TRIGEMINAL NEURALGIA Dr J Keaveny BEUAMONT HOSPITAL SPORTS SURGERY - - PowerPoint PPT Presentation

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TRIGEMINAL NEURALGIA Dr J Keaveny BEUAMONT HOSPITAL SPORTS SURGERY - - PowerPoint PPT Presentation

Nov 27, 2023 142 likes •748 views

TRIGEMINAL NEURALGIA Dr J Keaveny BEUAMONT HOSPITAL SPORTS SURGERY CLINIC TRIGEMINAL NEURALGIA PAIN Sensory and emotional experience with or without physical damage or the potential for such damage PAIN PHYSICAL/PSYCHOLOGICAL/SOCAL

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TRIGEMINAL NEURALGIA

Dr J Keaveny BEUAMONT HOSPITAL SPORTS SURGERY CLINIC

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TRIGEMINAL NEURALGIA

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PAIN

Sensory and emotional experience with or without physical damage or the potential for such damage

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PAIN

  • PHYSICAL/PSYCHOLOGICAL/SOCAL

PHYSICAL PSYCHOLOGICAL

SOCIAL

PAIN

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Facial Pain

regular attendee at pain clinic PHN

BURNING

TGN

SHOOTING

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Facial Pain

regular attendee at pain clinic CONSTANT INTERMITTENT

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Causes of Facial Pain

  • Sinus
  • Nose
  • Ear
  • Mastoid
  • Teeth
  • Soft Tissue Infection
  • Neurological
  • Parotid
  • Eye
  • Headaches
  • Tumours
  • Bone
  • Atypical Facial Pain
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Facial Pain

Musculoskeletal Origin

  • TMJ Disorders
  • Myofascial Pain Syndromes
  • Bony Lesions:

infection/trauma/degeneration

  • Metastatic lesions
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Atypical Facial Pain

  • Constant Pain
  • Rarely pain-free
  • Burning
  • Entire face
  • Paraesthesia
  • No trigger points
  • non-tender
  • 30years old
  • Female 75-90%
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TRIGEMINAL NEURALGIA

  • SHARP SHOOTING PAIN
  • VERY SEVERE
  • FEW SECONDS to MINUTES
  • PAINFREE INTERVALS
  • NO NUMBNESS
  • TRIGGERS

– HOT/COLD/TOUCH/WIND/EATING/TALKING

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TRIGEMINAL NEURALGIA

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TRIGEMINAL NEURALGIA

  • ALL DIVISIONS
  • 1

1%

  • 2

17%

  • 3

15%

  • 1 & 2

16%

  • 2 & 3

42%

  • 1, 2 & 3

9%

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TRIGEMINAL NEURALGIA

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TRIGEMINAL NEURALGIA

  • UNCOMMON
  • CAUSE RARELY FOUND

– VASCULAR – MS – METASTATIC DISEASE

  • MAINLY FEMALE 65%
  • OVER 40s

median 57yrs

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TRIGEMINAL NEURALGIA

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Trigeminal Neuralgia

  • Jannetta

– Mechanical compression TGN in Pons – Cross compression by major artery

  • superior cerebellar
  • posterior inferior cerebellar
  • vertebral
  • anterior inferior cerebellar

– Vein – AVM or Tumor

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Trigeminal Neuralgia

  • 16th century stone carvings
  • Johannes Bausch 1672
  • Andre “tic doloureux” 1756
  • Fothergill 1773
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Trigeminal Neuralgia

  • Poor early medical therapies

– trichloroethylene 1920s

  • Surgical procerdures early 18th century
  • Bell & Magendie early 19th

– anatomy & functions 5th & 7th nerves

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Trigeminal Neuralgia

  • Mears 1884

– surgery gasserian gnaglion

  • Sir Victor Horsley 1891

– Subtemporal retrobasserian neurectomy

  • Fraser 1901

– Suboccipital retrogasserian neurectomy

  • Sjoqvist 1937

– Trigeminal medullary tractotomy

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Trigeminal Neuralgia

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Trigeminal Neuralgia

INVESTIGATIONS

  • MRI
  • MR ANGIOGRAPHY
  • IF OTHER SYMPTOMS or < 40 yrs FULL

NEUROLOGICAL INVESTIGATION

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TRIGEMINAL NEURALGIA

TREATMENTS

  • MEDICAL

– 70% successful

  • NERVE BLOCKS
  • PERCUTANEOUS LESIONS
  • SURGERY
  • PSYCHOLOGICAL SUPPORT
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TRIGEMINALNEURALGIA

MEDICAL TREATMENT

  • ANTICONVULSANTS

– Na channel blockers – Ca channel blockers

  • ANTISPASMODICS
  • ANTIDEPRESSANTS

– Tricyclics

  • OPIATES
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Trigeminal Neuralgia

