27. Синдром поражения тройничного нерва на различных уровнях.

При раздражении тройничного нерва (той или иной его ветви) возникают очень сильные боли, которые иррадиируют во все веточки нерва. Они выражены в области лба, волосистой части головы, глаза, уха, щеки, нижней челюсти, отдает в зубы. Для определения локализации основного поражения выявляют болевую точку в местах выхода ветвей нерва.

Поражение узла тройничного нерва и чувствительного корешка тройничного нерва вызывает нарушение чувствительности в зоне иннервации всех веточек нерва, а также высыпание пузырьков на лице по ходу отдельных нервных стволов.

Поражение одной из ветвей тройничного нерва приводит к нарушению всех видов чувствительности, иннервируемой этой ветвью, к появлению болей и к угасанию соответствующих рефлексов (при поражении глазной ветви исчезают надбровный, корнеальный и конъюнктивальный рефлексы; при поражении нижнечелюстной ветви — нижнечелюстной рефлекс).

Тригеменальный невриты, невропатии и невралгии.

В составе тройничного нерва имеются три чувствительные ветви, образуемые дендритами тройничного (Гассерова) узла, и двигательный жевательный нерв, образуемый аксонами двигательного ядра. Поражение двигательной части нерва проявляется парезом жевательной, височной и крыловидных мышц; поражение чувствительной части – анестезией и болью в зонах соответствующей иннервации.

Первая ветвь вовлекается в процесс при синдроме верхней глазничной щели, любая из трех ветвей может поражаться при полиневропатиях, невритах или множественных невропатиях и невритах, при воспалительных, опухолевых и других процессах в глазнице, нижней глазничной щели, в челюстях, придаточных пазухах носа, на основании черепа. При вирусном (ветряночном) ганглионите гассерова узла развивается опоясывающий лишай. Каждый из вегетативных узлов, сопровождающих ветви тройничного нерва (ресничный, крылонебный и ушной), может поражаться при органических процессах в этих образованиях.

Невралгия тройничного нерва. (болевой тик Труссо) стоит в центре проблемы лицевых болей. Классификация: I. Первичная или есенциальная (собственно) невралгия тройничного нерва. II. Симптоматические тригеминальные боли. I. Первичная (есенциальная) невралгия тройничного нерва. Болеют люди пожилого возраста (после 40 лет) и чаще женщины.

Этиология.

Невралгия тройничного нерва является мультифакториальным заболеванием. Указывают на этиологическую роль общих инфекций, хронических местных инфекций, таких как гайморит, атеросклероза сосудов с нарушением васкуляризации нисходящего корешка тройничного нерва, заболеваний зубов, верхней и нижней челюсти, патологического прикуса, узости костных каналов и др. В последние годы стали придавать значение туннельному, компрессионному происхождению тригеминальных невралгий.

Патогенез невралгии тройничного нерва до конца не изучен. Основное в механизме провоцирования болевого приступа придают теперь не Гассеровому узлу, а нарушениям функций нисходящего корешка тройничного нерва. Расположенное в толще ретикулярной формации, оно обладает обширными связями с ядрами VII, VIII и X пар черепных нервов, ретикулярной формации, мозжечком и конечным мозгом. Клетки орального отдела нисходящего корешка обладают той же высокой специализацией, что и высоко дифференцированные структуры эпилептических очагов вообще. Все это приобретает особое значение в силу сходства клинических признаков эпилепсии и невралгии пароксизмальность, мощность проявлений, положительный эффект противоэпилептических средств. Так как невралгические разряды возникают в ретикулярной формации, можно полагать, про патогенетический секрет невралгии в особенности чувствительных клеток ядер ствола и в их взаимоотношениях с ретикулярной формацией ствола. Под влиянием патологических афферентных импульсов, проводимых тройничным нервом, особенно при существовании хронического очага на периферии, у больных с указанной готовностью центров ствола формируется тот мультинейрональный рефлекс, который клинически выражается как невралгия тройничного нерва.

В клинической картине невралгии тройничного нерва как правило выделяют 5 основных особенностей. 1. Строгая локализация боли на территории, иннервируемым тройничным нервом справа или слева, или в зоне иннервации одной из ветвей тройничного нерва. Чаще всего в зоне II ветви (суборбитального нерва), реже III ветви (подбородочного нерва) и еще реже I ветви (супраорбитального нерва). Каждый приступ начинается с одной и той же территории и лишь в дальнейшем может распространяться на территории других, соседних ветвей тройничного нерва. 2. Приступообразное течение и характер боли. Речь идет о приступообразном появлении резкой боли сверлящего, дергающего характера чаще всего в кожных покровах, в слизистой или в тех и других, реже в зубах длительностью от нескольких секунд до нескольких десятков секунд с последующим периодом угасания болевого приступа, которым в свою очередь растянут до нескольких десятков секунд. Общая длительность приступа до 1,5-2 минут. Во время приступа больной замирает в страдальческой гримасе, мимическая мускулатура лица чаще в состоянии тонического сокращения, может быть гиперсаливация, усиленное слезотечение, назорея. 3. Провоцируемый характер приступов с наличием пусковой триггерной зоны, зоны гашетки, раздражение которой (разговор, мимика, пальпация, прием пищи, бритье, даже простая улыбка) может вызвать приступ. Чаще всего это кожа в области носогубной складки, верхней губы, крылья носа, реже бровь и другие участки. Следует отметить, что сильное раздражение этой зоны (сильное давление или укол при исследовании чувствительности) не вызывает приступа и переносится благополучно. 4. Сразу после приступа наблюдается рефрактерный период длительностью до нескольких минут, когда наличие раздражения корковой зоны не вызывает нового приступа и которым пользуются больные в тяжелых случаях, чтобы принять пищу или произвести туалет лица. 5. Отсутствие объективных данных при неврологическом осмотре в межприступный период. Течение заболевания. Частота приступов очень вариабельна. Считается, что 5-10 приступов в день – это еще относительно доброкачественное течение. При тяжелых формах приступы идут один за другим в течении дня. Боль истощает все волевые запасы больного, приводит к кахексии и когда лечение не было разработанным – эти формы приводили к суицидальным попыткам.

