Trigeminal neuralgia or, as it is also called trigeminal neuralgia, is a disease of the peripheral nervous system in which one or more branches of the trigeminal nerve that provides sensitivity to the face is affected. This is accompanied by sudden, severe paroxysmal pain, the localization of which depends on which of the branches are affected since they are responsible for the innervation of different third parties.
Causes of trigeminal neuralgia
Neuralgia can be primary or secondary. The first develops in isolation, while the second is a consequence of the progression of a particular disease. It occurs in both women and men.
Today, all the causes of damage to the trigeminal nerve are still unknown for certain. However, it is known for sure that this is facilitated by:
- pathologies of the nervous system, including cerebral palsy, multiple sclerosis, encephalopathy that develops after a head injury, epilepsy, brain tumors, viral and tuberculous meningoencephalitis, hypoxia, cerebrovascular accidents, etc.;
- viral diseases, in particular, poliomyelitis, herpes infection;
- odontogenic causes, including jaw injuries, flux, errors in filling a tooth, non-standard reaction to anesthesia;
- compression of the trigeminal nerve, which can be triggered by brain tumors formed after trauma or surgery, scars, as well as significantly enlarged as a result of atherosclerosis, aneurysm or congenital disorders of the blood vessels, stroke or increased intracranial pressure due to osteochondrosis.
- compression of the posterior cerebellar artery of the trigeminal nerve. As a result, the nerve is irritated and inflamed by constant pulsation.
Increase the risk of developing the disease:
- frequent stress;
- chronic fatigue;
- metabolic disorders;
- vitamin deficiency;
- autoimmune pathologies or allergies;
- severe infectious diseases;
- inflammatory processes in the oral cavity.
Neuralgia is not accompanied by nerve inflammation. It occurs as a result of demyelination of the nerve fiber or the occurrence of disturbances in the regulation of its work by the central nervous system. Demyelination occurs in 80–90% of cases. The destruction of the specific myelin sheath, which acts as a kind of insulating layer of the nerve, occurs due to the compression of the Gasser’s node by pathologically altered vessels, neoplasms of various nature. Therefore, the impulses coming from the central nervous system also spread to nearby nerves, which provokes the onset of pain.
In the second case, nerve impulses are transmitted at a different speed. This causes irritation of the nuclei of neurons and, as a result, pain syndrome.
Trigeminal neuralgia symptoms
The trigeminal nerve is part of 12 pairs of cranial nerves, is the 5th pair, and runs on both sides of the face. It is formed by three bundles:
- eye – is responsible for the innervation of the forehead, temporal and superciliary regions, eyes and
- eyelids; maxillary – is responsible for the transmission of nerve impulses in the upper jaw, facial muscles, and the nose;
- mandibular – innervate the neck, lower jaw, and chin.
Accordingly, the clinical picture in neuralgia will depend on which of the branches of the trigeminal nerve is affected. This is accompanied by:
- a sharp short-term burning, powerful one-sided pain strictly along with the affected nerve bundle, persisting up to 3 minutes and repeating from 1 to 10 times during the day (at night, lumbago is observed in less than 1% of patients);
- pain always arises in the same area, then flows to a neighboring area, but does not radiate to other parts of the body;
- spasm of the facial muscles during an attack;
- intensive separation of saliva and lacrimal fluid;
- dilated pupils;
- absolute immobility of a person throughout the entire attack;
- the occurrence of pain syndrome when touching the skin in the projection of the affected branch of the nerve, therefore, patients always describe the localization of discomfort without touching directly to the face.
In 7% of patients, pain persists for several days. But in the initial stages, patients may be disturbed only by short-term mild shooting pains. Seizures usually occur spontaneously. But they can also be provoked by the impact on specific trigger points (most often located in the area of the nasolabial triangle).
If the causes of the development of pathology lie in disorders affecting the brain, their manifestations may additionally be present: differences in the size of the pupils, difficulty breathing, drooping of the eyelid.