  • Carbamazepine
  • Gabapentin
  • Pregablin
  • Lamotrigine
  • Clonazepam
  • Oxcarbazepine
  • Topiramate
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MEDICATIONS TGN

  • AMITRIPTYLINE
  • DULOXETINE
  • VALAFAXINE
  • FLUOXETINE
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Anticonvulsants

  • Somnolence
  • Dizziness
  • Fatigue/tiredness
  • GI upset
  • Ataxia
  • Skin rash
  • Weight gain
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TRIGEMINAL NEURALGIA

NERVE BLOCKS

  • SUPRA-ORBITAL

6% phenol 1-2cc

  • INFRA-ORBITAL

6% phenol 1-2cc

  • MAXILLARY
  • GASSERIAN GANGLION BLOCK
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TRIGEMINAL NEURALGIA

SURGERY

  • MICROVASCULAR DECOMPRESSION
  • PARTIAL TRIGEMINAL RHIZOTOMY
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TRIGEMINAL NEURALGIA

PERCUTANEOUS TECHNIQUES

  • RADIOFREQUENCY RHIZOTOMY
  • GLYCEROL RHIZOTOMY
  • BALLOON COMPRESSION
  • GAMMA KNIFE RADIATION
  • CYBER KNIFE
  • PROTON BEAM THERAPY
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Rf Lesioning

D Buggy et al

  • PAIN DISTRIBUTION
  • Mandibular

35%

  • Maxillary

28%

  • Ophthalmic

1%

  • Mand & Max

22%

  • Ophth & Max

13%

  • All divisions

1%

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RF Lesioning

D Buggy et al

  • COMPLICATIONS
  • None

77%

  • Corneal Reflex damage

10%

  • Facial Dyseasthesia

8%

  • Minor oral bleeding

2%

  • Masseter malocclusion

2%

  • Retro-orbital bleed

0.67%

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Review of RF lesioning

  • Brisman Moraci

Beaumont Zak

  • No

157 607 150 265

  • %female 60.5% 62%

61% 60%

  • %right

58% 55% 52% 59%

  • Age

64% 65% 67% 54%

  • Duration

7.2ys 5ys 6.5ys n/a

  • %success 97% 96%

97% 99%

  • Recurrence

24% 16% 15% 50%

  • Relief

1.6ys 2.5ys 1.9ys 2ys

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TRIGEMINAL ABLATION

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TRIGEMINAL ABLATION

  • 70* X 90 SECONDS X 2
  • EACH DIVISION
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TRIGEMINAL NEUROPATHY

ATYPICAL FACIAL PAIN

  • Constant Pain
  • Rarely pain-free
  • Burning
  • Entire face
  • Paraesthesia
  • No trigger points
  • non-tender
  • 30years old
  • Female 75-90%

Cause unknown Associated conditions fibromyalgia headaches backpain dysmenorrhia

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ATYPICAL FACIAL PAIN

TREATMENT

  • ASSESSMENT
  • MINIMAL INVESTIGATIONS
  • ANTI-DEPRESSANTS
  • TRICYCLICS
  • PSYCHOLOGICAL SUPPORT
  • SYMPATHETIC GANGLION BLOCKS
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SUNCT

  • SHORT LASTING
  • UNILATERAL
  • NEURALGIFORM HEADACHE
  • CONJUNCTIVAL INJECTION
  • TEARING
  • ORBITAL/SUPRAORBITAL/TEMPORAL
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SLIDE 55

SUNCT

  • STABBING PAIN
  • 5-240 SECS
  • 3-200 ATTACKS/DAY
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SLIDE 56

SUNA

  • SHORT LASTING
  • UNILATERAL
  • NEURALGIFORM HEADACHE
  • CRANIAL AUTONOMIC FEATURE

– NASAL CONGESTION – RHINORRHOEA – EYELID OEDEMA

  • ORBITAL/SUPRAORBITAL/TEMPORAL
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SLIDE 57

SUNA

  • STABBING
  • LAST 2-10 MINS
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ATYPICAL FACIAL PAIN

TREATMENT

  • ASSESSMENT
  • MINIMAL INVESTIGATIONS
  • ANTI-DEPRESSANTS
  • TRICYCLICS
  • PSYCHOLOGICAL SUPPORT
  • SYMPATHETIC GANGLION BLOCKS
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POST HERPETIC HEURALGIA

  • COMMON
  • CAN BE DEBILITATING/SUICIDAL
  • ANTIVIRAL AGENTS EARLY

– synthetic purine analogues – inhibit activity against human herpes viruses

  • NEUROGENIC PAIN
  • TRICYCLIC ANTIDEPRESSANTS
  • ANTICONVULSANTS
  • ?CAPSACIN
  • SYMPATHETIC GANGLION INJECTIONS