Обычно приступы длятся несколько дней или недель, а затем наступает светлый период в несколько месяцев и лет. Доброкачественным течением считается тогда, когда интесивность боли невелика, приступы редки. II. Симптоматические тригеминальные боли или симптоматическая тригеминальная невралгия V нерва (синдром Редера, синдром Ханра, синдром Костена, при сирингобульбии, при органических процессах в мостомозжечковом углу: опухоли, воспалительные процессы, аневризмы сосудов и др.).

Симптоматические тригеминальные боли являются весьма частыми и объясняются как физиологическими факторами: богатством чувствительной иннервации; анатомическим фактором: сложностью анатомических связей тройничного нерва, который вовлекается в множественные патологические органические процессы и, наконец, функциональными, психологическими факторами по причине особого значения лица в жизненном стереотипе человека, т.е. его внешнего вида, потребности в ощущении комфорта, связанных с лицом.

Таким образом, причины симптоматической невралгии тройничного нерва чаще всего органические процессы, вовлекающие нерв на различных его анатомических участках. Клиническая картина.

Самым близким признаком симптоматической невралгии, заставляющей его дифференцировать с истинной невралгией тройничного нерва является тригеминальная локализация боли, которая может соответствовать топографии иннервации тройничного нерва.

Однако, других трех классических признаков: 1)приступообразность; 2) провоцирующий характер болей с наличием курковых (пусковых) зон и 3)отсутствие объективных данных при неврологическом обследовании – либо совсем нет, либо не носят тех черт, которые характерны для истинной невралгии.

Более чаще всего постоянные, хотя на этом фоне могут быть приступы усиления болей, характер болей совсем не тот, они более терпимы. Провокаторы могут быть те же (разговор, прием пищи, бритье), но пусковых зон нет. Наконец, всегда есть объективные симптомы: снижение корнеального рефлекса, гипестезия, не говоря уже о патологии двигательной порции тройничного нерва, или других черепно-мозговых нервов так или иначе участвующих в иннервации лица (VI,VII,VIII,IX,X, XI,XII).Все это заставляет думать о симптоматической невралгии тройничного нерва.

Частная неврология

1.Рассеянный склероз

Рассеянный склероз – хроническое демиелинизирующее заболевание, развивающееся вследствие воздействия внешнего патологического фактора (наиболее вероятно, инфекционного) на генетически предрасположенный организм. При этом заболевании наблюдается многоочаговое поражение белого вещества центральной нервной системы, в редких случаях с вовлечением и периферической нервной системы.

Клинические проявления. В типичных случаях первые клинические симптомы РС появляются у лиц молодого возраста (от 18 до 45 лет), хотя в последнее время все чаще описывают дебют РС как у детей, так и у лиц старше 50 лет.

Первыми симптомами заболевания часто бывают:

• ретробульбарные невриты

• снижение остроты зрения

• скотомы,

• ощущения нечеткости изображения

• пелена перед глазами

• преходящая слепота на один или два глаза .

Заболевание может начинаться с:

• глазодвигательных расстройств (диплопия, косоглазие, межъядерная офтальмоплегия, вертикальный нистагм)

• неврита лицевого нерва

• головокружения

• пирамидных симптомов (центральный моно-, геми– или парапарез с высокими сухожильными и периостальными рефлексами, клонусами стоп, патологическими пирамидными рефлексами, исчезновением брюшных кожных рефлексов)

• мозжечковых нарушений (пошатывание при ходьбе, статическая и динамическая атаксия, интенционное дрожание, горизонтальный нистагм)

• расстройств поверхностной (онемение, диз– и парестезии) или глубокой чувствительности (сенситивная атаксия, сенситивный парез, гипотония).

В большинстве случаев у больных имеются симптомы поражения и головного, и спинного мозга (цереброспинальная форма). В некоторых случаях в клинической картине преобладают симптомы поражения спинного мозга (спиналъная форма) или мозжечка (мозжечковая или гиперкинетическая форма).

Течение. У 85—90 % больных заболевание имеет волнообразное течение с периодами обострений и ремиссий, которое после 7—10 лет болезни практически у всех больных сменяется вторичным прогрессированием, когда наблюдается постепенное ухудшение состояния больных. В 10– 15 % случаев РС с самого начала имеет первично прогрессирующее (прогредиентное) течение.

Лечение. В связи с тем, что этиология заболевания неясна, этиотропного лечения РС в настоящее время нет. Принципы лечения больных с РС основываются на индивидуальном подходе.

Патогенетическое лечение направлено на борьбу с обострением или прогрессированием заболевания и включает в основном противовоспалительные и иммуносупрессивные препараты(кортикостероиды и препараты адренокортикотропного гормона (АКТГ)). Патогенетическая терапия направлена на предупреждение деструкции ткани мозга активированными клетками иммунной системы и токсичными веществами.

Большое значение имеют адекватно подобранное симптоматическое лечение и медико-социальная реабилитация больных.

Симптоматическая терапия направлена на поддержание и коррекцию функций поврежденной системы, компенсацию имеющихся нарушений. Важным аспектом симптоматической терапии РС является снижение патологического мышечного тонуса. Для этого назначают миорелаксанты (сирдалуд, баклофен, мидокалм), препараты бензодиазепинового ряда (диазепам, вигабатрин, дантролен), иглорефлексотерапию, точечный массаж, применяют методы физической релаксации.

