been achieved, the drug dose should be kept at maintenance
level or withdrawn and restarted if symptoms appear.
31. Clonazepam
• Dose- initial- 0.5mg
maintainance- 4 mg max 20mg
• Side effects: Drowsiness, fatigue, lethargy.
32. Phenytoin
• Dose—100 mg three times a day.
• Side effects: nystagmus, ataxia, dysarthria, ophthalmoplegia (paralysis of
eye movements) as well as drowsiness and mental confusion.
• Gingival hyperplasia (enlargement of the gums in the mouth) and
hypertrichosis (excessive hair growth).
34. Baclofen (Lioresal)
• Dose- initial-5mg tds
Maintainence- 80 mg max
• One tenth of sufferers cannot tolerate baclophen.
• Should not be discontinued abruptly after prolonged use because
hallucinations or seizures may occur.
• Side effects: drowsiness, dizziness, nausea and leg weakness.
35. Gabapentin
• An anti-epileptic drug that is structurally related to the neurotransmitter
GABA.
• This drug is almost as effective as carbamazepine but involves fewer
side effects.
• The starting dose is usually 300mg three times a day and this is
increased to a maximal dose.
36. Multiple drug therapy
• AED therapy routinely begins with a single agent, given in gradually
increasing doses until pain attacks are either suppressed or satisfactorily
reduced.
• When a patient only partially responds to single drug therapy at
dosages that evoke side effects, adding a second AED may enhance the
therapeutic response.
• Because AEDs have differing mechanisms of action as well as differing
side effect patterns, combining agents is a reasonable approach.
37. Treatment of Acute Exacerbations
• Peripheral local anesthetic block
• Intravenous lidocaine.
• Intravenous AED
Role of Analgesic medication
Ineffective in TN
39. Surgical managements
• Gasserian ganglion procedures
• Percutaneous stereotactic radiofrequency thermal lesioning of the
trigeminal ganglion and/or root (rfl)
• percutaneous glycerol gangliolysis of the trigeminal ganglion
• percutaneous balloon microcompression of the trigeminal
ganglion
• Intracranial procedures
• MVD
• Partial sensory rhizotomy
• Gamma knife radiation to the trigeminal root entry zone GKR
40. Other procedure
• TENS
• Deep brain stimulation
• Biofeedback
• Hypnosis/ Autosuggestion
• Psychiatric counselling
41. PERIPHERAL INJECTIONS
• Produces anesthesia in the trigger zones
• Care should be taken to avoid IV injections
• Very effective in relieving pain
42. Long acting anesthetic agents
• Emergency pain relieving technique
• Injected proximally to nerve site
• Pain free period will be very short
43. Alcohol injections
• 95% alchohol injectionproduces anesthesia of the region
• May cause local tissue toxicity inflammation and fibrosis.
• It may also cause alcohol neuritis.
• Pain relief for 6-12 months may be seen.
44. Peripheral neurectomy
• Carried out under GA
• Most effective pain peripheral nerve destructive technique.
• Pain may return after amputed nerve stump regenerates .
• Done in patients where craniotomy contraindicated due to age ,
systemic diseases.
46. Intra oral approach
• U – shaped caldwell luc incision is made
• Infra-orbital foramen located.
• The nerve is located and avulsed from the skin surface.
• The foramen may be plugged with poly ethylene plug.
47. Brauns trans-antral approach
• An intra oral incision is made from the maxillary tubarosity to the
midline of vestibule.
• Mucoperiosteal flap is reflected to anterior and lateral maxillary wall.
• A 3 cm window is created, the lining of the posterior superior portion of
the antrum is carefully exised..
48. • Complications
(i) inadvertent section of the vessels in the pterygopalatine fossa
• (ii) inadvertent sectioning of the branches of the sphenopalatine
ganglion entering the posterior aspect of the ganglion.
57. Extra-oral approach
• Risdons incision,where after reflection of masseter , a bony window is
created in Outer cortex and nerve is reflected with nerve hook and is
avulsed from its superior attatchment.
• mental nerve is avulsed anteriorly through the same approach
58. Intra-oral apprroach
• Dr GINWALLAS incision.: incision is made along anterior border of
ascending ramus, extending lingualy and buccaly in a fork like an
inverted “Y”.
• The incision is deepend on the medial aspect of ascending ramus .
