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Trigeminal neuralgia - Wikipedia
Several theories exist to explain the possible causes of this pain syndrome. It was once believed that the nerve was compressed in the opening from the inside to the outside of the skull; but leading research indicates that it is an enlarged or lengthened blood vessel — most commonly the superior cerebellar artery — compressing or throbbing against the microvasculature of the trigeminal nerve near its connection with the pons. This can lead to pain attacks at the slightest stimulation of any area served by the nerve as well as hinder the nerve's ability to shut off the pain signals after the stimulation ends.
This type of injury may rarely be caused by an aneurysm an outpouching of a blood vessel ; by an AVM arteriovenous malformation ; [15] by a tumor ; such as an arachnoid cyst or meningioma in the cerebellopontine angle ; [16] or by a traumatic event such as a car accident. Short-term peripheral compression is often painless.
Chronic nerve entrapment results in demyelination primarily, with progressive axonal degeneration subsequently. Postherpetic neuralgia , which occurs after shingles , may cause similar symptoms if the trigeminal nerve is damaged. When there is no [apparent] structural cause, the syndrome is called idiopathic. Trigeminal neuralgia is diagnosed via the result of neurological and physical test, as well as the individuals medical history. As with many conditions without clear physical or laboratory diagnosis, TN is sometimes misdiagnosed. A TN sufferer will sometimes seek the help of numerous clinicians before a firm diagnosis is made.
There is evidence that points towards the need to quickly treat and diagnose TN. It is thought that the longer a patient suffers from TN, the harder it may be to reverse the neural pathways associated with the pain. The differential diagnosis includes temporomandibular disorder. Masticatory pain will not be arrested by a conventional mandibular local anesthetic block. The evidence for surgical therapy is poor.
All destructive procedures will cause facial numbness, post relief, as well as pain relief. Psychological and social support has found to play a key role in the management of chronic illnesses and chronic pain conditions, such as trigeminal neuralgia. Chronic pain can cause constant frustration to an individual as well as to those around them. Trigeminal neuralgia was first described by physician John Fothergill and treated surgically by John Murray Carnochan , both of whom were graduates of the University of Edinburgh Medical School.
Historically TN has been called "suicide disease" due to studies by Harvey Cushing involving cases of TN during and From Wikipedia, the free encyclopedia. Trigeminal neuralgia Synonyms Tic douloureux, [1] prosopalgia, [2] Fothergill's disease [3] suicide disease [4] The trigeminal nerve and its three major divisions shown in yellow: Specialty Neurology Symptoms Typical: Archived from the original on 19 November Retrieved 1 October A text-book of practical medicine.
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A Life , Bloomington: Indiana University Press, , p. Rarely, both sides of the face may be affected at different times in an individual, or even more rarely at the same time called bilateral TN. TN is associated with a variety of conditions. TN can be caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem.
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This compression causes the wearing away or damage to the protective coating around the nerve the myelin sheath. Rarely, symptoms of TN may be caused by nerve compression from a tumor, or a tangle of arteries and veins called an arteriovenous malformation. Injury to the trigeminal nerve perhaps the result of sinus surgery, oral surgery, stroke, or facial trauma may also produce neuropathic facial pain. Pain varies, depending on the type of TN, and may range from sudden, severe, and stabbing to a more constant, aching, burning sensation.
The intense flashes of pain can be triggered by vibration or contact with the cheek such as when shaving, washing the face, or applying makeup , brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. Bouts of pain rarely occur at night, when the affected individual is sleeping. TN is typified by attacks that stop for a period of time and then return, but the condition can be progressive.
The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. Eventually, the pain-free intervals disappear and medication to control the pain becomes less effective. The disorder is not fatal, but can be debilitating. Due to the intensity of the pain, some individuals may avoid daily activities or social contacts because they fear an impending attack.
Trigeminal neuralgia occurs most often in people over age 50, although it can occur at any age, including infancy. The possibility of TN being caused by multiple sclerosis increases when it occurs in young adults.
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The incidence of new cases is approximately 12 per , people per year; the disorder is more common in women than in men. Other disorders that cause facial pain should be ruled out before TN is diagnosed. Some disorders that cause facial pain include post-herpetic neuralgia nerve pain following an outbreak of shingles , cluster headaches, and temporomandibular joint disorder TMJ, which causes pain and dysfunction in the jaw joint and muscles that control jaw movement.
Because of overlapping symptoms and the large number of conditions that can cause facial pain, obtaining a correct diagnosis is difficult, but finding the cause of the pain is important as the treatments for different types of pain may differ. Most people with TN eventually will undergo a magnetic resonance imaging MRI scan to rule out a tumor or multiple sclerosis as the cause of their pain. This scan may or may not clearly show a blood vessel compressing the nerve. Special MRI imaging procedures can reveal the presence and severity of compression of the nerve by a blood vessel.
Diagnosis of TN2 is more complex and difficult, but tends to be supported by a positive response to low doses of tricyclic antidepressant medications such as amitriptyline and nortriptyline , similar to other neuropathic pain diagnoses. Anticonvulsant medicines—used to block nerve firing—are generally effective in treating TN1 but often less effective in TN2. These drugs include carbamazepine, oxcarbazepine, topiramate, gabapentin, pregabalin, clonazepam, phenytoin, lamotrigine, and valproic acid.
Tricyclic antidepressants such as amitriptyline or nortriptyline can be used to treat pain. Common analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN1, although some individuals with TN2 do respond to opioids. Eventually, if medication fails to relieve pain or produces intolerable side effects such as cognitive disturbances, memory loss, excess fatigue, bone marrow suppression, or allergy, then surgical treatment may be indicated.
Since TN is a progressive disorder that often becomes resistant to medication over time, individuals often seek surgical treatment.
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Some procedures are done on an outpatient basis, while others may involve a more complex operation that is performed under general anesthesia. Some degree of facial numbness is expected after many of these procedures, and TN will often return even if the procedure is initially successful. Depending on the procedure, other surgical risks include hearing loss, balance problems, leaking of the cerebrospinal fluid the fluid that bathes the brain and spinal cord , infection, anesthesia dolorosa a combination of surface numbness and deep burning pain , and stroke, although the latter is rare.
A rhizotomy for TN always causes some degree of sensory loss and facial numbness. Several forms of rhizotomy are available to treat trigeminal neuralgia:. Neurectomies also may be performed by cutting superficial branches of the trigeminal nerve in the face. When done during microvascular decompression, a neurectomy will cause more long-lasting numbness in the area of the face that is supplied by the nerve or nerve branch that is cut.
However, when the operation is performed in the face, the nerve may grow back and in time sensation may return. With neurectomy, there is risk of creating anesthesia dolorosa. Surgical treatment for TN2 is usually more problematic than for TN1, particularly where vascular compression is not detected in brain imaging prior to a proposed procedure. Many neurosurgeons advise against the use of MVD or rhizotomy in individuals for whom TN2 symptoms predominate over TN1, unless vascular compression has been confirmed.