Thus, it is not difficult to make a diagnosis for an experienced doctor, since the symptoms of trigeminal neuralgia are quite specific. The frequent recurrence of attacks during brushing, talking or eating only confirms it.
Treatment of trigeminal neuralgia
Initially, treatment always begins with the appointment of conservative therapy. Only in the case of its complete ineffectiveness, patients are offered surgical intervention.
Conservative treatment for trigeminal neuralgia includes:
- drug therapy;
The use of folk remedies is possible with the permission of a neurologist, but only as an adjunct to medication and physiotherapy. On their own, traditional medicine is powerless in the fight against the disease.
It is important not to let the course of neuralgia take its course. Non-intervention can subsequently provoke serious damage to the nervous system, which will not only provoke prolonged pain but also paralysis or paresis of the muscles of the face, hearing loss, nervous tics, and facial asymmetry.
The basis of therapy is the appointment of drugs carbamazepine and its analogues of new generations. This compound is classified as an anticonvulsant or anticonvulsant. It was first synthesized in the middle of the last century. Subsequently, carbamazepine was improved, as a result of which oxcarbazepine, pregabalin and other anticonvulsants appeared on the pharmaceutical market, which rarely causes side effects and gives a more pronounced effect.
Therapy begins with the minimum doses of the selected drug. In the absence of a positive result, the neurologist gradually increases the dosage until the signs of neuralgia disappear. Treatment continues for at least 30 days, after which a decision is made about the possibility of reducing the dose. When seizures resume, a second doctor’s consultation and a new dosage revision are required.
In about half of the cases, it is possible to completely eliminate the pain syndrome and gradually stop taking anticonvulsants. However, their effectiveness progressively decreases as the duration of the course of neuralgia increases. Therefore, patients living with such a diagnosis for several years require a longer intake of carbamazepine and its analogues.
Unfortunately, in severe cases, the symptoms of neuralgia sometimes cannot be eliminated even after 10 years. There is also a certain percentage of people who have an immunity to the drugs used.
Additionally, patients are prescribed:
- muscle relaxants to reduce muscle tone;
- agents that improve blood circulation to normalize nerve nutrition and restore the myelin sheath;
- drugs of the NSAID group that have anti-inflammatory and analgesic effects;
- antidepressants to reduce the rate of conduction of pain impulses;
- B vitamins.
Physiotherapy helps to increase the effectiveness of the drug treatment and helps to reduce the dosage of the drugs used. For these purposes, the course is assigned:
UVB – the use of medium-wave ultraviolet radiation leads to the active release of neurotransmitters responsible for inhibition of excitation. Traditionally, the course includes 10 procedures. Laser therapy – the thermal energy of the laser reduces the sensitivity of nerve fibers. Usually, 10 sessions of 4 minutes are prescribed.
Diadynamic currents – the method involves fixing electrodes in the area of the most sensitive points, including on the nasal mucosa, if required. An electric current with a frequency of 50,000 Hz is passed through them, called the Bernard current. This helps to reduce the pain threshold and block the transmission of nerve impulses along the trigeminal nerve. Thanks to this, you can achieve complete elimination of pain. The addition of electrophoresis increases the effectiveness of the procedure. As a rule, several courses lasting 5 days are required to obtain a good effect. Take a week break between them. Each session takes about a minute.
HFC – high-frequency currents have proven themselves in the treatment of neuralgia. Their effect leads to an improvement in blood circulation and lymph flow, as well as restoration of the sodium-potassium nerve membranes transmitting impulses. Patients are recommended to undergo 15 to 20 sessions, the duration of each of which is 15 minutes.
Electrophoresis – the method is often used to eliminate pain by injecting anesthetic drugs directly into the lesion. With neuralgia, novocaine, platifillin and diphenhydramine are administered with the help of electrophoresis. They block the transmission of nerve impulses by acting on the potassium-sodium channels. To improve the nutrition of nerve fibers, which is especially important in the destruction of the myelin sheath, vitamins of group B can also be administered. Electrophoresis is carried out every 2 days 10 times.