• Temporal and medial pterygoid muscles are split and INFERIOR
ALVEOLAR NERVE IS LOCATED.
59. Lingual neurectomy
• A vertical incision is made at the inner border of the ascending ramus,
extending from the coronoid process down the level of the floor of the
mouth.
• nerve lies even more superficially and it can be easily found between
the anterior pillar of the fauces at the root of the tongue.
• After dissection, the nerve is grasped with a hemostat and is then
either avulsed or cauterized and cut.
63. • 1900, first open surgeries done on gasserian ganglion for trigeminal
neuralgia.
• 1910, harris , hartel introduced approaches to ganglion via foramen
ovale.
• 1931, kirschner introduced percutaneous electrocoagulation of
gasserian ganglion.
64. Radio frequency
thermocoagulation
• Percutaneous radiofrequency thermal lesioning of the trigeminal nerve
was repopularized by Sweet and Wepsic in 1974
• It preserves motor function of trigeminal nerve.
• Lower recurrence rate
• well tolerated by elderly and medically compromised patients.
65. • Principle- This technique is based on the findings that the compound
action potentials of nociceptive fibers (A-d and C fibers) in nerves are
blocked at lower temperatures than those of larger A-a and A-b fibers
carrying tactile sensations.
66.
67. • A ALTERNATING CURRENT OF HIGH FREQUENCY CAUSES IONISATION
OF BIOLOGICAL TISSUES . WHICH FURTHER LEADS TO COAGULATION
OF TISSUES.
68. Percutaneous glycerol
chemoneurolysis
• Percutaneous chemoneurolysis with glycerol was introduced in 1981 by
Hakanson.
• Glycerol, a mild neurolytic, provides excellent pain relief while largely
sparing trigeminal nerve function in most patients.
• pure anhydrous (99.5%) glycerol is instilled into the trigeminal cistern.
69. Balloon compression
• Percutaneous balloon compression of the gasserian ganglion with a
balloon catheter was introduced by Mullan and Lichtor in 1983
• a technique to traumatize the trigeminal ganglion and preganglionic
rootlets mechanically using a percutaneously inserted balloon-tipped
catheter.
• It is then inflated using a radiopaque contrast agent to a predetermined
pressure to compress the neural structures.
• 1.3 – 1.5 atm pressure.
70. OPEN PROCEDURS
• MICROVASCULAR DECOMPRESSION OF THE SENSORY ROOT
• Popularized by jannetta in 1967
• Open craniotomy approach is used to gain access to the trigeminal root
entry zone and adjacent brain stem.
• Most commonly performed intra cranial procedure done to decompress
superior ceribellar artery has mortality rate of 2%
71. TRIGEMINAL ROOT SECTION
• Extradural sensory root section(fraziers approach1901)
• Intra dural root section – discribed by wilkins in1966
• less chances of damage to sup petrosal n. and facial n.
• Can cause damage to 5,7,8 cranial nerves.
72. • Trigeminal tract totomy or medullary tract totomy – done at the cervico
medullary junction
• Very useful in patients with glossopharyngeal and pharyngeal pain
distribution
• Causes loss of pain and temperature sensation in ipsilateral face and
pharynx.
73. Gamma knife radiation to the
trigeminal root entry zone GKR
• Relatively recent procedure, that employs computerized stereotactic
methods to concentrate gamma radiation on the trigeminal root entry
zone.
• It has gained wide acceptance, however long term results of GKR in TN
remain to be established. Advocated in old, frail patients.
74. Summary
• An early and accurate diagnosis of TN is important.
• Patients with TN are usually initially treated pharmacologically.
• The best treatment for the patient depends on the age of the patient,
medical comorbidities, and the risks the patient is willing to assume.
78. References
1. Toda K. Operative treatment of trigeminal neuralgia: review of current
techniques. Oral Pathol Oral Radiol Endod 2008;106:788-805.
2. Scrivani SJ, Mathews SE, Maciewicz RJ. Trigeminal neuralgia. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2005;100:527-38.
3. Liu JK, Apfelbaum RI. Treatment of trigeminal neuralgia. Neurosurg
Clin N Am 2004;15: 319–334
4. Textbook of oral and maxillofacial surgery by Neelima malik.
It is a truly agonizing condition, in which patient may clutch the hand over the face and experience severe, lancinating pain associated with spasmodic contractions of the facial muscles during attacks—a feature that led to the use of the term (its archaic name) ‘Tic Douloureux’ (painful jerking)
Trigeminal neuralgia is not a specific disease , but a symptom ellicited by pathology of 5th cranial nerve.
