Trigeminal Neuralgia

Roderick Agbuya

Definition

Sudden, usually unilateral, severe brief stabbing pain in the distribution of one of more branches of the V nerve (IASP)

Anatomy of Trigeminal nerve

There are three divisions of V nerve: The ophthalmic (V1) supplies sensation to upper face including eyes. The maxillary (V2) supplies sensation to middle face including upper teeth. The mandibular (V3) supplies sensation to lower jaw including anterior two-thirds of tongue. All divisions come from the trigeminal ganglion, also known as Gasserian ganglion. From the gasserian ganglion, sensory input is conducted to the trigeminal nuclear complex.

Anatomy of Trigeminal Nerve

Anatomy of Trigeminal Nerve

Anatomy of Trigeminal Nerve

Etiology and Pathophysiology

TN may be idiopathic (primary) or symptomatic (secondary). Most cases of idiopathic TN are the result of vascular compression of V nerve near its entry into the pons Symptomatic causes include: multiple sclerosis, tumors, and basilar artery aneurysm or ectasia. Pathophysiology is not fully elucidated. Demyelinative lesions of trigeminal fibers appear to set up ectopic generation of spontaneous nerve impulses and their ephaptic conduction to adjacent fibers. This may disinhibit pain pathways in the spinal trigeminal nucleus.

Normal Trigeminal Nerve

Vascular compression of V nerve

Vascular irritation of V Nerve

Tumor of V Nerve

Diagnosis
TN remains a clinical diagnosis. A careful search for ipsilateral dental pathology should be undertaken. Routine imaging is generally not indicated. MRI and MRA can be performed if there is suspicion of underlying pathology.

Treatment
Medical

treatment treatment

Invasive

Medical Treatment of TN

Trigeminal Nerve Block

Mandibular Nerve Block

Mandibular Nerve Block

Maxillary Nerve Block

Maxillary Nerve Block

Peripheral Block of V nerve

Percutaneous Radiofrequency Rhizotomy (Gasserian Ganglion Block)

It is widely used technique for treatment of TN. Needle is introduced percutaneously and passed through the foramen ovale Then RF lesion is applied (Heating or Pulsed lesion) Success rate reported more than 75%.

Percutaneous Radiofrequency Rhizotomy

Glycerol Rhizotomy
Injection of 0.1 - 0.2 ml of glycerol into the Meckels cave, through a percutaneous needle placement. High success rate with low morbidity has been reported This procedure has a relatively high recurrence rate

Percutaneous Glycerol Rhizotomy

Microvascular Decompression
Involves a craniotomy via the posterior fossa This presumes the demonstration of vascular compression by MRI/MRA High long-term success rate (above 70%) has been reported Morbidity includes facial dysaesthesia, cerebellar injuries and hearing loss.

Microvascular Decompression of V nerve

Microvascular Decompression of V nerve

Microvascular Decompression of V nerve

Microvascular Decompression of V Nerve

Microvascular Decompression of V nerve

Gamma Knife
Single high dose radiotherapy delivered with exquisite precision to a radiographically defined target, at the junction of trigeminal nerve and brain stem. Several series of small numbers of patients report high rates of pain relief, with low rates of morbidity, mostly facial numbness.

Gamma Knife

Gamma Knife

Balloon Compression of Trigeminal Ganglion

It is done by introduction of a balloon via the percutaneous route The balloon is then inflated with small volumes 0.5-1 ml of contrast until it occupies Meckels cave Compression times vary from 1 to 6 minutes Success rate are not dissimilar to other techniques.

Balloon Compression of Trigeminal Ganglion

Balloon Compression of Trigeminal Ganglion

Nursing Diagnosis
Fear Risk for injury Pain Altered nutrition, less than body requirements

Nursing Interventions
Instruct the client to avoid factors that can trigger the attack and result in exhaustion and fatigue. Avoid foods that are too cold or too hot.

Chew foods in the affected side. Use cotton pads gently, wash face and for oral hygiene. Provide teaching to clients who have sensory loss as a result of a treatment.

Inspection of the eye for foreign bodies, which the client will not be able to feel, should be done several times a day. Warm normal saline irrigation of the affected eye two to three times a day is helpful in preventing corneal infection.

Dental check ups every 6 months is encouraged, since dental caries will not produce pain. Explain to the client and his family the disease and its treatments.