90000 Trigeminal neuralgia — Symptoms — NHS 90001 90002 90003 The main symptom of trigeminal neuralgia is sudden attacks of severe, sharp, shooting facial pain that last from a few seconds to about 2 minutes. 90004 90005 90002 The pain is often described as excruciating, like an electric shock. The attacks can be so severe that you’re unable to do anything while they’re happening. 90005 90002 Trigeminal neuralgia usually affects one side of the face.In some cases it can affect both sides, although not usually at the same time. 90005 90002 The pain can be in the teeth, lower jaw, upper jaw or cheek. Less commonly the pain can also be in the forehead or eye. 90005 90002 You may sense when an attack is about to happen, although they usually start unexpectedly. 90005 90002 After the most severe pain has subsided you may experience a slight ache or burning feeling. You may also have a constant throbbing, aching or burning sensation between attacks.90005 90002 You may experience regular episodes of pain for days, weeks or months at a time. Sometimes the pain may disappear completely and not return for several months or years. This is known as remission. 90005 90002 In severe cases of trigeminal neuralgia the attacks may happen hundreds of times a day and there may be no periods of remission. 90005 90020 Symptom triggers 90021 90002 Attacks of trigeminal neuralgia can be triggered by certain actions or movements, such as: 90005 90024 90025 talking 90026 90025 smiling 90026 90025 chewing 90026 90025 brushing your teeth 90026 90025 washing your face 90026 90025 a light touch 90026 90025 shaving or putting on make-up 90026 90025 swallowing 90026 90025 kissing 90026 90025 a cool breeze or air conditioning 90026 90025 head movements 90026 90025 vibrations, such as walking or travelling in a car 90026 90049 90002 However, pain can happen spontaneously with no trigger whatsoever.90005 90020 Further problems 90021 90002 Living with trigeminal neuralgia can be very difficult and your quality of life can be significantly affected. 90005 90002 You may feel like avoiding activities such as washing, shaving or eating so you do not trigger the pain, and the fear of pain may mean you avoid social activities. 90005 90002 However, it’s important to try to live a normal life and be aware that becoming undernourished or dehydrated can make the pain worse.90005 90002 The emotional strain of living with repeated episodes of pain can lead to psychological problems, such as depression. During periods of extreme pain some people may even consider suicide. Even when pain-free, you may live in fear of the pain returning. 90005 90002 Read more advice about coping with chronic pain. 90005 90020 When to see a GP 90021 90002 You should see a GP if you experience frequent or persistent facial pain, particularly if standard painkillers such as paracetamol and ibuprofen do not help and a dentist has ruled out any dental causes.90005 90002 Trigeminal neuralgia can be difficult to diagnose. The GP will try to identify the problem by asking about your symptoms and ruling out other conditions that could be responsible for your pain. 90005 90002 Read more about diagnosing trigeminal neuralgia. 90005 90002 Page last reviewed: 6 August 2019 90073 Next review due: 6 August 2022 90005 .90000 Trigeminal Neuralgia — Causes, Symptoms and Treatments 90001 90002 90003 90004 90005 Trigeminal Neuralgia | American Association of Neurological Surgeons 90006 90007 90008 90009 90010 90005 Trigeminal neuralgia 90006, also known as tic douloureux, sometimes is described as the most excruciating pain known to humanity. The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye.This intense, stabbing, electric shock-like pain is caused by irritation of the 90005 trigeminal nerve 90006, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face. 90015 90010 Although trigeminal neuralgia can not always be cured, there are treatments available to alleviate the debilitating pain. Normally, 90005 anticonvulsive medications 90006 are the first treatment choice. Surgery can be an effective option for those who become unresponsive to medications or for those who suffer serious side effects from the medications.90015 90010 90021 The Trigeminal Nerve 90022 90015 90010 The trigeminal nerve is the fifth of 12 pairs of cranial nerves in the head. It is the nerve responsible for providing sensation to the face. One trigeminal nerve runs to the right side of the head, while the other runs to the left. Each of these nerves has 90005 three distinct branches 90006. ( «Trigeminal» derives from the Latin word «tria,» which means three, and «geminus,» which means twin.) After the trigeminal nerve leaves the brain and travels inside the skull, it divides into three smaller branches, controlling sensations throughout the face: 90015 90028 90029 The first branch controls sensation in a person’s eye, upper eyelid and forehead.90030 90029 The second branch controls sensation in the lower eyelid, cheek, nostril, upper lip and upper gum. 90030 90029 The third branch controls sensations in the jaw, lower lip, lower gum and some of the muscles used for chewing. 90030 90035 90010 90021 Prevalence and Incidence 90022 90015 90010 It is reported that 150,000 people are diagnosed with trigeminal neuralgia every year. While the disorder can occur at any age, it is most common in people over the age of 50.The National Institute of Neurological Disorders and Stroke (NINDS) notes that trigeminal neuralgia is more common in women than in men. Additionally, there is evidence that the disorder runs in families, likely as a result of an inherited blood vessel formation. 90005 Hypertension 90006 and 90005 multiple sclerosis 90006 (MS) also are risk factors. 90015 90010 90021 Causes 90022 90015 90010 The pain associated with trigeminal neuralgia represents an irritation of the nerve. The cause of the pain usually is due to contact between a healthy 90005 artery 90006 or 90005 vein 90006 and the 90005 trigeminal nerve 90006 at the base of the brain.This places pressure on the nerve as it enters the brain and causes the nerve to misfire. 90015 90010 Other causes of trigeminal neuralgia include pressure of a 90005 tumor 90006 on the nerve or MS, which damages the 90005 myelin sheaths 90006. Development of trigeminal neuralgia in a young adult suggests the possibility of MS. 90015 90064 Your contribution can help 90065 90021 Fund Neurosurgical Research While You Shop 90022 90010 90021 Symptoms 90022 90015 90010 Most patients report that their pain begins spontaneously and seemingly out of nowhere.Other patients say their pain follows a car accident, a blow to the face or 90005 dental surgery 90006. Most physicians and dentists do not believe that dental work can cause trigeminal neuralgia. In these cases, it is more likely that the disorder was already developing, and the dental work caused the initial symptoms to be triggered coincidentally. 