A CME lecture presented by myself

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

2. 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.
 Alternate names: Tic doulorex, prosopalgia,
Fothergill’s disease.

3. Some Facts about TN
 Prevalence (approximate): 1 per 15,000.
 Age mainly affected: 50–70 year age group.
 Gender mainly affected: F > M

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

5. Etiopathogenesis
Of TN

6. 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.

11. Etiopathogenesis
Trigeminal neuralgia (TN) appears to result from
demyelination causing abnormal nerve signal
transmission. In 90–95% of cases, no neurological lesion
is identified, and the condition is then labeled ITN. The
cause of ITN may be the superior cerebellar artery
becoming atherosclerotic and less flexible, 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.

12. Clinical Features
International Headache Society (IHS) defines 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.

13. 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 superficial, 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.

14. Differential Diagnosis
 Cluster headaches,
 dental problems,
 Trigeminal neuropathy attributed to acute Herpes
zoster
 Post-herpetic neuralgia,
 glossopharyngeal neuralgia,
 Mixed connective tissue disease (MCTD),
 idiopathic facial pain
 MS

15. 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,
Only if all imaging and blood investigations prove negative can a
diagnosis of ITN be made

16. 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, Autogenous Platalet riched plasma.
Surgical Options-
 cryosurgery, peripheral rhizotomy, radiofrequency
thermocoagulation.

17. percutaneous radiofrequency trigeminal gangliolysis
(PRTG), Fogarty balloon microcompression (FBM),
and retrogasserian glycerol rhizotomy (PRGR).
Gamma knife stereotactic radiosurgery.
Open surgical procedures
include posterior cranial fossa procedures
-microvascular decompression of the trigeminal root
(MVD)
-retrogasserian rhizotomy

18. Thank you