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Trigeminal neuralgia
Speaker: R2 楊芝琳
Supervisor: Dr. 林嘉祥
1. The clinical journal of pain, 18(1), 2002
2. Surgical Neurolog...
IntroductionIntroduction
Neuralgia
 Unexplained peripheral nerve pain
 The most common site: head and neck
 The most f...
Characteristics of trigeminal neuralgiaCharacteristics of trigeminal neuralgia
 paroxysms of severe, lancinating,
electri...
AnatomyAnatomy
Pathogenesis of trigeminal neuralgiaPathogenesis of trigeminal neuralgia
Uncertain
 Traumatic compression of the trigemi...
Types of Trigeminal Neuralgia
Typical TN
Atypical TN
Pre-TN
Multiple sclerosis-related TN
Tumor-related TN
Post-trau...
DiagnosisDiagnosis
Classic TNClassic TN
Atypical or mixed TNAtypical or mixed TN
A persistent and dull ache between paroxy...
TreatmentTreatment
 Medical treatment
 Carbamazepine (Tegretol) – first line
 Oxcarbazepine
 Gabapentin (Neurontin)
 ...
Mechanism of medical therapy
Surgical treatment
 Gasserian ganglion-level procedures
 Microvascular decompression (MVD)
 Ablative treatments
• Radi...
Microvascular decompressionMicrovascular decompression
(MVD)(MVD)
Mechanism of ablationMechanism of ablation
treatmenttreatment
RadiofrequencyRadiofrequency
thermocoagulation (RFT)thermocoagulation (RFT)
 CSF flow when entry Mechel’s cave
 45~90 sec. cycles of 60~90℃
 Perceiving a sharp pinprick as a light touch (hypalges...
Glycerol rhizolysis (GR)Glycerol rhizolysis (GR)
 Test dose: 0.1-0.15 ml
 0.05~0.1 ml at 3~5 min. intervals
 Total dose: 0.1~0.4 ml
 Sensory changes: pain, burning or ...
Balloon compressionBalloon compression
(BC)(BC)
 0.5~1 ml of contrast
 Pear-shape balloon
 Compression time:
1~7 min.
Stereotactic radiosurgeryStereotactic radiosurgery
(SRS)(SRS)
Peripheral proceduresPeripheral procedures
 Peripheral neurectomy
 Alcohol block
 0.5~1.5 ml of 80~100%
alcohol
 Whole branch & smaller
peripheral nerve branches...
Ganglion-level proceduresGanglion-level procedures vs.
Peripheral proceduresPeripheral procedures
Ganglion-level ablative...
Flow chart of the current practice of surgery for TN at UCLA.
ThanksThanks for yourfor your
attention!!attention!!
(a) Thermal lesion of trigeminal nerve.(a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode.(b) Misloc...
