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Trigeminal Neuralgia

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by

Rama Mustafa

on 21 March 2012

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Transcript of Trigeminal Neuralgia

Presentation Outline
What is TGN Epidemiology Pathophysiology of TGN Pain Treatment Options Conclusion TREATMENT
- Cannot be cured but many treatment options exist

Pharmacological
Surgical
Non-pharmacological
PHARMACOLGICAL TREATMENT
-->Anti-seizure drugs blocks nerve firing and pain signals
-->May cause excess fatigue
o Carbamazepine (Tegretal)
o Lamotrigine,
o Phenytoin (Dilantin)
o Valproate,
o Pregabalin
o Oxcarbazepine

SURGICAL TREATMENT
Pharmacological treatment isn’t enough to reduce/ relieve pain.

Dependent on:
o Preference
o Physical well-being
o Previous surgeries
o Presence of multiple sclerosis
o Area of trigeminal nerve involvement

Surgery can be either or nerve preserving or nerve damaging
NERVE PRESERVING SURGERY
- Isolates the trigeminal nerve without causing any permanent damage
- Success rate of 85-90%
- Pain will return after 15-20 years

NERVE DAMAGING SURGERY
- A rhizotomy is a procedure in which select nerve fibres are destroyed to block pain.
- Several different ways to perform this type of procedure
NERVE DAMAGING SURGERY
1) Balloon compression
2) Glycerol Injections
3) Radiofrequency lesioning
4) Stereostatic radiosurgery

•Microvascular decompression
SIDE EFFECTS OF SURGERY
-->Numbness in almost all cases
-->TN may return regardless of initial success rate

Surgical Risks Include
o Hearing loss
o Balance problems
o Infection
o Stroke

CURRENT RESEARCH
The National Institute of Neurological Disorders and Stroke
Identify any abnormal sensory input from the peripheral nervous system
* Better understanding the neural mechanisms of TGN
* Find better treatments for TGN and other nerve disorders

NIH-funded research
* Examines functional and chemical changes in sensory neurons in the PNS and CNS
* Evaluates the roles of nerve growth factor and sympathetic nerves in the development of neuropathic pain
(Bennetto et al., 2007) http://akshayghai.wordpress.com/2010/04/02/tattletale-pills-reveal-when-youre-off-your-minds/ (Bennetto et al., 2007) (Lopez et al., 2004) (Gronseth et al., 2008) (The International Classification of Headache Disorders: 2nd edition) EPIDEMEIOLOGY

- Roughly 1.7 million people in the United States alone suffer from TGN

- The annual incidence of TGN 4 to 13 per 100,000 people

- Approximately 15,000 new cases occur in the United States each year
(Katusic et al., 1991) (Rozen et al., 2001) - The rate of occurrence of TGN in men and women is 2.5 and 5.7 per 100,000 per year respectively

- This slight female predominance may be related to the increased longevity of women compared with men

- The onset of TN can come from different sources: inherited pattern of blood vessel formation in families or can be sporadic
(Fleetwood et al. 2001) - TGN can occur at any age but commonly affects individuals 50 years or older

-The youngest child reported to have TGN was only a 1-year-old infant

-TGN is one of the most frequently seen neuralgias in the elderly

-Younger individuals are usually affected by symptomatic trigeminal neuralgia.
Trigeminal Neuralgia
University of Windsor
07-95-464 Michelle Kidd
Katie Martin
Rama Mustafa
Angela Sekulovska WHAT IS TGN?

Definition:
Trigeminal neuralgia (TGN) is sudden, unusually unilateral, severe brief stabbing recurrent pains in the distribution of one or more branches of the 5th cranial nerve.”
(Nurmikko et al., 2001) PAIN LOCATION
Trigeminal nerve is the fifth head (cranial) nerve
Ganglion is the main part

Nerve divides into 3 branches
PAIN CHARACTERISTICS

- Each pain episode generally lasts only a few seconds up to 2 minutes and occurs irregularly
- Occurs commonly over the course of a few hours to several weeks
- Sudden attacks of pain may be repeated one after the other
The patient is usually asymptomatic between paroxysms, but dull background pain may persist in some cases
- Pain-free periods may last for several months or years
(Macianskyte et al., 2011) TN is considered to be one of the most painful conditions observed in medicine and accompanied by severe limitations in the patients quality of life.
Chronic pain is one of the main causes of physical and psychological distress. Pain causes suffering and anxiety.

PSYCHOLOGICAL IMPLICATIONS http://www.trigeminalneuralgia.us/app/images/brain.gif
(Macianskyte et al., 2011) PAIN GENERATION

• No agreement on one theory
• The TG nerve is the site of pain generation, not the CNS
• Sensory impairment  increased excitability in TG afferents  TGN
• Degernerative hypermyelination
• Ganglion cells still intact.
• Vasodilation
• No neurogenic inflammation
• Microscopically: demylination and remylination  ectopic firing
Why is the pain not continuous?

- AKA Paroxysmal pain or spontaneous discharges
- Dorsal root ganglion cells can have this kind of firing property
- After compression  dorsal root ganglions increased subthreshold oscillations in resting membrane potentials of A-neurons reaching threshold
- ^ spike activity hyperexcitability neighbouring c-cells are cross-excited
- ^ neurons recruited  nociceptive pain signal
- Sudden signal stoppage  due to inherent cellular self-quenching mechanisms

Other theories...

- Altered Ca2+ channel expression
- Alterned Na Channel subtypes CONCLUSION
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