Rehabilitation of patients suffering Trigeminal Nerve Neuralgia.

---------Li Chenxiao & Carlos

Gr.14

IntroductionWhat is Trigeminal neuralgia?

Trigeminal neuralgia is sudden, usually unilateral, severe brief stabbing pain in the distribution of one of more branches of the Vth cranial nerve

The condition is the most frequently occurring of all the nerve pain disorders. The pain, which comes and goes, feels like bursts of sharp, stabbing, electric-shocks. pain

Introduction Anatomy

There are three divisions of V nerve

1. The ophthalmic (V1) supplies sensation to upper face including eyes. 2.The maxillary (V2) supplies sensation to middle face including upper teeth.

3. The mandibular (V3) supplies sensation to lower jaw including anterior two-thirds of tongue.

Introduction Clinical features Female > Male Incidence : 4.3 / 100,000 Age group : 50 - 60 years Paroxysmal recurrent pain of short duration Trigger point(s), allodynia Periods of remission Recurrent episodes of pain with progressively shorter

periods of remission Distribution of pain :– localised to Trigeminal nerve– 80% Maxillary / Mandibular combination– Right side > Left side Clinical examination : Usually normal

Rehabilitation & Treatment I.Massage Therapy

Step1.Yang Bai pointIn the frontal region, 1 finger's breadth superior to the eyebrow, aligned with the pupil when the eyes are focused forward.  Massage it by forefinger for 1-3 minutes.

Massage TherapyDizziness - Eye Disorders - Eyelid Itching - Eyelid Spasm - Facial Muscle Paralysis - Headache Frontal - Lacrimation - Lacrimation Upon Wind Exposure - Ptosis - Supraorbital Neuralgia - Vertigo - Visual Disturbances

Rehabilitation & Treatment I.Massage Therapy

Step2.Si Bai pointBelow the pupil about one finger's breadth, in a depression at the infraorbital foramen. Make an effort a little bit to Massage it by forefinger for 1-3 minutes.

Massage TherapyDizziness - Eye Deviation - Eye Disorders - Eyelid Spasm - Facial Edema - Facial Muscle Paralysis - Facial Pain - Headache - Lacrimation - Mouth Deviation - Respiratory Disorders - Trigeminal Neuralgia - Visual Disturbances

Rehabilitation & Treatment I.Massage Therapy

Step3.Jing Ming pointThe crater between the canthus and the bridge of a nose. Make an effort a little bit to Massage it for 1-3 minutes.Massage TherapyBenefits The Ears ,Benefits The Teeth, Gums And Lips ,Clears Heat Chills - Dizziness - Eye Disorders - Headache - Lacrimation - Lacrimation Upon Wind Exposure - Visual Disturbances

Rehabilitation & Treatment II. Medical Management

The goal of pharmacologic therapy is to reduce pain.

◦ Carbamazepine (Tegretol) – first line◦ Oxcarbazepine◦ Gabapentin (Neurontin)◦ Lamotrigine◦ Baclofen◦ Phenytoin◦ Clonazepam◦ Valproate◦ Mexiletine◦ Topiramate

Second line

Others

Rehabilitation & Treatment II. Medical Management

Side-effects occur in some people who take these medications, more likely if higher doses are needed.

The most common include: - drowsiness, - feeling sick, - tiredness, -dizziness. Quite often these are only temporary, so it is worth persisting with the drug if the pains

ease and side-effects are not too bad.70% of patients get adequate control.

Rarely, these medications can cause serious blood or liver problems. Therefore, tell your doctor if you develop any of the following whilst taking this drug: fever, sore throat, ulcers in your mouth, unexplained bruising or bleeding, yellowing of your skin, a rash - particularly if the rash is of small purple spots, peeling of the skin, abdominal pain, nausea or vomiting.

Rehabilitation & Treatment III. Surgical Management

A surgical procedure is recommended for patients who continue to experience severe pain or side effects from medications.

*Prior to considering surgery, all trigeminal neuralgia patients should have a MRI, with close attention being paid to the posterior fossa.

Imaging is performed to rule out other causes of compression of the trigeminal nerve such as mass lesions, large ectatic vessels, or other vascular malformations.