90015 90010 Pain often is first experienced along the upper or lower jaw, so many patients assume they have a 90005 dental abscess 90006. Some patients see their dentists and actually have a 90005 root canal 90006 performed, which inevitably brings no relief.When the pain persists, patients realize the problem is not dental-related. 90015 90010 The pain of trigeminal neuralgia is defined as either Type I (sometimes also referred to as «classic») or Type II (may also be called «90005 atypical 90006»). With classic pain, there are definite periods of 90005 remission 90006. The pain is intensely sharp, throbbing and shock-like and usually triggered by touching an area of ​​the skin or by specific activities.Type II pain often is present as a constant, burning sensation affecting a more widespread area of ​​the face.With atypical trigeminal neuralgia, there may not be a remission period, and symptoms are usually more difficult to treat. 90015 90010 Trigeminal neuralgia tends to run in cycles. Patients often suffer long stretches of frequent attacks followed by weeks, months or even years of little or no pain. The usual pattern, however, is for the attacks to intensify over time with shorter pain-free periods. Some patients suffer less than one attack a day, while others experience a dozen or more every hour.The pain typically begins with a sensation of electrical shocks that culminates in an excruciating stabbing pain within less than 20 seconds. The pain often leaves patients with uncontrollable 90005 facial twitching 90006, which is why the disorder is also known as tic douloureux. 90015 90010 Attacks of trigeminal neuralgia may be triggered by the following: 90015 90028 90029 Touching the skin lightly 90030 90029 Washing 90030 90029 Shaving 90030 90029 Brushing teeth 90030 90029 Blowing the nose 90030 90029 Drinking hot or cold beverages 90030 90029 Encountering a light breeze 90030 90029 Applying makeup 90030 90029 Smiling 90030 90029 Talking 90030 90035 90010 The symptoms of several pain disorders are similar to those of trigeminal neuralgia.90005 Temporal tendinitis 90006 involves cheek pain and tooth sensitivity, as well as headaches and neck and shoulder pain. This condition is called a «migraine mimic» because its symptoms are similar to those of a 90005 migraine 90006. Ernest syndrome is an injury of the 90005 styomandubular ligament 90006, which connects the base of the skull with the lower jaw, producing pain in areas of the face, head and neck. 90005 Occipital neuralgia 90006 involves pain in the front and back of the head that sometimes extends into the facial region.90015 90010 90021 Diagnosis 90022 90015 90010 90005 Magnetic resonance imaging (MRI) 90006 can detect if a tumor or MS is irritating the trigeminal nerve. However, unless a tumor or MS is the cause, imaging of the brain will seldom reveal the precise reason why the nerve is being irritated. The vessel next to the nerve root is difficult to see even on a high-quality MRI. Tests can help rule out other causes of facial disorders. Trigeminal neuralgia usually is diagnosed based on the description of the symptoms provided by the patient.90015 90010 90021 Treatment 90022 90015 90010 There are several effective ways to alleviate the pain, including a variety of medications. 90015 90028 90029 90005 Carbamazepine 90006, an anticonvulsant drug, is the most common medication that doctors use to treat trigeminal neuralgia. In the early stages of the disease, carbamazepine controls pain for most people. When a patient shows no relief from this medication, a physician has cause to doubt whether trigeminal neuralgia is present.However, the effectiveness of carbamazepine decreases over time. Possible side effects include 90005 dizziness 90006, 90005 double vision 90006, 90005 drowsiness 90006 and 90005 nausea 90006. 90030 90029 90005 Baclofen 90006 is a 90005 muscle relaxant 90006. Its effectiveness may increase when it is used with either carbamazepine or phenytoin. Possible side effects include 90005 confusion 90006, 90005 depression 90006 and drowsiness. 90030 90029 90005 Phenytoin 90006, an anticonvulsant medication, was the first medication used to treat trigeminal neuralgia.Possible side effects include gum overgrowth, balance disturbances and drowsiness. 90030 90029 90005 Oxcarbazepine 90006, a newer medication, has been used more recently as the first line of treatment. It is structurally related to carbamazepine and may be preferred because it generally has fewer side effects. Possible side effects include dizziness and double vision. 90030 90035 90010 Other medications include 90005 gabapentin 90006, 90005 clonazepam 90006, 90005 sodium valporate 90006, 90005 lamotrigine 90006 and 90005 topiramate 90006.90015 90010 There are drawbacks to these medications other than side effects. Some patients may need relatively high doses to alleviate the pain, and the side effects can become more pronounced at higher doses. Anticonvulsant drugs may lose their effectiveness over time. Some patients may need a higher dose to reduce the pain or a second anticonvulsant, which can lead to adverse drug reactions. Many of these drugs can have a toxic effect on some patients, particularly people with a history of 90005 bone marrow suppression 90006 and 90005 kidney 90006 and 90005 liver toxicity 90006.These patients must have their blood monitored to ensure their safety. 90015 90010 90021 Non-medical & Surgical Treatments 90022 90015 90010 If medications have proven ineffective in treating trigeminal neuralgia, there are several surgical procedures that may help control the pain. Surgical treatment is divided into two categories: 90005 90006 1) open cranial surgery or 2) lesioning procedures. In general, open surgery is performed for patients found to have pressure on the trigeminal nerve from a nearby blood vessel, which can be diagnosed with imaging of the brain, such as a special MRI.This surgery is thought to take away the underlying problem causing the trigeminal neuralgia, and is thus often the treatment of choice for most patients. In contrast, lesioning procedures include interventions that injure the trigeminal nerve on purpose, in order to prevent the nerve from delivering pain to the face. The effects of lesioning are often short-lived, lasting months to years, and results in numbness to the face. Lesioning procedures are often considered for the following patients: those who have recurrent pain after open surgery, those without evidence of a blood vessel pushing on the nerve, and those are poor surgical candidates.90015 90010 90201 Open Surgery: 90202 90015 90010 90005 Microvascular decompression 90006 involves 90005 microsurgical 90006 exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve and gentle movement of the blood vessel away from the point of compression. Decompression may reduce sensitivity and allow the trigeminal nerve to recover and return to a more normal, pain-free condition. While this generally is the most effective surgery, it also is the most invasive, because it requires opening the skull through a 90005 craniotomy 90006.There is a small risk of 90005 decreased hearing 90006, facial weakness, facial numbness, double vision, 90005 stroke 90006 or death. The risk of facial numbness, however, is less likely with procedures that involve damaging the trigeminal nerve. 