Lloyd, etal JOMSI 1992 ; 58;621-628
The cause of this disease process is unknown it is usually idiopathic. However , the fact that benign tumors and vascular anomalies that compress the TN root can produce symptoms clinically indistinguishable from classical tn strongly implies that injury to the nerve root is an imp initiating factor in this ds
based on the morphologic and physiologic
changes following partial nerve injury,
The condition may begin at any age, although it tends to occur more frequently with advancing age and it afflicts women somewhat more often than men.
During attack, patient grimaces with pain, clutches his hands over the affected side, stops all activities, rubs his face, which may redden or the eyes may water.
Patients may experience many attacks daily and, although they are pain-free between attacks, they live in fear of
impending pain.
Despite their repeated occurrence,
the painful spasms occur infrequently at night, and
periods of spontaneous remission are common.
Trigger zones: A TN ‘‘trigger zone’’ is an area of facial skin or oral mucosa where low-intensity mechanical stimulation (such as light touch, an air puff, or even hair-bending) can elicit a typical pain attack. TN trigger zones are typically only a few millimeters in size and are nearly exclusively found in the perioral region.
An accurate history is paramount for proper diagnosis, because physical findings are minimal or absent; few syndromes are as consistent and no other condition has this
Diagnosis is made from well taken history
White and Sweet made a significant contribution by articulating precise diagnostic criteria for TN.
Classic TN is the most common idiopathic form of the disorder (although it also includes cases associated with vascular compression).
Symptomatic TN has the same key features
of TN but results from another disease process (such as multiple sclerosis or a cerebellopontine angle tumor).
A detailed intraoral examination of the dentition, oral cavity, oropharynx, salivary glands, and associated oral structures should be performed to rule out any odontogenic or nonodontogenic source for the pain
• Always begin injections at surface site of pain and then move proximally. For example, if the pain is perceived in the lower lip, then inject lower lip, then mental nerve and then inferior alveolar nerve.
• Inject 0.5 cc of normal saline at test site. Wait for
5 minutes. If pain is relieved, then psychogenic pain
is likely.
• If the pain persists, then inject 0.5 ml of 2 percent
lignocaine without adrenaline at surface site and
wait for 5 minutes. If pain is relieved, then direct
therapy at small nociceptor fibers.
• If the pain persists–inject little deeper and wait for 5
minutes. If pain is relieved, then consider musculoskeletal
origin of pain.
• If pain is not relieved, inject at more proximal portion
of nerve—If pain is relieved, direct therapy at site,
when relief occurred.
• Thus, selective inferior alveolar, lingual, buccal,
infraor bital, posterior superior alveolar blocks can
be given to know the involvement of the branch of
the trigeminal nerve.
Carbamazepine is highly specific in only relieving pain of TN and not any other type of facial pain. It has, therefore, suggested that its response can be used as a diagnostic indicator.
Carbamazepine
MRI
Mathews and Scrivani40 have proposed a simple
algorithm for the differential diagnosis and management
of TN
Today trigeminal neuralgia is usually treated with drugs called anti-convulsants, Modification of
the Paroxysmal Pain at Cortical Level which include
Bourguignon (1942), used anticonvulsant phenytoin to effectively control attacks of pain in TN.
Blom (1962), showed a response to anticonvulsants
Anti-convulsants are thought to reduce TN attacks by decreasing the hyperactivity of the trigeminal nerve nucleus in the brain stem
Today trigeminal neuralgia is usually treated with drugs called anti-convulsants, Modification of
the Paroxysmal Pain at Cortical Level which include
Bourguignon (1942), used anticonvulsant phenytoin to effectively control attacks of pain in TN.
Blom (1962), showed a response to anticonvulsants
Anti-convulsants are thought to reduce TN attacks by decreasing the hyperactivity of the trigeminal nerve nucleus in the brain stem.
Treatment - initiated with one drug such as Tegretol or Neurontin.
The dose is increased as needed and tolerated.
If any single drug proves ineffective, alternative drugs may be tried alone or in combination with other drugs.
Medical therapy is initially effective for most patients with TN.
Surgical treatments are then considered.
