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Trigeminal neuralgia is a disease of the nerve of the face called Trigeminal nerve, where the patient
experiences intense pain on one side of the face. Trigeminal nerve is the largest cranial nerve
emerging from the brain. Trigeminal nerve is responsible for carrying sensations like touch, pain,
temperature arising from face to brain. It also helps in biting and chewing by controlling the muscles
involved in these two actions.
Trigeminal neuralgia is a recurring, chronic and extremely painful condition. Patient experiences
sudden bout of extreme pain by mildest of stimuli like slight touch on the face, slight breeze or
brushing the teeth or shaving. It is also known as Prosopalgia. It was formerly known as suicide
disease as patients felt like committing suicide because of the severe pain associated with the
disease.
Treatment options for Trigeminal Neuralgia
This includes
I. Medical treatment: This includes prescribing certain painkillers and muscle relaxants for pain relief.
On a long run medical treatment becomes less effective with considerable side effects of the
prescribed drugs.
II. Surgical treatment: Once medical treatment becomes ineffective, patient of trigeminal neuralgia
has to consider the surgical option. Trigeminal neuralgia surgeries are indicated in patients who
experience the pain despite of the best medical treatment. It is more viable and effective treatment for
trigeminal neuralgia where the medical line of treatment fails to offer any relief. It includes following
methods.
1. Microvascular Decompression (MVD): It is also known as Janetta procedure. It is a type of
open surgery for trigeminal neuralgia wherein a small incision is made into ears and a small
hole in the skull. With the help of microscope the trigeminal nerve is visualized and exposed.
One can see a blood vessel either an artery or nerve compressing and irritating the trigeminal
nerve. This is moved away from the nerve and a small padding is put between the nerve and
the vessel.
MVD is the most effective surgical option for the trigeminal neuralgia. It makes the patient of
trigeminal neuralgia pain free.
Risk involved with MVD: Although MVD is a very effective surgical option for the patients of
trigeminal neuralgia; it has some risk of decreased hearing, double vision, facial numbness
and stroke in the patient.
2. Gamma knife radiosurgery: This is a least invasive surgical option for trigeminal neuralgia.
Technically, we cannot term it as a surgery as no incisions are taken on the patients body for
this procedure.
Gamma knife is a device with which a surgeon directs a focused, precise and controlled dose
of radiation to the root of trigeminal nerve where it enters the brainstem.
It damages the trigeminal nerve itself so that the nerve is unable to carry any painful stimuli.
This procedure is done on outpatient basis. And it successfully eliminates pain in most
patients.
If the pain recurs, the doctor can repeat the same procedure.
This is a risk free, nonsurgical option. So it is widely used for the patients of trigeminal
neuralgia.
Risk involved in Gamma Knife surgery: Mild tingling and numbness on the face is the only side
effect produced by Gamma Knife surgery.
3. Rhizotomy: It is a neurosurgical procedure where the nerve fibers causing facial numbness
are destroyed by the surgeon. There are different ways of doing Rhizotomy.
Glycerol injections: In this procedure the doctor inserts a needle or a tube through the
cheeks and it is guided up to the Gasserian ganglion (a point from where the trigeminal
nerve divides into three branches.) and a small amount of glycerol is injected which
damages the nerve and thus blocks the signals of any kind of pain.
Balloon compression: The trigeminal nerve is damaged by inflating the balloon with
enough pressure.
Radiofrequency thermal lesioning: In this procedure the Gasserian ganglion is
heated and damaged with the help of a mild electric current passing through the tip of
an electrode.
Above procedures are aimed at damaging the trigeminal nerve itself which is unable to carry any
painful stimuli to the brain. The patient can go home same day after undergoing the above
procedures.
This is all about the surgical ways of managing Trigeminal neuralgia. The surgical procedures do
carry some risk of side effects like numbness of the face, bleeding, difficulty in moving the facial
muscles.
the stabbing pains of trigeminal neuralgia. However, experts are not completely sure of the cause.
Pressure on the trigeminal nerve may also be caused by a tumor or multiple sclerosis.
Below is a list of known and suspected causes:
Some patients may experience bouts of pain regularly for days, weeks or months at a time. Attacks of
pain may occur hundreds of times each day in severe cases. Some patients may have periods
without any symptoms which last for months or even years.
