What is trigeminal neuralgia?
Trigeminal neuralgia is characterized by intense, stabbing pain in the face, and is considered one of the worst pains that can occur in humans.
What is trigeminal neuralgia due to?
Classical trigeminal neuralgia is due to abnormal function of the trigeminal nerve (5th cerebral conjugation) and is usually caused by pressure in the nerve from a neighbouring vesel, in the area of its release from the brain stem. This triggers trigeminal nerve irritation and abnormal discharges that make the quality of pain as if an electrical current is passing through the trigeminal nerve. However, it may also be due to Tumors or multiple sclerosis, but usually its symptomatology differs and is characterized as atypical trigeminal neuralgia.
What are the characteristics of classical and atypical trigeminal neuralgia of the trigeminal nerve?
The characteristics of the pain in our face help us to diagnose the trigeminal neuralgia correctly and this is crucial for the choice of treatment for optimal management of patients.
The characteristics of pain in classical trigeminal neuralgia are:
1.The pain distribution follows the three branches of the nerve
2. It is episodic, that is, pain comes and goes away from time to time
3. Pain is like electricity
4. It has trigger points, that is, the pain starts with chewing or speech, etc.
5. Neurological examination is normal
6. It responds to Carbamazefine (Tegretol) therapy
The characteristics of pain in atypical trigeminal neuralgia are:
1. Continuous pain without pain free intervals
2. Burning feeling
3. The distribution is not anatomically related to nerve distribution,
4. Pain can pass the middle line of the face
Trigeminal neuralgia - DIAGNOSIS
How to diagnose trigeminal neuralgia?
The diagnosis of trigeminal neuralgia is based on the patient's detailed history in conjunction with brain magnetic resonance imaging (MRI).
Magnetic resonance imaging is carried out for two reasons:
1. Detection of the blood vessel that presses the nerve in its exit region from the brain stem and
2. To exclude another underlying pathology, such as a brain tumour or demyelinating disease (Multiple Sclerosis)
Trigeminal neuralgia - TREATMENT
What is the treatment for Trigeminal neuralgia?
In principle, the pharmaceutical treatment is Tegretol, Gamapentin or Lyrica.
In the event of inadequate pain relief or serious side effects from medication, alternative therapies based on the history, age, co-occuring medical problems, and the patient's personal choice are considered. Detailed information on the benefits and possible complications of treatment option should be provided to the patient.
The invasive treatments for Trigeminal neuralgia which are available to us are:
1. Transdermal, nerve-damaging techniques using radio frequency, glycerol, balloon or radiosurgery
2. Anatomical, such as microvascular decompression of the trigeminal nerve
More specifically, transdermal techniques aim at the Gasserian ganglion at the base of the skull. They are performed with a needle-guided by x-ray, and either radio frequency is applied, drugs are injected, or an expanding balloon is applied, causing partial nerve disabling or destruction. It is contraindicated for trigeminal neuralgia of the first branch because there is a risk of hypoaesthesia in the eye and the cornea.
is the application of targeted high-energy radiation, 5-8mm from the trigeminal nerve exit area from the brain stem. The goal is to cause a nerve injury such as to stop the pain but not to lose its function, that is, not to change or lose sensation in the face. The success rate of Radiation Surgery for trigeminal neuralgia depends on the dose of radiation and ranges from 58-83%. The rate of face dysaesthesia varies from 2-4% at lower doses, and at 15% at higher doses of radiation.
Microvascular decompression of the trigeminal nerve is a more invasive intervention for treating trigeminal neuralgia, but it is an anatomic operation that does not normally cause destruction to the nerve. The aim is to move the blood vesel that presses the trigeminal nerve in its exit area so that there is no pressure and irritation. It is a 3 cm diameter hole in the back of the skull. Hospitalization lasts 2-3 days. The surgery has a 90% success rate, with the risk of 10% recurrence in 8-10 years. The rate of complications ranges to 3%.
How will I choose which treatment is right for me?
Always the first choice for treating trigeminal neuralgia is pharmaceutical.
If trigeminal neuralgia does not adequately respond to medication, or its side effects are serious, then the choice of optimal invasive treatment is based on the age of the patient, the type and location of trigeminal neuralgia, co-morbidity and patient preference for a particular treatment. All of the above should be considered and explained by your doctor, along with the benefits and possible side effects, complications of each treatment.
Contact us to let you know about the alternative treatments for your problem in detail.