90015 90010 90201 Lesioning Procedures: 90202 90015 90010 90005 Percutaneous stereotactic rhizotomy 90006 treats trigeminal neuralgia through the use of 90005 electrocoagulation 90006 (heat). It can relieve nerve pain by destroying the part of the nerve that causes pain and suppressing the pain signal to the brain.The surgeon passes a hollow needle through the cheek into the trigeminal nerve. A heating current, which is passed through an 90005 electrode 90006, destroys some of the nerve fibers. 90015 90010 90005 Percutaneous glycerol rhizotomy 90006 utilizes 90005 glycerol 90006 injected through a needle into the area where the nerve divides into three main branches. The goal is to damage the nerve selectively in order to interfere with the transmission of the pain signals to the brain. 90015 90010 90005 Percutaneous balloon compression 90006 utilizes a needle that is passed through the cheek to the trigeminal nerve.The neurosurgeon places a balloon in the trigeminal nerve through a 90005 catheter 90006. The balloon is inflated where fibers produce pain. The balloon compresses the nerve, injuring the pain-causing fibers. After several minutes, the balloon and catheter are removed. 90015 90010 90005 Stereotactic radiosurgery 90006 (through such procedures as 90005 Gamma Knife 90006, 90005 Cyberknife 90006, 90005 LINAC 90006) delivers a single highly concentrated dose of 90005 ionizing radiation 90006 to a small, precise target at the trigeminal nerve root.This treatment is noninvasive, and avoids many of the risks and complications of open surgery and other treatments. Over a period of time and as a result of radiation exposure, the slow formation of a lesion in the nerve interrupts transmission of pain signals to the brain. 90015 90010 Overall, the benefits of surgery or lesioning techniques should always be weighed carefully against its risks. Although a large percentage of trigeminal neuralgia patients report pain relief after procedures, there is no guarantee that they will help every individual.90015 90010 90201 Deafferentation Pain: 90202 90015 90010 Sometimes, lesioning procedures can result in too much injury to the trigeminal nerve, such that the nerve does not recover and the face becomes permanently numb with a different, more difficult to treat type of pain, called deafferentation pain. In these situations, another surgical procedure can be done, that includes placement of one or more electrodes underneath the skull over the covering of the brain, or sometimes directly on the brain, to deliver electrical stimulation to the part of the brain responsible for sensation of the face.This procedure is called motor cortex stimulation; it can be very effective in some patients, and less so in other patients. Since this condition is so rare, motor cortex stimulation is not FDA approved, thus the procedure is considered off-label. 90015 90010 90015 90010 90201 How to Prepare for a Neurosurgical Appointment: 90202 90015 90010 1) Write down your symptoms. This should include: What your pain feels like (for example, is it sharp, shooting, aching, burning, or other), where exactly is your pain is located (lower jaw, cheek, eye / forehead), is it accompanied by other symptoms (headache, numbness, facial spasms), duration of pain (weeks, months, years), pain-free intervals (longest period of time without pain or in between episodes), severity of pain (0 = no pain, 10 = worst pain) 90015 90010 90015 90010 -Note any triggers of pain (eg brushing teeth, touching face, cold air) 90015 90010 90015 90010 -Make a list of medications (prior medications, did they work, were there side effects), current medications (duration and dose) 90015 90010 90015 90010 -Write down questions in advance 90015 90010 90015 90010 90021 Additional Information 90022 90015 90010 The following websites offers additional helpful information on trigeminal neuralgia and its causes, treatment options, support and more (90287 Note: These sites are not under the auspice of AANS, and their listing here should not be seen as an endorsement of the sites or their content 90288).90015 90010 90287 The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS ‘Find a Board-certified Neurosurgeon online tool. 90288 90015 .90000 Trigeminal neuralgia — Diagnosis and treatment 90001 90002 Diagnosis 90003 90004 Your doctor will diagnose trigeminal neuralgia mainly based on your description of the pain, including: 90005 90006 90007 90008 Type. 90009 Pain related to trigeminal neuralgia is sudden, shock-like and brief. 90010 90007 90008 Location. 90009 The parts of your face that are affected by pain will tell your doctor if the trigeminal nerve is involved. 90010 90007 90008 Triggers.90009 Trigeminal neuralgia-related pain usually is brought on by light stimulation of your cheeks, such as from eating, talking or even encountering a cool breeze. 90010 90019 90004 Your doctor may conduct many tests to diagnose trigeminal neuralgia and determine underlying causes for your condition, including: 90005 90006 90007 90008 A neurological examination. 90009 Touching and examining parts of your face can help your doctor determine exactly where the pain is occurring and — if you appear to have trigeminal neuralgia — which branches of the trigeminal nerve may be affected.Reflex tests also can help your doctor determine if your symptoms are caused by a compressed nerve or another condition. 90010 90007 90008 Magnetic resonance imaging (MRI). 90009 Your doctor may order an MRI scan of your head to determine if multiple sclerosis or a tumor is causing trigeminal neuralgia. In some cases, your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiogram). 90010 90019 90004 Your facial pain may be caused by many different conditions, so an accurate diagnosis is important.Your doctor may order additional tests to rule out other conditions. 90005 90002 Treatment 90003 90004 Trigeminal neuralgia treatment usually starts with medications, and some people do not need any additional treatment. However, over time, some people with the condition may stop responding to medications, or they may experience unpleasant side effects. For those people, injections or surgery provide other trigeminal neuralgia treatment options. 90005 90004 If your condition is due to another cause, such as multiple sclerosis, your doctor will treat the underlying condition.90005 90040 Medications 90041 90004 To treat trigeminal neuralgia, your doctor usually will prescribe medications to lessen or block the pain signals sent to your brain. 