Trigeminal neuralgia
}June 8, 2021
jDr. Muhannad Al-Khatib

Trigeminal neuralgia | Here are all the important details

Trigeminal neuralgia | Here are all the important details

Table of Contents

    pain trigeminal nerve, or: facial nerve pain, or Fifth nerve pain It is severe pain affecting the face area, accompanied by muscle spasms in the same area. Episodes of facial pain — similar to an electric shock — can happen without warning, or they can be triggered by touching certain areas of the face. Although the exact cause of trigeminal neuralgia isn't fully understood, a blood vessel is often found pressing on the nerve.

    Medications, injections, surgery, and radiation may be used to treat pain. Every treatment offers benefits, and every treatment has its limitations, so it is up to you and your doctor to determine which treatment is best for you.

     

    What is trigeminal neuralgia?

    Trigeminal neuralgia

    Trigeminal neuralgia

    Neuralgia is severe pain caused by injury or damage to a nerve. The trigeminal nerve is the fifth nerve that originates from the brainstem within the skull. It is divided into three branches and then exits the skull to provide sensation and movement to the face, as they are in the figure:

    • Ocular cleavage (V1) provides sensation to the forehead and eye.
    • The maxillary division (V2) provides sensation to the cheek, upper lip, and roof of the mouth.
    • Mandibular split (V3) provides sensation to the jaw and lower lip; It also provides movement for the muscles involved in biting, chewing, and swallowing.

    When the trigeminal nerve becomes irritated, a severe pain attack results. Also known as tic doulouureux (painful facial tic) due to the uncontrollable trembling of the face caused by the intensity of the pain.

    Trigeminal neuralgia is dangerous, as it interferes with many aspects of a person's life. Typical trigeminal neuralgia involves brief episodes of severe pain, such as an electric shock, to one side of the face. This pain comes in repetitive waves that last an hour or more. At first, the patient may experience short, light episodes with periods of remission. But trigeminal neuralgia can develop, causing long, recurring episodes of burning pain.

     

    What are the symptoms of fifth nerve pain?

    Patients describe a seizure as a "pins and needles" sensation that turns into a burning or tingling pain, or as an electric shock that may last a few seconds or minutes. Everyday activities can trigger a seizure. Some patients are sensitive to certain areas of the face, called trigger areas, which when touched cause a seizure (Figure 2). These areas are usually near the nose, lips, eyes, ears, or inside the mouth. So some patients avoid talking, eating, kissing or drinking. Other activities, such as shaving or brushing teeth, can also cause pain.

    Trigeminal neuralgia usually has the following features:

    1. It affects one side of the face
    2. It can last for several days or weeks, followed by a lull for months or years
    3. Painful attacks increase in frequency over time and may become disabling

    A less common type of disorder, called atypical fifth neuritis, causes constant, less severe pain and a mild or excruciating burning. This pain sometimes occurs with electric shock-like pricks that may last a day or more. Atypical facial pain is difficult to treat.

     

    What are the causes of trigeminal neuralgia?

    Many believe that the protective sheath of the trigeminal nerve deteriorates and erodes, thus sending abnormal messages along the nerve. These abnormalities disrupt the nerve's normal signaling and cause pain. Several factors, such as aging, multiple sclerosis, and tumors, can cause this protective sheath to deteriorate. But most doctors agree that it's often caused by an abnormal vein or artery pressing on a nerve.

    Some types of facial pain can be caused by an infected tooth, sinusitis, shingles, post-herpetic neuralgia, or any previous nerve injury.

     

    Who is at risk of trigeminal neuralgia?

    Trigeminal neuralgia affects 5 out of every 100,000 people and occurs more frequently in women than in men. Patients are usually middle-aged and elderly. Some people with multiple sclerosis also develop trigeminal neuralgia.

     

    How is the diagnosis made?

    When a person first experiences facial pain, a primary care physician or . is often consulted dentist. If the pain requires further evaluation, a neurologist or neurosurgeon may be recommended. The doctor examines and touches areas of your face to determine exactly where the pain is occurring and which branches of the trigeminal nerve may be affected.

    MRI scan

    MRI scan

    The underlying causes of fifth neuralgia are rarely serious. However, the possibility of a tumor or multiple sclerosis should be ruled out. Therefore, a magnetic resonance imaging (MRI) scan is usually done. An MRI scan can detect any blood vessels pressing on the fifth facial nerve. Trigeminal neuralgia is diagnosed after careful evaluation of the patient's symptoms.