Currently, carbamazepine is the initial drug of choice for the management of trigeminal neuralgia [26–28] because it controls the pain in approximately 90% of patients
100 mg twice daily with meals, increasing by 100 mg every other day until pain control is achieved or toxicity develops.
The gradual increase in dosage allows many patients to tolerate large doses of this medication.
Response to medication and clinical side effects are the most useful dosing indicators; blood levels do not correlate well with
clinical response.
Twenty percent to 40% of patients treated with carbamazepine experience drug-related side effects,
The most common idiosyncratic side effects are hematologic, including neutropenia, thrombocytopenia, and, rarely, aplastic anemia
A baseline complete blood cell count and liver and renal function tests should be obtained before initiating carbamazepine therapy. These studies should be repeated at 2-week intervals initially and then periodically thereafter. Carbamazepine should be discontinued if the peripheral white blood cell count drops below 3000 cells/lL or if side effects become intolerable.
Oxcarbazepine, a derivative of carbamazepine, is a newer drug that is reported to have similar clinical effectiveness but fewer side effects than carbamazepine [29,30].
Because there are fewer side effects, higher doses of oxcarbazepine are often tolerated. Patients with trigeminal neuralgia refractory
to carbamazepine have demonstrated a good response when they were switched to oxcarbazepine.
Clonazepam, a benzodiazepine derivative, has been used in the treatment of trigeminal neuralgia since 1975 [19].
clinical efficacy in 60% to 70% of patients with trigeminal neuralgia [17,18].
A typical maintenance dose of clonazepam for trigeminal neuralgia is 6 to 8 mg/d. S
sedation, which is the major dose-related side effect, limits its usefulness
Phenytoin may also be administered intravenously to treat severe exacerbations of TN.
Less effective than carbamazepine, may be useful in many patients because it has lower toxicity [31].
Patients who have obtained effective pain relief while on carbamazepine but can no longer tolerate it seem to be the best candidates for phenytoin.
Can be used in conjunction with carbamazepine.
Plasma levels are useful for dosage regulation and to avoid toxicity.
Because only 25% to 60% of patients achieve satisfactory control [31
A morbilliform rash can commonly occur.
Baclofen, a gamma-aminobutyric acid (GABA) agonist, has some efficacy in the treatment of trigeminal neuralgia [24,25,32]. There seems to be a synergism between baclofen and either carbamazepine or phenytoin; therefore, combination therapy in specific cases is a reasonable option [33].
The initial dose is 10 mg three times daily. The dose should be increased incrementally until pain relief is achieved or toxicity is encountered.
Baclofen is typically well tolerated and does not have the potentially life-threatening side effects of carbamazepine or phenytoin.
Gabapentin (Neurontin) has apparently been widely promoted for the treatment of trigeminal neuralgia,
its effectiveness in classical trigeminal neuralgia is low, probably less than 10%. It is more useful for deinnervation and
dysesthetic pain syndromes.
Peripheral local anesthetic block. Many clinicians find that a standard local block that anesthetizes the facial region containing the trigger often results in an immediate reduction in TN attacks. The local anesthetic block frequently allows the patient to talk and provides a practical way for the clinician to get a full history before making decisions regarding definitive treatment. Local anesthetic blocks have also been reported to potentially eliminate the bouts of pain for prolonged periods of time, outlasting the duration of the particular anesthetic agent utilized
Intravenous lidocaine. A standard loading dose of 100 mg infused at 20 mg/min has few contraindications, and rapidly provides a therapeutic blood level associated with symptomatic relief. This effect is relatively transient, however, because the drug redistributes in tissue. Although often highly effective, intravenous infusions of lidocaine carry additional risks. These treatments should be administered only where monitoring and emergency care are available.
Intravenous AED. initial treatment with a parenteral ‘‘loading’’ dose of an AED. Intravenous drug therapy also should be administered only where monitoring and emergency care are available.
Analgesic medication. Patients with unrelieved TN pain attacks are frequently given opioid and nonopioid analgesics as part of the therapeutic regimen. These medications are largely ineffective in TN, given the nature and quality of pain attacks. The present authors believe standard analgesics should be avoided in this patient group.
It has got the potential to have sound treatment for intractable V2 neuralgia, because of the direct access and visualization it provides.
Careful dissection is now performed to expose the descending palatine branches of V2, which are then traced superiorly to the sphenopalatine ganglion
In order to provide anatomical verification, the infraorbital nerve is identified in the roof of the maxillary sinus and is carefully
followed posteriorly to the trunk of V2 near the sphenopalatine ganglion.