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  1. 1. Trigeminal neuralgia Speaker: R2 楊芝琳 Supervisor: Dr. 林嘉祥 1. The clinical journal of pain, 18(1), 2002 2. Surgical Neurology 66 (2006), 350–356 3. JADA, Vol. 135, 2004,1713-1717 4. 2007;334;201-205 BMJ
  2. 2. IntroductionIntroduction Neuralgia  Unexplained peripheral nerve pain  The most common site: head and neck  The most frequently diagnosed form: trigeminal neuralgia (TN)trigeminal neuralgia (TN)  Fothergill’s disease  Tic douloureux (painful jerking)  Mean age: 50 y/o  Female predominance (male : female = 1:2 ~2:3)
  3. 3. Characteristics of trigeminal neuralgiaCharacteristics of trigeminal neuralgia  paroxysms of severe, lancinating, electric shock-like bouts of pain restricted to the distribution of the trigeminal nerve  Unilaterally (right side)  The mandibular (V3) and/or maxillary (V2) branch or, rarely, the ophthalmic (V1) branch  Spontaneously attack or triggered by trigger zone & movement of the face  Seconds to minutes
  4. 4. AnatomyAnatomy
  5. 5. Pathogenesis of trigeminal neuralgiaPathogenesis of trigeminal neuralgia Uncertain  Traumatic compression of the trigeminal nerve by neoplastic (cerebellopontine angle tumor) or vascular anomalies  Infectious agents Human herpes simplex virus (HSV)  Demyelinating conditions Multiple sclerosis (MS)
  6. 6. Types of Trigeminal Neuralgia Typical TN Atypical TN Pre-TN Multiple sclerosis-related TN Tumor-related TN Post-traumatic TN (trigeminal neuropathy) Failed TN
  7. 7. DiagnosisDiagnosis Classic TNClassic TN Atypical or mixed TNAtypical or mixed TN A persistent and dull ache between paroxysms or mild sensory loss
  8. 8. TreatmentTreatment  Medical treatment  Carbamazepine (Tegretol) – first line  Oxcarbazepine  Gabapentin (Neurontin)  Lamotrigine  Baclofen  Phenytoin  Clonazepam  Valproate  Mexiletine  Topiramate Second line Others
  9. 9. Mechanism of medical therapy
  10. 10. Surgical treatment  Gasserian ganglion-level procedures  Microvascular decompression (MVD)  Ablative treatments • Radiofrequency thermocoagulation (RFT) • Glycerol rhizolysis (GR) • Balloon compression (BC) • Stereotactic radiosurgery (SRS)  Peripheral procedures  Peripheral neurectomy  Cryotherapy (cryonanlgesia)  Alcohol block Neuro- destructive procedure Surgical decompress
  11. 11. Microvascular decompressionMicrovascular decompression (MVD)(MVD)
  12. 12. Mechanism of ablationMechanism of ablation treatmenttreatment
  13. 13. RadiofrequencyRadiofrequency thermocoagulation (RFT)thermocoagulation (RFT)
  14. 14.  CSF flow when entry Mechel’s cave  45~90 sec. cycles of 60~90℃  Perceiving a sharp pinprick as a light touch (hypalgesia)  Divisional cutaneous facial flushing
  15. 15. Glycerol rhizolysis (GR)Glycerol rhizolysis (GR)
  16. 16.  Test dose: 0.1-0.15 ml  0.05~0.1 ml at 3~5 min. intervals  Total dose: 0.1~0.4 ml  Sensory changes: pain, burning or paresthesia
  17. 17. Balloon compressionBalloon compression (BC)(BC)
  18. 18.  0.5~1 ml of contrast  Pear-shape balloon  Compression time: 1~7 min.
  19. 19. Stereotactic radiosurgeryStereotactic radiosurgery (SRS)(SRS)
  20. 20. Peripheral proceduresPeripheral procedures
  21. 21.  Peripheral neurectomy  Alcohol block  0.5~1.5 ml of 80~100% alcohol  Whole branch & smaller peripheral nerve branches  External approach & intraoral method  Cryotherapy  Exposed surgically and direct application of a cryoprobe  -50~-140℃  3 cycles of 2 min. with a 5 min. thawing period in between
  22. 22. Ganglion-level proceduresGanglion-level procedures vs. Peripheral proceduresPeripheral procedures Ganglion-level ablative procedures  Similar long-term success rate  Varying degrees of sensory loss  Balloon compression: least likely to impair corneal sensation or to cause anesthesia dolorosa Peripheral procedures  High recurrence rates  No benefit over ganglion-level procedures  Reserved for emergency use
  23. 23. Flow chart of the current practice of surgery for TN at UCLA.
  24. 24. ThanksThanks for yourfor your attention!!attention!!
  25. 25. (a) Thermal lesion of trigeminal nerve.(a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode.(b) Mislocation of the electrode. (c) Expansion of thermal energy to neighboring neural structures.(c) Expansion of thermal energy to neighboring neural structures.

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