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Trigeminal neuralgia
Understanding Trigeminal Neuralgia


Trigeminal Neuralgia


Trigeminal neuralgia, also known as tic doloreaux, is a painful condition of the face that comes from problems affecting the trigeminal nerve. The diagnosis of trigeminal neuralgia is made by patient history and description of symptoms, as there is no test that can conclusively diagnose this condition. MRI can be useful and is essential before treatment decisions are made to exclude other conditions. It can only infrequently suggest true trigeminal neuralgia (a small artery pressing on the trigeminal nerve at the brainstem, see above image) because the vessel is so small and often missed on the MRI. Because it is diagnosed by patient description (symptoms), it can be easily misdiagnosed. Diseases such as multiple sclerosis, herpes simplex viral infections (cold sores), herpes-zoster (shingles), dental disease, and tumors of the trigeminal nerve or nearby structures, can all cause the same symptoms. Futhermore, many patients with true trigeminal neuralgia are misdiagnosed with other problems. and have undergone treatment for supposed herpes-zoster, herpes simplex, and dental disease. I have personally seen many patients who have had multiple dental procedures including root canals and multiple extractions.

Becasue trigeminal neuralgia is diagnosed by symptoms, it is generally classified into "typical trigeminal neuralgia" and "atypical trigeminal neuralgia" to differentiate those patients that might be a candidate for surgery. Typical trigeminal neuralgia presents with new sudden onset of sharp, jabbing, electrical type of pain on one side of the face, and generally in only one part of one side. The trigeminal nerve has three divisions on each side of the face, and although all three can be involved, it usually only affects one, or at times two adjacent divisions of the nerve. The three divisions include the frontal (forehead), the maxillary (cheek and upper teeth), and mandibular (jaw/chin and lower teeth). In atypical trigeminal neuralgia, the pain is burning, aching, searing and involves the entire side or is present on both sides of the face. Typical trigeminal neuralgia often has a very memborable onset and patients can often remember the onset even years later. Typical trigeminal pain is triggered by very mild stimuli such as wind or water on the face, touching the face, brushing teeth, chewing/swallowing, and smiling or movement of the face. Atypical trigeminal neuralgia does not have triggers. Finally, typical trigeminal neuralgia more often than not will respond favorably to Tegretol, the mainstay of medical (non-surgical) treatment. If your face pain responds to Tegretol, outcomes with surgical treatment are more favorable. Atypical trigeminal neuralgia may or may not respond to Tegretol.

For those with very typical trigeminal neuralgia, in whom other potential causes have been excluded (dental, multiple sclerosis, herpes simplex or zoster, tumors), there are three surgical alternatives. The primary surgery that gets directly to the cause, a small artery or vein direclty compressing the trigeminal nerve as it exits the brainstem (see picture above), is called a retromastoid craniectomy and microvascular decompression of the trigeminal nerve. This is done under general anesthesia and takes about two hours. You would be in the hospital for about 3 days. It is done through a small 1" to 2" incision behind the ear, a bone opening about 1" across, and through a microscope. After the trigeminal nerve is identified, the vessel compressing the nerve is mobilized off the nerve and held away from the nerve with a small teflon pledget. This procedure was developed and pioneered by Peter J. Jannetta in Pittsburgh, with whom I trained for 7 years. The success rate is 70 to 75% at 10 years (complete pain relief on no medications). In my opinion, this is the ideal procedure with the highest long-term cure rate.

Other options for atypical pain, patients not healthy enough for the brain procedure, and those with other reasons for pain (multiple sclerosis, herpes-zoster, nerve injury after dental procedures) incude gamma-knife radiosurgery (very focused radiation to injure the nerve and make it less painful) and glycerol rhizotomy (a very deep injection through the cheek into the trigeminal nerve that deadens the pain fibers). These are ancillary to the mainstay described above in my opinion. They do not get at the problem (at least for "typical" trigeminal neuralgia, but treat the symptoms by deadening the nerve.

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