Trigeminal neuralgia 2_
- 1. TRIGEMINAL NEURALGIA Presented by Wita I.Septina Supervised by Harmas Yazid Yusuf, drg. SpBM
- 2. INTRODUCTION • Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve. • Incidence 4-5 cases : 100.000 • TN or Tic douloureux occur patients > 50 years. • Male : Female ratio 2 : 3 • Unilateral (97%). Most affected V2 and V3. • The pain is intense, usually sharp, electric shocklike pain in face, lasting periods of seconds to 2 minutes ,
- 3. ANATOMY TRIGEMINAL NERVE • Cranial Nerve V o Sensoric e Portio major o Motoric Portio minor o Sensoric + motoric n Gasseri
- 4. Fig 1. DistributionTrigeminal nerve
- 5. CLASSIFICATION 1.Typical Trigeminal Neuralgia (Tic Douloureux) • Most common form of TN • Caused by blood vessels compressing the trigeminal nerve root enters the brain stem • Irritation from repeated pulsations t caused hyperactivity of the trigeminal nerve nucleus p resulting TN pain • Fig 2
- 6. (a) (b) (c) Fig 2. Anatomy Trigeminal nerve and Trigeminal neuralgia
- 7. CLASSIFICATION 2. Atypical Trigeminal Neuralgia • Unilateral • Prominent constant • Boring or burning pain • Caused by vascular compression upon a specific part of trigeminal nerve (portio minor) • A more severe from or progression of typical TN
- 8. CLASSIFICATION 3. Pre - Trigeminal Neuralgia Symptoms : odd sensations of pain or discomfort before the first attack of TN pain 4. Multiple Sclerosis-Related Trigeminal Neuralgia • The symptoms & characteristics identical o • 2 - 4% patients with TN have multiple sclerosis (MS) • MS formation of demyelinating plaques within the brain • First attack of pain y younger patients , bilateral
- 9. CLASSIFICATION 5. Secondary Trigeminal Neuralgia • Caused by a lesion (tumor) • A tumor y compresses or distorts the trigeminal nerve facial numbness, weakness of chewing muscles, constant pain • Fig 3. 6. Post-Traumatic Trigeminal Neuralgia • Develop following cranio-facial trauma, dental trauma, sinus trauma, destructive procedures (rhizotomies) • Injury t cold, start immediately or days to years following injury
- 10. Fig. 3 MRI--- Tumor compressed trigeminal nerve
- 11. CLASSIFICATION 7. Failed Trigeminal Neuralgia Medications, microvascular decompression, and destructive rhizotomy procedure ineffective in controlling TN pain
- 12. ETIOLOGY 1.Blood vessels compression at the trigeminal nerve root – Demyelination nerve – A tumor compresses trigeminal nerve – Injury to the trigeminal nerve – Un known
- 13. Clinical Features 1. Severe paroxysmal pain – The pain intense, stabbing, electrical shock- like, one side – Frequently pain free between attacks. – Lasting only seconds to two minutes – Each attack spontaneously or be triggered by specific light stimulation – Common triggers include touch, talking, eating, drinking, chewing, tooth brushing, hair combing and kissing.
- 14. Fig. 4 Progression of Trigeminal Neuralgia
- 15. DIAGNOSIS • Anamnesis • Clinical examination • CT scan and MRI • MRIA
- 16. Differential Diagnosis 1.Glossopharyngeal neuralgia – Occipital neuralgia – Paroxysmal hemicrania syndromes – Migraine and cluster headaches – Trigeminal neuropathy
- 17. TREATMENT • Medication • Surgical procedure
- 18. TREATMENT Medication • Carbamazepin (Tegretol) o Anticonvulsants, Drug of choice for TN, effective dose 600 -1200 mg/ day for 3-4 x/ day o Maintenance dosage 200 mg/d to prevent recurrences o Side effect : drowsiness, mental confusion, dizziness, nystagmus,ataxia • Oxycarbazepine (Trileptal) o Side effect : nausea, fatique, tremor o Dose : 2 x 300mg, maximum dose : 2400-3000 mg/day
- 19. TREATMENT • Phenytoin (Dilantin) o Dose: 300-500mg/day for 3x/day • Side effect : nystagmus, dysarthria, gingival hyperplasia, hypertrichosis, allergic skin rash • Gabapentin (Neurontin) o Dose : 1200 - 3600mg/d, initial dose ; 3x300mg/d. o Side effect : somnolen, ataxia, fatique
- 20. TREATMENT • Baclophen (Lioresal) Antispasmodic agents Initial dose : 2-3 x 5 mg/ day. Duration of action x Side effect : nausea, fatique
- 21. TREATMENT Surgical Procedure For patients e medical therapy has failed surgery is a viable and effective option • Microvascular decompression • Nerve Injury/ Destructive Procedure (Rhizotomy) 1. Percutaneus Glycerol Rhizotomy • Percutaneus Balloon Compression Rhizotomy • Radiofrequency Rhizotomy • Stereotactic Radiosurgery (Gamma Knife) • Microsurgical Rhizotomy
- 22. TREATMENT • Microvascular decompression o non-destructive technique o Under general anesthesia, incising the skin behind the ear (Craniotomy) o Identify an arterial loop compressing the nerve n pad the vascular structure with Teflon felt o Complication: CSF leaks, hearing loss, permanent anesthesia over the face
- 23. TREATMENT • Nerve Injury/ DestructiveProcedure (Rhizotomy) 1. Percutaneus Glycerol Rhizotomy The surgeon introduces a trocar or needle lateral to the corner of the mouth into foramen ovale l glycerol–ganglion Gasseri f nerve injury 2. Percutaneus Ballon Compression Rhizotomy Under general anestesia – operator insert a balloon catheter through the the foramen ovale r the region of the ganglion
- 24. TREATMENT 3. Radiofrequency Rhizotomy Intravena sedation h electroda insert to ganglion electroda to heat thermal injury r to ganglion 4. Strereotactic Radiosurgery (Gamma Knife) Gamma Knife Radiosurgery g stereotactic MRI, determined radiation dose to guickly relief pain without facial sensory loss 5. Microsurgical Ryzotomy
- 25. CONCLUSION • Trigeminal Neuralgia (TN) is neuropathic facial pain arising from the trigeminal nerve. • Treatment for TN n initial therapy if pharmacologic treatment fails l surgical procedure.