Dissection is then completed by isolating and identifying the trunk of V2 superiorly and
posteriorly to the sphenopalatine ganglion. The trunk
of the maxillary nerve (V2) is then sectioned posterior
to the sphenopalatine ganglion near the foramen rotundum
and close to the inferior orbital fissure
or the vidian nerve
Fig. 1. Coronal Tl-weighted MRI shows round trigeminal nerve (arrows) at the root entry zone with signal
similar to the surrounding brain tissue. There is no significant lesion or vascular contact or compression in this
patient. (P, pons; T, temporal lobe; I, interpenduncular cistern; and Th, third ventricle.)
Fig. 2. Patient is 60-year-old women with MS for more
than 10 years and new onset of trigeminal neuralgia. T2-
weighted MRI shows hyperintense lesions (arrows), consistent
with MS plaques, scattered throughout the white
matter. (L, lateral ventricle.)
Fig. 3. Patient is 74-year-old women with left trigeminal neuralgia in the distribution of V2. Tl-weighted
coronal (A) and axial (B) images with contrast show the left pons and the preganglionic segment are compressed
by a meningioma (arrows) arising from the surface of the left tentorium cerebelli. Removal of the
tumor relieved pain. (L, lateral ventricle; Th, third ventricle; P, pons; SS, sphenoid sinus; I, internal carotid
artery; T, temporal lobe; A, aqueduct.)
Fig. 4. Patient is 37-year-old woman with trigeminal neuralgia involving V2 and V3. T 1-weighted coronal
(A) and axial (B) images show an extraaxial lobulated mass (M) (epidermoid tumor) in the left cerebellar
pontine cistern compressing the trigeminal nerve and pons (arrow). Removal of the tumor relieved pain. (Th,
third ventricle; P, pons; SS, sphenoid sinus; T, temporal lobe.)
Fig. 5. Coronal T 1-weighted without gadolinium (A), with gadolinium (B), and axial T 1-weighted with
gadolinium ((2) images show vessel contact (arrows) the left trigeminal nerve. The vessel enhancement with
contrast (gadolinium) help to identify the vascular contact. (P, pons, T, temporal lobe.)
Fig. 6. Dolichoectatic basilar artery (arrow heads) causing
compression and displacement of the right preganglionic
segment the trigeminal nerve (arrow). (L, lateral ventricle;
Th, third ventricle; P, pons; T, temporal lobe.)
Two heavy black linen threads are then looped around the nerve using nerve hook and then divided between the 2 threads. This is done as high as possible and the upper end is cauterized, while dividing and lower end is held with the hemostat.
Another linear incision is made in the buccal vestibule overlying the mental foramen. A mucoperiosteal flap is reflected to expose the mental nerve.
It is then tied with heavy black linen just little away from the foramen. The nerve is then caught with the hemostat distal to the knot and is divided between the two.
The distal part held between the hemostat and is wound around it and the peripheral branches entering the mucosa are avulsed out. There is puckering of the skin surface seen during this procedure.
Now after the mental nerve is freed, then at the mandibular foramen, the distal part of the nerve which is held with the hemostat is pulled until the entire nerve length of the canal is avulsed out.
If any obstruction is encountered, a window may be made in the buccal cortex posterior to the mental foramen, along the level of the inferior alveolar canal and the nerve is lifted out of the canal through the window. The wound is closed
with interrupted sutures.
the dissection is continued downwards until the lingual nerve comes into view at the border of the medial pterygoid muscle. In the region of the floor of the mouth, the
The wound is closed with interrupted sutures.
Direct applications of cryotherapy probe at temperatures colder than –60ºC are known to produce Wallerian degeneration without destroying the nerve sheath itself.
For this procedure the nerve is exposed as described in peripheral neurectomy procedure and is frozen with a cryoprobe (Nitrous oxide probe) for a period of 1 to 2 minutes followed by 3 minutes thaw, to be repeated three times. The pain remission follows the procedure.
But regeneration of axons is expected. But the procedure is relatively simple.
A radiofrequency electrode that has the capacity to definitely destroy the pain fibers is used in this procedure.
RF neurolysis has been shown to induce pain remission in 80 percent of cases with a 20 percent/year recurrence rate.
