Which Operation for Trigeminal Neuralgia

Abstract

INTRODUCTION Trigeminal neuralgia is a severe, debilitating facial pain disorder that has driven some to suicide when unable to obtain relief. Afflicted patients often describe the pain as ‘shocking’, ‘lightning’, or ‘electric’. If a patient describes pain in the face with words such as these, the diagnosis of trigeminal neuralgia should be at the top of the differential diagnosis. Historically, treatment has ranged from poultices and salves to injecting boiling water into the cheek to kill the nerve. The introduction of carbamazepine brought successful medical management to many, but adverse effects, and gradual development of refractory pain, mean that some patients still require invasive procedures to achieve pain control. The goal is to identify the point at which surgical intervention should be considered, and then to guide the choice of procedure. MEDICAL MANAGEMENT First line therapy for trigeminal neuralgia is carbamazepine (Tegretol). If the patient cannot tolerate carbamazepine, other anticonvulsants

Tic, Triggering, and Tearing: From CTN to SUNHA

“…2 Other features reported in CTN patients with persistent pain include longer attack duration of paroxysmal pain, 55 reduced prevalence, 2 or absence of a triggering mechanism, 42 waking from sleep, 35 CAS such as tearing, 7,39,62 less evidence for neurovascular compression on MRI, and poor response to both pharmacologic and surgical treatments. 2,3,[83][84][85] This profile is distinctly similar to that of the SUNHAs and supports the spectrum theory.…”

“…CTN will usually respond to carbamazepine, whilst SUNCT/SUNA are reported to display resistance to a wide range of drugs from their onset . Interestingly, CTN with concomitant persistent facial pain also exhibits poor response to both pharmacologic and surgical treatments . In our 2016 analysis of 81 CTN cases, a significant improvement was more frequent in the short attack duration CTN group (74%) than in the long attack group (50%) .…”

“…24 Interestingly, CTN with concomitant persistent facial pain also exhibits poor response to both pharmacologic and surgical treatments. 2,3,19,[83][84][85] In our 2016 analysis of 81 CTN cases, a significant improvement was more frequent in the short attack duration CTN group (74%) than in the long attack group (50%). 19 The short attack group demonstrated a statistically significant association between poor treatment response and longer disease duration, with the presence of CAS and atypical pain descriptors for pain quality.…”

Trigeminal neuralgia (part II): Factors affecting early pharmacotherapeutic outcome

“…There are indications that specific clinical features may be associated with a higher rate of treatment failures. These features include concomitant background facial pain and autonomic signs (9)(10)(11)(12)(13). Background pain occurs relatively commonly (13,14) and was recently recognised by the International Headache Society (IHS) as part of the clinical CTN phenotype (15).…”

Trigeminal Neuralgia: The New Surgical Treatment Modalities

“…It is well tolerated by patients who describe it as a "totally pain free experience". Morbidity is minimal, and the recurrence rate is not significantly higher than other procedures for trigeminal neuralgia (22,23).…”