90005 90006 90007 90004 90008 Anticonvulsants. 90009 Doctors usually prescribe carbamazepine (Tegretol, Carbatrol, others) for trigeminal neuralgia, and it’s been shown to be effective in treating the condition. Other anticonvulsant drugs that may be used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal) and phenytoin (Dilantin, Phenytek).Other drugs, including clonazepam (Klonopin) and gabapentin (Neurontin, Gralise, others), also may be used. 90005 90004 If the anticonvulsant you’re using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.90005 90010 90007 90008 Antispasmodic agents. 90009 Muscle-relaxing agents such as baclofen (Gablofen, Lioresal) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness. 90010 90007 90008 Botox injections. 90009 Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medications. However, more research needs to be done before this treatment is widely used for this condition.90010 90019 90040 Surgery 90041 90004 Surgical options for trigeminal neuralgia include: 90005 90006 90007 90004 90008 Microvascular decompression. 90009 This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root to stop the nerve from malfunctioning. During microvascular decompression, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, your surgeon moves any arteries that are in contact with the trigeminal nerve away from the nerve, and places a soft cushion between the nerve and the arteries.90005 90004 If a vein is compressing the nerve, your surgeon may remove it. Doctors may also cut part of the trigeminal nerve (neurectomy) during this procedure if arteries are not pressing on the nerve. 90005 90004 Microvascular decompression can successfully eliminate or reduce pain most of the time, but pain can recur in some people. Microvascular decompression has some risks, including decreased hearing, facial weakness, facial numbness, a stroke or other complications. Most people who have this procedure have no facial numbness afterward.90005 90010 90007 90004 90008 Brain stereotactic radiosurgery (Gamma knife). 90009 In this procedure, a surgeon directs a focused dose of radiation to the root of your trigeminal nerve. This procedure uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and may take up to a month. 90005 90004 Brain stereotactic radiosurgery is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated.Facial numbness can be a side effect. 90005 90010 90019 90004 Other procedures may be used to treat trigeminal neuralgia, such as a rhizotomy. In a rhizotomy, your surgeon destroys nerve fibers to reduce pain, and this causes some facial numbness. Types of rhizotomy include: 90005 90006 90007 90004 90008 Glycerol injection. 90009 During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. Your doctor guides the needle into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root.Then, your doctor will inject a small amount of sterile glycerol, which damages the trigeminal nerve and blocks pain signals. 90005 90004 This procedure often relieves pain. However, some people have a later recurrence of pain, and many experience facial numbness or tingling. 90005 90010 90007 90004 90008 Balloon compression. 90009 In balloon compression, your doctor inserts a hollow needle through your face and guides it to a part of your trigeminal nerve that goes through the base of your skull.Then, your doctor threads a thin, flexible tube (catheter) with a balloon on the end through the needle. Your doctor inflates the balloon with enough pressure to damage the trigeminal nerve and block pain signals. 90005 90004 Balloon compression successfully controls pain in most people, at least for a period of time. Most people undergoing this procedure experience at least some transient facial numbness. 90005 90010 90007 90004 90008 Radiofrequency thermal lesioning. 90009 This procedure selectively destroys nerve fibers associated with pain.While you’re sedated, your surgeon inserts a hollow needle through your face and guides it to a part of the trigeminal nerve that goes through an opening at the base of your skull. 90005 90004 Once the needle is positioned, your surgeon will briefly wake you from sedation. Your surgeon inserts an electrode through the needle and sends a mild electrical current through the tip of the electrode. You’ll be asked to indicate when and where you feel tingling. 90005 90004 When your neurosurgeon locates the part of the nerve involved in your pain, you’re returned to sedation.Then the electrode is heated until it damages the nerve fibers, creating an area of ​​injury (lesion). If your pain is not eliminated, your doctor may create additional lesions. 90005 90004 Radiofrequency thermal lesioning usually results in some temporary facial numbness after the procedure. Pain may return after three to four years. 90005 90010 90019 90040 More Information 90041 Show more related information 90002 Alternative medicine 90003 90004 Alternative treatments for trigeminal neuralgia generally have not been as well-studied as medications or surgical procedures, so there’s often little evidence to support their use.90005 90004 However, some people have found improvement with treatments, such as acupuncture, biofeedback, chiropractic, and vitamin or nutritional therapy. Be sure to check with your doctor before trying an alternative treatment because it may interact with your other treatments. 90005 90002 Coping and support 90003 90004 Living with trigeminal neuralgia can be difficult. The disorder may affect your interaction with friends and family, your productivity at work, and the overall quality of your life.90005 90004 You may find encouragement and understanding in a support group. Group members often know about the latest treatments and tend to share their own experiences. If you’re interested, your doctor may be able to recommend a group in your area. 90005 90002 Preparing for your appointment 90003 90004 Make an appointment with your primary care provider if you have symptoms common to trigeminal neuralgia. After your initial appointment, you may see a doctor trained in the diagnosis and treatment of brain and nervous system conditions (neurologist).90005 90040 What you can do to prepare 90041 90006 90007 90008 Write down any symptoms you’ve been having, 90009 and for how long. 90010 90007 90008 Note any triggers 90009 that bring on your attacks of facial pain. 90010 90007 90008 Make a list of your key medical information, 90009 including any other conditions for which you’re being treated and the names of any medications, vitamins or supplements you’re taking. 90010 90007 90008 Take a family member or friend along, 90009 if possible.Someone who accompanies you may remember something that you missed or forgot. 90010 90007 90008 Write down questions in advance 90009 to ask your doctor at your appointment. Creating your list of questions in advance can help you make the most of your time with your doctor. 