Neuro-destructive procedure

Rehabilitation & Treatment III. Surgical Management

Gasserian ganglion-level procedures Microvascular decompression (MVD) Ablative treatments

Radiofrequency thermocoagulation (RFT) Glycerol rhizolysis (GR) Balloon compression (BC) Stereotactic radiosurgery (SRS)

Peripheral procedures Peripheral neurectomy Cryotherapy (cryonanlgesia) Alcohol block

Surgical decompress

Neuro-destructive procedure

Rehabilitation & Treatment III. Surgical Management

There are 5 important neurosurgical procedures. Each is effective, but not always, and occasionally has to be repeated.

These procedures are: 1.Gamma Knife radiosurgery (GKRS) 2.Radiofrequency Electrocoagulation (RFE) 3.Glycerol Injection (GLY) 4.Balloon Microcompression (BMC) 5.Microvascular Decompression (MVD)

All of these procedures treat the trigeminal nerve at around the same place, close to where it leaves the brain.

III. Surgical Management 1.Gamma Knife radiosurgery (GKRS)

It is the most recent and least invasive neurosurgical treatment for trigeminal neuralgia.

Of all the surgical procedures, it is least likely to cause complications and uncomfortable new facial sensations (dysesthesias).

GKRS is a method for treating certain problems in the brain without making an incision. Two hundred-one beams of cobalt-60 radiation are focused precisely on a specific region in the brain.

In the case of TN, the target area is the trigeminal nerve, just where it leaves the brain. The treatment does not require general anesthesia, and the patient stays in the hospital for less than five hours.

The success rate is roughly 80%-85%

A single 4 mm isocenter is focused on the left trigeminal nerve for Gamma Knife treatment.

III. Surgical Management 2.Radiofrequency Electrocoagulation

It destroys nerve fibers associated with pain. A needle is inserted through the face and into the opening in

the skull for the trigeminal nerve. Once the needle is in place, an electrode is threaded through the needle until the electrode rests against the nerve root.

The electrode's position is verified by electrically stimulating

the trigeminal nerve. A current is passed through the tip of the electrode until it is heated to the desired temperature for about 70 seconds.

The heated electrode damages the nerve fibers and creates an

area of injury (lesion). If the pain is not eliminated, additional lesions may be created.

III. Surgical Management 3.Glycerol Injection (GLY)

Injection of glycerol into the gasserian ganglion is a simple and effective treatment.

Using a brief, intravenous anesthetic a needle is

introduced into the nerve in the base of the skull and a small amount of glycerol injected.

The treatment only takes a few minutes.

85%of patients achieve immediate pain relief and persisting numbness in the face is unusual and infection is rare. Recurrence rates are relatively high: about ½ will recur over 3 to 4 years. Re-injection may be performed, but glycerol injections become less effective after several are performed.

III. Surgical Management 4.Balloon Microcompression (BMC)

In this treatment a small balloon catheter is introduced through the needle into the nerve in the skull base.

With the patient anesthetized the balloon is briefly

inflated to compress the nerve and then removed.

Initial pain relief is high: 93% and pain recurrence similar to radiofrequency treatment, about 20% over a few years. Numbness in the face, unfortunately is high (72%). Infection again is a hazard

0.5~1 ml of contrast Pear-shape balloonCompression time: 1~7 min.

III. Surgical Management 5.Microvascular Decompression (MVD)

It is the operation recommended for a healthy person who does not want numbness of the face and is willing to accept a major operation entering the skull. It relieves trigeminal neuralgia by placing a small pad between the trigeminal nerve and the blood vessels next to the nerve.

The operation requires making an incision in the back of the head, creating a small hole in the skull, and lifting an edge of the brain to expose the trigeminal nerve which is located approximately two inches deep. The incision is made behind the ear on the side of the head where the patient feels pain.

The blood vessels that press on the nerve when the nerve leaves the brain are exposed and pushed away from the nerve. A small pad is inserted between the nerve and the vessels. This relieves the pain in most patients.

Results of Surgery 95-99% Excellent Pain Control

Immediately 75-80% Cure Rate 20-25% Recurrence usually between

1year and 3 years post-operative 5% Complication Rate

THANK YOU~