Trigeminal neuralgia

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

Speaker: R2 楊芝琳
Supervisor: Dr. 林嘉祥
Introduction
 Neuralgia
Unexplained peripheral nerve pain
The most common site: head and neck
The most frequently diagnosed form:
trigeminal neuralgia (TN)
 Fothergill’s disease
 Tic douloureux (painful jerking)
 Mean age: 50 y/o
 Female predominance (male : female = 1:2 ~2:3)
Characteristics 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
Anatomy
Pathogenesis 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)
Types of Trigeminal Neuralgia

 Typical TN
 Atypical TN
 Pre-TN
 Multiple sclerosis-related TN
 Tumor-related TN
 Post-traumatic TN (trigeminal neuropathy)
 Failed TN
Diagnosis
Classic TN

Atypical or mixed TN
A persistent and dull ache between paroxysms or mild sensory loss
Treatment
 Medical treatment
 Carbamazepine (Tegretol) – first line
 Oxcarbazepine
 Gabapentin (Neurontin)
 Lamotrigine Second line
 Baclofen
 Phenytoin
 Clonazepam
 Valproate Others
 Mexiletine
 Topiramate
Mechanism of medical therapy
 Surgical treatment
Gasserian ganglion-level procedures
 Microvascular decompression (MVD) Surgical
decompress
 Ablative treatments
• Radiofrequency thermocoagulation (RFT)
• Glycerol rhizolysis (GR)
• Balloon compression (BC)
• Stereotactic radiosurgery (SRS)
Neuro-
Peripheral procedures destructive
 Peripheral neurectomy procedure

 Cryotherapy (cryonanlgesia)
 Alcohol block
Microvascular decompression
(MVD)
Mechanism of ablation
treatment
 Radiofrequency
thermocoagulation (RFT)
 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
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 paresthesia
Balloon compression
(BC)
 0.5~1 ml of contrast
 Pear-shape balloon
 Compression time:
1~7 min.
Stereotactic radiosurgery
(SRS)
Peripheral procedures
 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
Ganglion-level procedures vs.
Peripheral 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
Flow chart of the current practice of surgery for TN at UCLA.
Thanks for your
attention!!
(a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode.

(c) Expansion of thermal energy to neighboring neural structures.