TRIGEMINAL NEURALGIA (Tic Douloureux)

INTRODUCTION

·        It is defined as recurrent pain in the branches of fifth cranial nerve              

·        Pain is usually unilateral,severe,stabbing,recurrent type of pain 

·        It is also reffered as fothergill’s disease

ETIOLOGY

·        Dental etiology

·        Infections, Multiple sclerosis

·        Post traumatic neuralgia

·        Intra cranial tumors and vascular abnormalities

CLINICAL CHARACTERISTICS

·        Sudden unilateral intermittent paroxysmal,sharp shooting pain

·        Pain elicted by slight touching in “trigger pains”

·        Pain is of short duration and it lasts for few seconds

·        Presence of intra oral and extra oral trigger points

·        Pain does not occur during sleep

Trigger points

·        In V2 – points are located on the skin of the upper lip ,ala nasi ,or cheek

·        In V3 – trigger points seen over the lower lip,teeth ,or gums of the lower jaw

·        In V1—supra orbital ridge of the affected side

DIGNOSIS

·        “SWEET CRITERIA” for trigeminal neuralgia

1.      Pain is unilateral

2.      Pain is paraxysomal

3.       Pain is confined to trigeminal distribution (see cranial nerve blog for distribution of the nerve)

4.      Clinical examination is normal

5.      Pain is triggered by touch in the face

MANAGEMENT

·        There are two types of management

1.      Medicinal management

2.      Surgical management

Ø  MEDICINAL MANAGEMENT

1.      CARBAMAZEPINE 100 MG three times a day is given for 1-5 weeks period

2.      If carbamazepine does not control symptoms anti convulsants like sodium valporate 600 mg /day can be given

3.      When carbamazepine is contra indicated clonazepam  can be used

MULTIPLE DRUG THERAPY

·        It is given only if the patient partially responds to a single drug therapy

·        Adding a secong AED may enhance the response

 

Ø  SURGICAL MANAGEMENT

1.      Peripheral nerve injections

                                                                                       i.          Long acting local anesthetic agents with out adrenaline like bupivacaine

                                                                                      ii.          Alcohol injections like 95% absolute alcohol can be given intra orally in small quantities

2.      PHERIPHERAL NEURECTOMY

                                                                                       i.          Oldest and the effective pheripheral nerve destructive technique

                                                                                      ii.          Perforation is most common on infra orbital,inferior alveolar mental

                                                                                     iii.          Indicated in patients in whom craniotomy in contraindicated

3.      CRYOTHERAPY

                                                                                       i.          Application of cryotherapy probe at -60` C

                                                                                      ii.          Nerve is exposed and frozen with a cryo probe for period of three minutes

4.      PHERIPHERAL RADIO FREQUENCY NEUROLYSIS

                                                                                       i.          Radio frequency electrode that has capacity to break the pain is used

                                                                                      ii.          Lesioning  of the nerve has been used sparingly

5.      OPEN PROCEDURES (TRIGEMINAL ROOT SECTION)

a)      Extradural sensory root section

b)      Intradual root section

c)      Trigeminal tractotomy

 Thank you for reading

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