Acupuncture also gives good results. A point effect on the nerve receptors of trigger zones and on similar points on the opposite side of the face helps to eliminate pain. The duration of treatment for each patient is selected individually. In some cases, it is required to install needles for a fairly long period of time – more than a day. But often several procedures are enough to obtain pronounced results.
Manual influence on the muscles of the face, neck and head in general during remission of the disease promotes the activation of lymph and blood flow. Therefore, massage is indicated for patients with trigeminal neuralgia. A correctly performed procedure helps to prolong the remission of the disease, but requires highly qualified chiropractors.
The procedure is carried out very carefully. When performing it, the techniques of rubbing, stroking and vibration are used, but the impact on the trigger zones is completely excluded. A massage session performed by an insufficiently qualified specialist can provoke an attack of pain.
Surgical treatment of trigeminal neuralgia – surgery
When the possibilities of conservative therapy have been exhausted, and the patient continues to suffer from bouts of severe pain, surgical treatment of trigeminal neuralgia is recommended. This is still observed in about 30% of patients. Therefore, for them, the operation is the only way a person can get rid of severe pain.
There are several techniques for the surgical treatment of neuralgia. All of them are aimed at eliminating the irritating effect on the nerve, provided that its source is known, or the destruction of the nerve.
The methods differ not only in the degree of efficiency and safety but also in the price. For each patient, the surgeon individually selects the most suitable method of performing the operation, based on the level and degree of damage to the trigeminal nerve, the clinical picture and existing concomitant diseases.
Today in the arsenal of neurosurgeons there are:
- microvascular or microvascular decompression;
- radiofrequency ablation ;
- rhizotomy with glycerol;
- microcompression with a balloon;
- stereotactic radiosurgery.
In the absence of age-related and somatic contraindications, when diagnosing a neurovascular conflict, preference is usually given to microvascular decompression, since it belongs to the number of reconstructive operations and does not lead to a loss of sensitivity in a particular area of the face. But when a patient is found to have concomitant diseases, minimally invasive techniques are usually chosen, in particular, radiofrequency ablation. It is also indicated for most elderly patients.
But, preparing for the operation, patients should understand that surgical intervention on the nerves requires the highest possible qualifications from a neurosurgeon. The slightest careless movement in such situations can lead to irreversible consequences, including a complete loss of facial sensitivity. Therefore, it is important to approach the choice of a clinic and a specialist with utmost responsibility.
Gannett surgery or microvascular decompression is often used for facial neuralgia. Its main advantage is the preservation of the nerve, while all other operations are destructive. Therefore, after microvascular decompression, there is no risk of numbness in a part of the face.
But it can only be used in situations where the trigeminal nerve is compressed by a nearby passing blood vessel, from which pulsation is transmitted to the nerve fiber, which provokes pain.
Microvascular decompression is performed in an open manner through an incision behind the auricle. The surgeon enters the cranial cavity after trepanning the posterior cranial fossa and revises the position of the trigeminal nerve root, superior and inferior anterior cerebellar arteries, and the superior petrosal vein. After finding the place of compression, he separates the pathologically dilated vessels and introduces a special separating Teflon gasket. It will protect the nerve from mechanical irritation by a pulsating vessel, which will provide pain relief.
In the vast majority of cases, the method leads to a final recovery. Relapses are extremely rare. But microvascular decompression is an open surgical intervention, it is associated with high trauma and intraoperative risks. Therefore, the operation requires high qualifications from the surgeon.
After microvascular destruction, patients need to stay in the hospital for up to 10 days. During this time and afterwards, they may be bothered by pain caused by postoperative muscle spasms. To stop them, it is usually enough to take antispasmodics or NSAIDs. As the body recovers, the intensity of pain decreases and soon completely disappears.
Rehabilitation means taking a number of medications, undergoing a course of physiotherapy, and in the future – massage sessions. Such a set of measures will contribute to the speedy recovery and consolidation of the results achieved by surgery.