     

    Treatments for fifth nerve pain available in Turkey

    A variety of treatments are available, including medications, surgery, needle procedures, and radiation. The first treatment is medication. When medications fail to control pain or cause intolerable side effects, neurosurgeons may be consulted to discuss other procedures.

     

     Use of medicines

    Over-the-counter medications such as aspirin and ibuprofen are not effective against Fifth nerve pain. Anticonvulsants and muscle relaxants are prescribed to block pain stimuli from the nerve. These medications are the initial treatment for trigeminal neuralgia and are used as long as the pain is controlled and the side effects do not interfere with the patient's activities. About 80% of patients experience at least short-term pain relief with medication. For effective pain control, medications must be taken on a regular schedule to maintain a constant level in the blood.

    • anticonvulsants, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), gabapentin (Neurontin), phenytoin (Dilantin), lamotrigine (Lamictal), and pregabalin (Lyrica)

      The above types of treatments are used to control trigeminal neuralgia. If a medication begins to lose its effectiveness, your doctor may increase the dose or replace it with a different medication. Side effects include:

    1. drowsiness and imbalance;
    2. nausea;
    3. Skin rash.
    4. blood disorders;

    Therefore, patients are routinely monitored and undergo blood tests to ensure that the drug is at its safe therapeutic levels and that blood disorders and problems do not develop in the patient. Multiple drug therapy may be necessary to control pain (eg, Tegretol with Neurontin).

    • muscle relaxants, such as baclofen (Liorezal), are sometimes effective in treating trigeminal neuralgia. Side effects may include confusion, nausea, and drowsiness.

     

    Fifth nerve pain surgery in Turkey

    The goal of surgery is to stop blood vessels from compressing the trigeminal nerve, or to cut the nerve to prevent it from sending pain signals to the brain. The surgeries are performed under general anesthesia and involve making a hole in the skull. It is also necessary to stay in the hospital from one to two days until reassurance.

    • craniotomy

      craniotomy

      Microvascular decompression (MVD) It is a surgical procedure to gently reroute the blood vessels from compression of the trigeminal nerve by filling the vessel with a sponge. A 1-inch hole is made in the skull behind the ear, called a craniotomy. This opening reveals the attachment of the trigeminal nerve to the brainstem. There is often a blood vessel pressing on the nerve. After the nerve is released from compression, it is protected with a small Teflon sponge (Fig. 4). Sponges remain in the brain permanently.

    MVD provides immediate pain relief in 95% of patients. About 20% of patients experience a recurrence of pain within 10 years. The main benefit of MVD is that it does not cause facial numbness and if it does it is minimal. The main disadvantages are the risks of anesthesia as well as the risk of an operation near the brain.

    • Dorsal selective root cutting It is an irreversible cut of the root of the trigeminal nerve at its junction with the brainstem. A small opening is made at the back of the skull. The stimulus probe is used to locate the motor root of the nerve. The motor root that controls the masticatory muscles must be preserved. The sensory root fibers, which transmit pain signals to the brain, are severed (Figure 5). Cutting the nerve causes permanent facial numbness and should only be considered for recurrent pain that does not respond to other treatments.
    • Peripheral neurectomy It is a type of surgery that can be performed on nerve branches by exposing them to the face through a small incision in the skin. Severing the supraorbital nerve (branch of Section I v1) may be appropriate if the pain is isolated to the area above the forehead. Infraorbital nerve transection (a branch of section V2) may be performed if the pain is confined to the area below the eye along the upper cheekbone. Cutting the nerve causes complete facial numbness in the area supplied by the nerve.

     

    Radiosurgery to relieve trigeminal neuralgia

    Radiosurgery is a non-invasive, outpatient procedure that uses highly focused beams of radiation to destroy some of the nerve root fibers that cause trigeminal neuralgia. The two main technologies are Leksell Gamma Knife and linear acceleration systems such as BrainLab Novalis. A stereoscopic head frame or face mask is attached to the patient's head to precisely locate the nerve in an MRI scan and to keep the head completely still during treatment. Highly focused beams of radiation are sent to the root of the trigeminal nerve (Fig. 6). In the weeks after treatment, a lesion (lesion) appears where the radiation occurred.

    Pain relief may not occur immediately, but rather gradually and over time. As a result, patients continue to take pain relievers for a period of time. The success of radiosurgery becomes apparent when pain relievers are reduced or eliminated. After 4 weeks, about 50% of patients will experience remission without medication or with reduced medication. After 8 weeks, 75% of patients will experience remission of pain without medication or with medication reduction. Complications include facial numbness and dry eyes. In about 30% of patients, the pain recurs 3 to 5 years after treatment. Repeat radiosurgery can be effective; However, the risk of facial numbness increases.

