Trigeminal Neuralgia1.ppt

8/17/2019 Trigeminal Neuralgia1.ppt

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B. Wayne Blount, MD, MPH


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“Tic Doloureau”

4.3 per 100,000

Slight female predominance 1.!4t0 1

Pea" incidence #0$!0 y.o. %nu&ual 'efore age 40

(o racial prediliction


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“Tic Doloureau”

Higher incidence )ith M.S. *H+(

Spontaneou& remi&&ion po&&i'le,B%+ unu&ual

Mo&t patient& )ill hae epi&odicattac"& oer many year&


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Now 2 Types Are

Identified -la&&ical

Symptomatic


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Classical Criteria

. Paro/y&mal attac"& of pain la&tingfrom a fraction of a &econd to

minute&, aecting 1 or more dii&ion&of the trigeminal nere, * ful2llingcriteria B * -.

B. Pain ha& at lea&t 1 of the follo)ingcharacteri&tic& 1. nten&e, &harp, &uper2cial, or &ta''ing

Precipitated from trigger one& or 'y

trigger factor&


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Classical Criteria

-. ttac"& are &tereotyped in

the indiidual patient

D. (o clinically eident neuro de2cit

5. (ot attri'uted to another di&order.


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Symptomatic Criteria

. Paro/y&mal attac"& of pain la&tingfrom a fraction of a &econd to

minute&, )ith or )6o per&i&tence ofpain 'et)een paro/y&m&, aecting 1or more dii&ion& of the trigeminalnere, * ful2lling criteria B * -.

B. . Pain ha& at lea&t 1 of the follo)ingcharacteri&tic& 1. nten&e, &harp, &uper2cial, or &ta''ing Precipitated from trigger one& or 'y

trigger factor&


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Symptomatic Criteria

-. ttac"& are &tereotyped

in the indiidual patient

D. cau&atie le&ion, other thana&cular compre&&ion, ha& 'eendemon&trated 'y &pecialine&tigation& *6or po&terior fo&&ae/ploration.


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Pathophysiology


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Pathophysiology

Demyelination of the trigeminal nere,cau&ing ectopic impul&e& and thenephaptic conduction

7a&cular compre&&ion of the nere root 'ya'errant or tortuou& e&&el&

-ompre&&ion 'y tumor

myloid $7 malformation

Pon& nfarct

Bony compre&&ion


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Diagnosis

-linical

-on&ider in all patient& )ith

unilateral facial pain Prompt D/ important a& pain can 'e

&eere

Di&tingui&h cla&&ical from&ymptomatic for 89 purpo&e&

:oo" for ;red


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!ed "lags

'normal (euro e/am

'normal oral, dental, or ear e/am

ge > 40 yr&

Bilateral S9&

Diine&& or ertigo


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!ed "lags

Hearing lo&&

(um'ne&&

Pain la&ting ? minute&

Pain out&ide of trigeminal di&tri'ution

7i&ual change&


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Diagnostic #istory

7ery important

8ecurrent, unilateral facial pain

:a&t& &econd& May recur 100@& of time& per day

Pain

Seere Stereotypical Sharp Sta''ing

Super2cial Shoc"$li"e


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Diagnostic #istory

1 or more of the nere@& dii&ion& +rigger factor&

+al"ing Shaing Smiling pplying ma"e$up -he)ing Wind +eeth 'ru&hing

ge ? 40 yr&. &" a'out other neuro S/ &ymptomatic time or not A


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Physical $%am

%&ually a normal e/am

%&eful for identifying a'normal& that

point to other D9& H55(+, including +M * Ma&&eter

Cral e/am, including teeth * gum&

(euro e/am -hec" for trigger one&


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Diagnostic Testing

enerally (ot helpful

M8 i& the +e&t of -hoice E-@ 8ec

A +rigeminal re


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Differential &ist

-lu&ter H Dental Pain

iant -ell rteriti& Migraine

lo&&opharyngeal (euralgia Ctiti& Media

ntracranial +umor Sinu&iti&

Multiple Sclero&i& +M Syndrome Po&therpetic (euralgia

Paro/y&mal Hemicrania


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Treatment

Medical

Surgical

(o Behaioral, unle&& it 'ecome& a

cau&e of -hronic Pain


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'edical Treatment

-ar'amaepine E@ 8ec

((+ F .G Ior trigeminal (euralgiaJ

((H F 3.! Ior all di&ea&e&J Some &ugge&t it a& a diagno&tic trial

Do&e& range from 100 to ,400 mg perday

Mo&t re&pond to 00 to K00 mg per day

mmediate relea&e la&t& a'out # hr&.J

5/tended relea&e la&t& a'out 1 hr&.J


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'edical Treatment

-ar'amaepine Should 'e the initial8/ of choice for cla&&ical +rigeminal(euralgia

f get no or only partial re&pon&e tocar'amaepine, add or &u'&tituteanother pharmacologic agent


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'edical Treatment

Cther agent& to try (ot li&ted in anyorderJ

Baclofen 10 m$ K0 mg daily Dilantin :amictal (eurontin

+opama/ Llonopin Crap Depa"ene


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'edical Treatment

recent -ochrane reie) &aid there)a& in&ucient eidence to &ho)'ene2t from non$epileptic agent& intrigeminal neuralgia


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"ollow(up

chiee 'alance 'et)een pain andmed &ide eect&

Mo&t )ant complete remi&&ion, )hichi& po&&i'le and )arranted

-an try a trial &an& med& after;&eeral= month& &ymptom free

+hin" 4$#J


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Surgical Treatment

fter failure of Pharm agent&

%nu&ual

8ecurrence& occur for many Both percutaneou& * open techniNue&

lycerol inOectionBallon -ompre&&ion

8adio 8hiotomy amma "nife

Partial 8hiotomyMicroa&culardecompre&&ion


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Summary

+ype& of trigeminal neuralgia

clinical D9

5eryone get& a head * faceM8

-ar'amaepine i& thetreatment of choice.


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!eferences

Lraft, 8M. +rigeminal (euralgia.IP. 00K!!1Q1$1Q#.

-ochrane -olla'oration Haanpaa M, et al. (europathic

Iacial Pain. Suppl -lin(europhy&iol. 00#GK1G3$1!0.


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!eferences

-ruccu , et al. Diagno&i& oftrigeminal neuralgia. n -ruccu , etal. Brain&tem Iunction *Dy&function. m&terdam 5l&eier00#1!1$1K#.

Wayne Blount

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Trigeminal Neuralgia1.ppt