Topical anesthesia with mild sedation is used.
The patient is grounded in an electronic circuit and the
22 gauge lesion probe is positioned adjacent to nerve to
be lesioned. Paresthesias are elicited to ensure proximity
to the nerve and tissue temperature is measured with the
probe tip through the probe thermocouple. Lesioning
is then carried out at 65 to 75ºC for 1 to 2 minutes.
Repositioning may be required to ensure adequate RF
wave effect on the nerve fibers.
Advantages: Low morbidity in high risk/elderly patients.
Disadvantages: Needs specific electronic armamen tarium
and reasonable patient cooperation.
Modificn of electro
22 guage probe is used .30-90 sec duration 65-75 degree current is passed
Operative room with radiology suite
Short acting sedative
Along with neuroleptic fentanyl with domperodone
The patient is placed in the supine position.
Using the Hartel technique [52], a standard 100- mm length 18- to 20-gauge needle or cannula with a stylet is inserted in the cheek approximately 2.5 cm lateral to the oral commissure and through the foramen ovale under fluoroscopic guidance
Medial side of foramen
Guide lines on the patient’s face help to orient the needle close to the foramen ovale. The entry site is 2.5 to 3 mm lateral to the corner of the mouth. Two guide lines through this point are drawn, one to a point one third of the way from the external auditory canal to the lateral canthus of the eye and another toward the medial side of the iris of the eye. A needle kept
perpendicular to both of these lines will arrive at the skull base in close proximity to the foramen ovale. Final placement through the medial end of the foramen is performed using a fluoroscope
Fluoroscopic view of a right-sided percutaneous approach to the foramen ovale. The patient’s neck is hyperextended, and the head is rotated to the contralateral side about 15( to 20
Stylet removed
Radioectrode inserted along with thermocouple
Current
Stylet removed
25 watts 40-45 volts current 120-140mA is used .
It is not known whether the glycerol works by direct chemical action or by hyperosmotic damage to the nerve
Needle puncture. Canula is left insitu
Pt is transfer to hospital bed and glycerol is injected
Pt is instructed to be in sitting position for 2 hr
Most pt relieved pain if pain persist more than 7 days procedur is repeated
14 gause needle is used
Placed ext end of fpramen ovale
Priciple- technique is based on the observation that mechanical trauma could relieve the pain of trigeminal neuralgia, often for a significant period.
effective for first-division trigeminal neuralgia because of its low risk of corneal anesthesia and
because unmyelinated fibers that control the corneal reflex are not injured by compression.
It is less likely to cause corneal anesthesia because it does not selectively impair A-d and C fibers, as does the radiofrequency thermocoagulation technique.
This operation is based on the observation made by Dandy that the cause of trigeminal neuralgia is compression of the trigeminal nerve at its root entry zone adjacent to the brain stem
The usual cause aberrantly located and elongated arterial loop;
. This approach allows dissection at the root entry zone of the trigeminal nerve and displacement of the offending vascular structure, usually by the insertion of a small synthetic sponge prosthesis
interposed between the nerve and artery.
, because therapeutic interventions can reduce or eliminate pain attacks in the large majority of TN patients.
no strict rules are set and each patient should be evaluated individually.
Surgical approaches are performed when medication cannot control pain, patients cannot tolerate the adverse effects of the medication, or in medically complex patients with polypharmacy for other conditions.
MVD is generally performed when the patient is healthy and relatively young.
PSR is performed in addition to or in place of MVD, in whom posterior fossa exploration fails to reveal significant compression of the trigeminal sensory root or in whom MVD is technically infeasible.
Three percutaneous ablative procedures (radiofrequency thermocoagulation, glycerol gangliolysis, and balloon microcompression) and GKS are also performed in cases where MVD cannot be performed.
Gsk is inf to mvd and……, but superior in terms of infrequency of technical failure and incidence of complications.
Partial sectioning of the trigeminal nerve may be considered in patients who have negative explorations during a microvascular decompression or when other less invasive procedures have failed to provide adequate relief.
Peripheral procedures (cryotherapy, peripheral neurectomy, glycerol injection, and peripheral alcohol block) are usually performed in patients not suitable for or not wishing to have other procedures. Although their pain free period is relatively short and recurrence rates are relatively high, they have a low morbidity; however.
The role of stereotactic radiosurgery in the treatment of trigeminal neuralgia will be better defined in the future.