     

    Outpatient needle for trigeminal neuralgia

    Passing a hollow needle through the cheek into the nerve

    Passing a hollow needle through the cheek into the nerve

    Needle procedures are minimally invasive techniques to access the fifth facial nerve through the face without incisions in the skin or opening the skull. It is performed with a hollow needle inserted through the skin, from the cheek to the trigeminal nerve at the base of the skull (Figure 7). The goal of radiculotomy or injection procedures is to damage an area of the fifth nerve to prevent it from sending pain signals to the brain. Damage to the nerve causes mild to severe facial numbness in that area. A degree of facial numbness is an expected consequence of the procedure and is necessary for long-term pain relief. These procedures are usually performed on an outpatient basis under local and light sedation. Also, patients usually go home the same day.

    • Radiofrequency root canal, also called percutaneous stereotaxic radiofrequency (PSR) radiculotomy, uses a heating current to selectively destroy some of the trigeminal nerve fibers that cause pain. During sleep, a hollow needle and electrode are inserted through the cheek and into the nerve. The patient wakes up and passes a low current through the electrode to stimulate the nerve. Based on your observations, the surgeon will place the suture so that the tingling occurs at the site of your painful attacks. Once the area causing the pain is identified, the patient is put back to sleep and a heating current is passed through the electrode to damage only that part of the nerve (Fig. 8a).

    PSR provides immediate pain relief for 98% of patients [1]. About 20% of patients have a recurrent episode of trigeminal neuralgia within 15 years. Medications, repeat PSR, or another surgical procedure may be considered. Complications may include double vision, jaw weakness, loss of the corneal reflex, and very rarely, painful numbness. Partial numbness of the face is to be expected in the area where the pain is. Other complications, such as blurred vision or problems with chewing, are usually temporary.

    • Use of some types of injectionA glycerol needle is similar to a PSR injection in that a hollow needle is passed through the cheek into the nerve. The needle is placed into the trigeminal reservoir (fluid-filled area of the ganglion) (Fig. 8b). Glycerol is injected into the tank to damage some of the trigeminal nerve fibers that cause pain. Since the exact location of the glycerol cannot be controlled, the results are somewhat unpredictable.

    Glycerol injections provide immediate pain relief in 70% of patients [2]. About 50% of patients experience a recurrence of soreness within 3 to 4 years. As with PSR, partial numbness of the face is to be expected and complications are similar.

    • Balloon pressure, This technique is similar to PSR in that a hollow needle is passed through the cheek to the nerve. However, it is performed under general anaesthesia. The surgeon places a balloon into the trigeminal nerve through a catheter. The balloon is inflated as the fibers produce pain (Fig. 8c). The balloon compresses the nerve, injuring the pain-causing fibers. After several minutes, the balloon and catheter are removed.

    Balloon compression provides immediate pain relief for 80% of patients. About 20% of patients experience a recurrence of pain within 3 years. Complications may include slight numbness, problems with chewing, or double vision.

     

    Clinical trials on trigeminal neuralgia

    Clinical studies are a body of research about new treatments and ideas that can be applied to treat a condition such as trigeminal neuralgia. There are still many ongoing experiments whose results must be confirmed before they can be applied and approved.

     

    review of the above

    No single procedure is best for everyone and each procedure differs in its effectiveness versus side effects. The decompression of the small blood vessels (MVD) Several radiofrequency rootstocks (PSR) have similar rates of long-term pain relief, which are the highest among the options available. In a study of nearly 100 or more patients published in the past 10 years, pain relief rates were 77% at 7 years for MVD and 75% at 6 years for PSR rhizomes. Of patients treated with radiosurgery, an appropriate treatment for those who cannot undergo MVD or who wish to avoid facial numbness associated with PSR, 60% had 5-year analgesia.

    Trigeminal neuralgia can recur in sections of the nerve that were previously empty. This can happen after all previous treatments, and may be a progression of the underlying disorder, not a recurrence.

    Frequently asked questions about trigeminal neuralgia

    Are there side effects of anticonvulsants?

    Yes, there are multiple effects, including: drowsiness, imbalance, nausea, rash, and others.

    Are over-the-counter medications like pendulum and aspirin effective in treating fifth neuralgia?

    No, these medications are not effective in treating fifth neuralgia.

    Is fifth nerve pain specific to women without men?

    No, although it affects women more than men, it affects men as well.

    What are the symptoms of fifth nerve pain?

    They often come in the form of seizures, in which the patient experiences painful and burning stings, and they often come on one side of the face.

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