90010 90019 90004 For possible trigeminal neuralgia, some basic questions to ask your doctor include: 90005 90006 90007 What’s the most likely cause of my pain? 90010 90007 Do I need any diagnostic tests? 90010 90007 What treatment approach do you recommend? 90010 90007 If you’re recommending medications, what are the possible side effects? 90010 90007 Will I need treatment for the rest of my life? 90010 90007 How much do you expect my symptoms will improve with treatment? 90010 90007 Is surgery an option? 90010 90019 90004 In addition to the questions that you’ve prepared to ask your doctor, do not hesitate to ask questions during your appointment at any time that you do not understand something.90005 90040 What to expect from your doctor 90041 90004 Your doctor is likely to ask you a number of questions. Being ready to answer them may give you more time to go over points you want to discuss further. Your doctor may ask: 90005 90006 90007 What are your symptoms and where are they located? 90010 90007 When did you first develop these symptoms? 90010 90007 Have your symptoms gotten worse over time? 90010 90007 How often do you experience bouts of facial pain, and have you noticed if anything seems to trigger your facial pain? 90010 90007 How long does an attack of facial pain typically last? 90010 90007 How much are these symptoms affecting your quality of life? 90010 90007 Have you ever had dental surgery or surgery on or near your face, such as sinus surgery? 90010 90007 Have you had any facial trauma, such as an injury or accident that affected your face? 90010 90007 Have you tried any treatments for your facial pain so far? Has anything helped? 90010 90007 What side effects have you experienced from treatment? 90010 90019 .90000 Trigeminal neuralgia: Symptoms, causes, and treatment 90001 90002 Trigeminal neuralgia is a nerve disorder of the face. It causes abrupt, searing facial pain, especially in the lower face and jaw and around the nose, ears, eyes, or lips. 90003 90002 Also known as tic douloureaux, it is thought to be one of the most painful human conditions. 90003 90002 Neuralgia refers to severe pain along the course of a nerve, due to nerve irritation or damage. Trigeminal neuralgia affects the trigeminal nerve, one of the most wide-reaching nerves in the head.90003 90002 In the United States (U.S.), approximately 14,000 people develop the condition annually, and 140,000 people currently live with the condition. It is thought to affect about one million people worldwide. 90003 90010 Fast facts on trigeminal neuralgia 90011 90012 90013 90014 Trigeminal neuralgia is an extremely painful condition that affects the facial, or trigeminal, nerve. 90015 90014 It affects approximately 14,000 people in the United States (U.S.). 90015 90014 The pain will usually be severe and occur on one side of the face.90015 90014 Trigeminal neuralgia is often caused by blood vessels applying pressure to the root of the trigeminal nerve. 90015 90014 It is treated with anticonvulsant medication or a range of surgeries. 90015 90024 Share on PinterestTrigeminal neuralgia is one of the most intense pains a person can experience. 90002 Trigeminal neuralgia is a type of non-nociceptive pain. 90003 90002 Pain can be nociceptive and non-nociceptive. 90003 90013 90014 Nociceptive pain happens when an external stimulus triggers specific pain receptors in the nervous system, for example, the pain caused by a burn.90015 90014 Non-nociceptive pain results from damage or irritation to the nerves or a fault in the nervous system. The nerves themselves are sending pain messages to the brain. 90015 90024 90002 Neuralgia is a type of non-nociceptive pain, and trigeminal neuralgia is non-nociceptive pain caused by the trigeminal or 5th cranial nerve in the face. 90003 90002 People with neuralgia describe it as a short-lived but intense burning or stabbing pain. It may feel as if the pain is shooting along the course of the affected nerve.Although the pain is brief, trigeminal neuralgia is a chronic condition, which gets worse in time. 90003 90002 Bouts of pain can last a few minutes, usually on one side of the face. 90003 90002 Trigeminal neuralgia is twice as common in women than men, and it is more likely after the age of 50 years. 90003 90002 One or more of the following symptoms may occur: 90003 90013 90014 intermittent twinges of mild pain lasting from a few seconds to several minutes 90015 90014 severe episodes of searing, shooting, jabbing pain that feel like electric shocks 90015 90014 sudden attacks of pain triggered by stimuli that are usually not painful, such as by touching the face, chewing, speaking, or brushing the teeth 90015 90014 spasms of pain which last from a couple of seconds to a couple of minutes 90015 90014 episodes of cluster attacks, which may last much longer, but between them, there may be no pain 90015 90014 pain wherever the trigeminal nerve and its branches may reach, including the forehead, eyes, lips, gums, teeth, jaw, and cheek 90015 90014 pain in one side of the face, or, less frequently, both sides 90015 90014 pain that is focused in one spot or spreads in a wider pattern 90015 90014 attacks of pain that occur more regularly and intensely over time 90015 90014 tingli ng or numbness in the face before pain develops 90015 90024 90002 Attacks of pain may occur hundreds of times each day in severe cases.Some patients may have no symptoms for months or years between attacks. 90003 90002 Some patients will have specific points on their face that trigger pain when if touched. 90003 90010 Area of ​​pain 90012 90002 The area of ​​pain will be based on the three branches of the trigeminal nerve: 90003 90013 90014 90077 Ophthalmic 90078: Affects the forehead, nose, and eyes 90015 90014 90077 Maxillary 90078: Affects the lower eyelid, side of nose, cheek, gum, lip, and upper teeth 90015 90014 90077 Mandibular 90078: affects the jaw, lower teeth, gum, and lower lip 90015 90024 90002 Trigeminal neuralgia sometimes affects more than one branch at a time.90003 90010 Atypical trigeminal neuralgia 90012 90002 Atypical trigeminal neuralgia is a variation on typical trigeminal neuralgia. Pain may be described as burning, aching, or cramping, rather than sharp or stabbing. 90003 90002 It may occur on one side of the face, often in the region of the trigeminal nerve, and can extend into the upper neck or the back of the scalp. The pain can fluctuate in intensity from a mild ache to a crushing or burning sensation. 90003 90002 The atypical presentation of trigeminal neuralgia is harder to diagnose.90003 90002 The main cause of trigeminal neuralgia is blood vessels pressing on the root of the trigeminal nerve. 90003 90002 This makes the nerve transmit pain signals that are experienced as stabbing pains. Pressure on this nerve may also be caused by a tumor or multiple sclerosis (MS). 