The method is one of the percutaneous operations and is considered the most effective and safe in the treatment of a large number of various diseases, including trigeminal neuralgia.
With the help of the image intensifier, the surgeon has the ability to accurately control his every movement and time of exposure to radio waves. Other advantages of the method include:
- lack of risks associated with general anesthesia;
- extremely short and easy rehabilitation;
- the possibility of early activation of patients.
Radiofrequency ablation does not require large incisions or significant tissue trauma. The destruction of the provoking pain of a branch, its peripheral node or root is carried out by means of thermal energy released when ultrahigh-frequency currents pass through biological tissues.
It is carried out on special equipment, which consists of a generator and two electrodes: damaging and indifferent. The actual ablation of the nerve fiber is performed around the uninsulated end of the injury electrode. It is injected into the patient’s body to the selected point of destruction by means of a hollow guide needle. The length of such a cannula is 100 mm. It is installed under the control of an image intensifier to avoid accidental injury to healthy nerves.
For the destruction of sensitive fibers, a current with a frequency of 100 Hz is used, for motor fibers – 2 Hz. Radiofrequency ablation is performed under local anesthesia, so the patient is conscious throughout the operation. As the needle approaches the affected nerve, it may feel a slight tingling sensation. To accurately determine the desired branch of the nerve, it is stimulated with current.
After determining the damaged branch, the electrode heating mode is turned on. It can heat up to 70 ° C, then the exposure time is only one and a half minutes. But it is preferable to use the pulsed ablation mode, which assumes heating the tip of the active electrode only up to 42 ° C. This completely eliminates the likelihood of burns to the surrounding tissue, but it takes 2 minutes for a complete ablation.
In general, the whole procedure takes no more than 40 minutes. In 90% of cases, it leads to a complete recovery, and the pain syndrome either disappears immediately after its completion, or there is a gradual increase in the effect over 6–8 weeks.
After radiofrequency ablation, the patient does not require complex rehabilitation or prolonged bed rest. He can leave the clinic the same day.
Percutaneous selective rhizotomy with alcohol
The method involves performing an injection of the drug under the guidance of MRI or CT. A thin needle is inserted into the area of the affected nerve root, after which the solution is injected in small portions. Destruction of a part of the nerve fiber occurs 3-4 hours after the injection, as a result, the possibility of a pain impulse is eliminated.
The technique is very old and was used before when there were no other more modern methods of treating neuralgia. This does not exclude the likelihood of a relapse, but does not involve high risks of loss of sensation in the innervation zone of the affected branch of the trigeminal nerve.
Micro compression with a balloon
The operation involves the introduction of a special needle equipped with a small empty balloon. It is brought directly to the affected root of the trigeminal nerve and inflated until the effect of persistent compression is obtained. Pressure has a destructive effect on the nerve fiber and leads to the elimination of pain.
For more than 50 years, the treatment of neuralgic disorders has been carried out using the so-called Gamma Knife or CyberKnife. This is a completely bloodless technique that does not require any incisions. The impact is carried out by means of precisely directed ionizing radiation on the affected area of the trigeminal nerve. Guidance is performed using anatomical landmarks and a computer.
The rays formed by several hundred sources penetrate the tissues without damaging them, and are precisely focused at the point of impact, creating the required radiation concentration. The operation, including preparation, takes one day and the patient can immediately leave the clinic. If done correctly, there are no risks of side effects and complications.
The gamma knife acts on the nerve root located at the point where the trunk exits the brain. The operation leads to a lasting recovery in 80–90%. Only in 7% of patients after it there is a temporary decrease in facial sensitivity.
The method is used to help all patients in whom conservative therapy did not give results or was accompanied by severe side effects. In addition, it can be used to treat patients who have previously undergone microvascular decompression and other surgical interventions without obtaining positive changes. But the cost of stereotactic radiosurgery is significantly higher than other methods of surgical treatment of the disease