to CME Presentation on

Trigeminal Neuralgia,
DR. FAKHRUL IMAM
FCPS PART II TRAINEE
ORAL & MAXILLOFACIAL SURGERY
DEPARTMENT,
DHAKA DENTAL COLLEGE HOSPITAL

What is TN
Recurrent attacks of lancinating pain in the

distribution of a trigeminal nerve division.

It is considered to be the worst pain known to man.
In severe cases in gives rise to suicidal tendency to
the sufferers.

Some Facts about TN

Prevalence (approximate): 1 per 15,000.
Age mainly affected: 5070 year age group.
Gender mainly affected: F > M

Types of TN
According to TNA :
1) Classical TN or Primary TN 0r ITN
2) Symptomatic TN or secondary TN

Etiopathogenesis
Of TN

FIGURE : Transverse sections of a peripheral nerve (A) showing the outermost

epineurium, the inner perineurium that collects nerve axons in fascicles, and the
endoneurium that surrounds each myeli-nated fiber. Each myelinated axon (B) is
encased in the multiple membranous wrappings of myelin formed by one Schwann
cell, each of which stretches longitudinally over approximately 100 times the diameter
of the axon. The narrow span of axon between these myelinated segments, the node of
Ranvier, contains the ion channels that support action potentials. Nonmyelinated
fibers (C) are enclosed in bundles of 5 to 10 axons by a chain of Schwann cells that
tightly embrace each axon with but one layer of membrane.

Etiopathogenesis
Trigeminal neuralgia (TN) appears to result from
demyelination causing abnormal nerve signal transmission. In
9095% of cases, no neurological lesion is identied, and the
condition is then labeled ITN. The cause of ITN may be the
superior cerebellar artery becoming atherosclerotic and less
exible, pressing on the trigeminal nerve roots in the posterior
cranial fossa, damaging the myelin sheath.Demyelination may
also be caused by multiple sclerosis (MS), cerebrovascular
disease with pontine or medullary infarcts, neoplasms,
aneurysms, cysts, trauma, infections, deposits such as
amyloidosis or other causes (secondary TN). Some 2% of
patients with MS develop TN. Hypertension is increased in
patients with TN.

Clinical Features
International Headache Society (IHS) denes the
characteristics of TN as paroxysmal attacks of pain
which last a few seconds to < 2 minutes, especially in
the morning, rarely at night, as the disease progress
pain becomes more severe & prolonged in duration.
Right side is commonly affected with involvement of
Infraorbital nerve & Mental nerves.

Typical TN pain has the

following features:
intermittent
unilateral or Bilateral (10-12% cases)
distribution along one or more trigeminal division
a sudden severely intense, sharp supercial, stabbing or burning
quality or constant, dull burning or aching pain, sometimes with
occasional electric-shock-like stabs
absence of no sensory or motor deficiency
definative trigger areas or daily activities affecting the trigeminal area
such as eating, swallowing, talking, smiling, washing the face, shaving,
cleaning the teeth. Emotional or physical stress can increase the
frequency and severity of TN attacks.

Differential Diagnosis
Cluster headaches,
Causalgia,
Post-herpetic neuralgia,
glossopharyngeal neuralgia,
Mixed connective tissue disease (MCTD),
idiopathic facial pain,
dental problems,
MS,
Lyme Disease,
HIV,

Investigations
Imaging: Most physicians recommend elective MRI (gives
better of brain stem and cranial nerves than CT) of the entire
trigeminal nerve for all patients and it is certainly mandatory
if atypical features are present.
Blood tests:
Erythrocyte sedimentation rate (ESR) to exclude vasculitides,
Anti-RNP antibodies for MCTD, and serology for Lyme
disease or, rarely, HIV.
Only if all imaging and blood investigations prove negative can a
diagnosis of ITN be made

Management
Noninvasive treatment:
carbamazepine, Oxcarbamazepine, clonazepam, phenytoin,
gabapentin,topiramet, lamotrigine, pregabaline, valproic acid, Capsaicin.
Drug therapy should be slowly withdrawn if a patient remains pain free
for 3 months.
low intensity low frequency surface acoustic wave ultrasound
(painshield)
Invasive Treatment:
Injections: absolute Alcohol, Glycerol, streptomycin with or without LA.
Surgical OptionsPeripheral nerve surgery- cryosurgery, peripheral rhizotomy,
radiofrequency thermocoagulation.

Percutaneous approaches

inserting a needle through the face into the skull for

trigeminal gangliolysis, percutaneous radiofrequency
trigeminal gangliolysis (PRTG), Fogarty balloon
microcompression (FBM), and retrogasserian
glycerol rhizotomy (PRGR). Gamma knife
stereotactic radiosurgery, however, is the least
invasive procedure,with a high rate of pain control.

Open surgical procedures

include posterior cranial fossa procedures

-microvascular decompression of the trigeminal root
(MVD)
-retrogasserian rhizotomy

Thank you