90003 90002 Other causes may include: 90003 90013 90014 Multiple sclerosis: This is due to demyelinization of the nerve. Trigeminal neuralgia typically appears in the advanced stages of multiple sclerosis.90015 90014 A tumor presses against the trigeminal nerve: This is a rare cause. 90015 90014 Physical damage to the nerve: This could be the result of injury, a dental or surgical procedure, or infection. 90015 90014 Family history: The formation of blood vessels is inherited. 90015 90024 90002 Sometimes the cause remains unknown. 90003 90002 If an individual’s symptoms indicate trigeminal neuralgia, a doctor will examine their face to determine the affected areas. 90003 90002 A magnetic resonance imaging (MRI) scan may help eliminate other conditions with similar symptoms, such as tooth decay, a tumor, or sinusitis.However, an MRI is unlikely to show the exact cause of nerve irritation. 90003 90002 The main treatments for trigeminal neuralgia involve prescribed medications and surgery. 90003 90010 Medications 90012 90002 Medications are available to treat trigeminal neuralgia, but these may become less effective over time. 90003 90002 There is also a risk of undesirable side effects. In these cases, surgery may be the best option. 90003 90002 90077 Anticonvulsants 90078 90003 90002 Painkillers, such as paracetamol, will not relieve the pain of trigeminal neuralgia.Doctors, therefore, prescribe anticonvulsant medication. These are normally used to prevent seizures, but they can also reduce or block the pain signals sent to the brain. They do this by calming the nerve impulses. 90003 90002 The most common anticonvulsants for trigeminal neuralgia are: 90003 90013 90014 carbamazepine (Tegretol, Carbatrol, Epitol) 90015 90014 phenytoin (Dilantin) 90015 90014 gabapentin (Neurontin) 90015 90014 topiramate (Topamax) 90015 90014 valproic acid (Depakene, Depakote) 90015 90014 lamotrigine (Lamictal) 90015 90024 90002 Sometimes the anticonvulsant loses its effectiveness over time.If this happens, the doctor might increase the dosage or switch to another anticonvulsant. 90003 90002 Side effects of anticonvulsants include: 90003 90002 Make sure that you are not allergic to these medications, and consult with your doctor about any allergies. 90003 90002 90077 Antispasticity agents 90078 90003 90002 Baclofen is a muscle-relaxing agent. It can be prescribed alone or combined with anticonvulsants. Adverse effects include nausea, drowsiness, and confusion. 90003 90002 90077 Alcohol injection 90078 90003 90002 This numbs the affected areas of the face and provides temporary pain relief.The doctor injects alcohol into the painful part of the face. The patient may require either further injections or a more permanent solution later on. 90003 90010 Surgery 90012 90002 Surgery for trigeminal neuralgia aims to: 90003 90013 90014 stop a vein or artery from pressing against the trigeminal nerve 90015 90014 damage the trigeminal nerve so that the uncontrolled pain signals stop 90015 90024 90002 Damaging the nerve may lead to temporary or permanent facial numbness. Surgery can provide relief, but symptoms may return months or years later.90003 90002 There are a number of surgical options for trigeminal neuralgia. 90003 90002 90077 Microvascular decompression 90078 90003 90002 Microvascular decompression (MVD) involves relocating or removing the blood vessel that is pressing on the root of the trigeminal nerve. 90003 90002 The surgeon makes a small incision behind the ear on the side of the head near the location of the pain. A small hole is made in the skull, and the brain is lifted, exposing the trigeminal nerve. A pad is placed between the nerve and any touching arteries, effectively redirecting them away from the nerve.90003 90002 If no blood vessels are pressing against the nerve, the nerve may instead be severed. 90003 90002 MVD can be effective at eliminating or reducing pain, but sometimes the pain returns. There is also a small risk of some hearing loss, facial weakness, facial numbness, and double vision. 90003 90002 The procedure carries a very small risk of stroke and fatality. 90003 90002 90077 Percutaneous glycerol rhizotomy 90078 90003 90002 Percutaneous glycerol rhizotomy (PGR) is also known as a glycerol injection.A needle is inserted through the face and into an opening at the base of the skull. Imaging techniques guide the needle to the joining point of the three branches of the trigeminal nerve. 90003 90002 A small amount of sterile glycerol is injected. Within a few hours, the trigeminal nerve is damaged, and pain signals are blocked. 90003 90002 Most people experience significant pain relief with PGR, but pain may recur later. Many patients experience facial tingling or numbness. 90003 90002 90077 Percutaneous balloon compression of the trigeminal nerve 90078 90003 90002 A balloon is sent down a hollow needle for inflation next to the nerve.This damages the nerve and blocks uncontrolled signals. 90003 90002 The procedure is effective, but the pain may return. Most patients experience some facial numbness and over half experience temporary or permanent weakness of the muscles used for chewing. 90003 90215 90002 90077 Percutaneous stereotactic radiofrequency thermal rhizotomy 90078 90003 90002 This procedure uses electrical currents to destroy specifically selected nerve fibers linked to pain. 90003 90002 An electrode is attached to the nerve root under sedation.The patient is woken from sedation to identify whether they can feel the electrical pulses and put back under while the electrodes heat up and destroy the nerve. 90003 90002 Most patients undergoing PSRTR will experience some facial numbness afterward. 90003 90002 90077 Partial sensory rhizotomy 90078 90003 90002 The doctor makes a small hole in the skull and severs the nerve. As the base of the nerve is severed, the patient will have permanent facial numbness. Sometimes the doctor rubs the nerve instead of severing it.90003 90002 90077 Gamma-knife radiosurgery 90078 90003 90002 A high dose of radiation is aimed at the root of the trigeminal nerve, gradually resulting in nerve damage and pain reduction. The patient will experience slowly improving pain relief over several weeks. Initial benefits may take several weeks to appear. 90003 90002 GKR is effective for most patients. However, some may experience a recurrence of pain later on. 90003 90002 There are no guidelines for preventing the development of trigeminal neuralgia.However, the following steps may help prevent attacks once diagnosed: 90003 90013 90014 eating soft foods 90015 90014 avoiding foods that are too cold or hot 90015 90014 washing your face with lukewarm water 90015 90014 using cotton pads when washing your face 90015 90014 if tooth brushing triggers an attack, rinsing your mouth with lukewarm water after eating 90015 90014 as far as possible, avoiding known triggers 90015 90024 90002 Trigeminal neuralgia can be debilitating, but managing the symptoms can drastically improve the quality of life.90003.