Some patients will have specific points on their face that if touched trigger attacks of pain. It is not
uncommon for many patients to avoid potential triggering activities, such as eating, brushing their
teeth, shaving, and even talking.
Area of pain
The area of pain can be broken down into the three branches of the trigeminal nerve. In medicine the
trigeminal nerve is known as the fifth cranial nerve. It is often referred to using the Roman numeral
'V'. Below are the three branches broken down - 'V' refers to the trigeminal nerve:
Some people with trigeminal neuralgia may have just one branch affected, while others are affected
by more branches.
The pain felt by people with Typical Trigeminal Neuralgia differs from what people with Atypical
Trigeminal Neuralgia experience:
Medications are typically the first treatment for trigeminal neuralgia, and most patients respond well
and require no subsequent surgery. However, some may find that their medications become less
effective over time, or they experience undesirable side effects. In such cases injections and/or
surgery may be required.
Medications
These medications lessen or block the pain signals sent to the brain.
Anticonvulsants - normal painkillers, such as Tylenol (paracetamol) do not relieve the pain in
trigeminal neuralgia, so doctors prescribe anticonvulsant medication. Although these
medications are used to prevent seizures (epilepsy), they are effective in calming down nerve
impulses, which helps people with neuralgia.
The most common anticonvulsants for trigeminal neuralgia are carbamazepine (Tegretol,
Carbatrol), phenytoin (Dilantin, Phenytek) and oxcarbazepine (Trileptal). Doctors sometimes
prescribe lamotrigine (Lamictal) or gabapentin (Neurontin).
Sometimes the anticonvulsant begins to lose its effectiveness over time. If this happens the
doctor may either up the dosage or switch to another anticonvulsant.
Side effects of anticonvulsants include:
Dizziness
Confusion
Drowsiness
Vision problems
Nausea
Suicidal thoughts - some studies indicate anticonvulsants may be linked to suicidal thoughts in
some cases. The patient and doctor should monitor mood closely.
Carbamazepine allergy - some patients, especially those of Asian ancestry, may have a
serious drug reaction to Carbamazepine. Genetic testing may be recommended beforehand.
In many cases surgery helps, but symptoms may return months or even years later. Surgical options
for trigeminal neuralgia include:
Microvascular decompression (MVD) - this involves relocating or removing the blood vessel
which is pressing against the trigeminal nerve - at its root - and separating the nerve root and
blood vessels.
The surgeon makes a small incision behind the ear on the same side of the head where the
pain is. A small hole is made in the skull and the brain is lifted, exposing the trigeminal nerve. A
pad is placed between arteries that touch the nerve and the nerve - effectively redirecting them
away from the nerve.
If the surgeon finds no blood vessels pressing against the nerve, the nerve may be severed
instead.
MVD has a good success rate at eliminating or significantly reducing pain. However, in some
cases pain may recur.
MVD carries a very small risk of some hearing loss, facial weakness, facial numbness, and
double vision. There is an extremely small risk of stroke, and even death.
Percutaneous glycerol rhizotomy (PGR) - also called glycerol injection. A needle is inserted
through the face and into an opening at the base of the skull. Imaging guides the needle to
where the three branches of the trigeminal nerve join and a small amount of sterile glycerol is
injected. Within a few hours the trigeminal nerve is damaged and the pain signals are blocked.
Most people experience significant pain relief with PGR. However, there are cases of later
recurrences of pain. Many patients experience facial tingling or numbness.
PSR (partial sensory rhizotomy) - part of the trigeminal nerve at the base of the brain is
severed (cut). The doctor makes an incision behind the ear, makes a small hole in the skull,
and severs the nerve. As the base of the nerve is severed the patient will have permanent
facial numbness. Sometimes the doctor rubs the nerve instead of severing it.
GKR (gamma-knife radiosurgery) - a high dose of radiation is aimed at the root of the
trigeminal nerve. This results in nerve damage, which eliminates or reduces the pain. As the
damage from radiation is gradual, the patient will experience slowly improving pain relief over
several weeks. Initial benefits may take several weeks to appear.
GKR is effective for most patients, however some may experience recurrence of pain later on.