Neurology

How to ‘face’ up to trigeminal neuralgia

In this blog post the chief neurosurgeon at GIN gets under the skin of a disorder that causes extreme pain in the face and talks about how it can be cured completely with early diagnosis and treatment.


Affecting the nerve that transmits sensory information from the eyes, mouth and jaw to the brain, trigeminal neuralgia is a nervous system disorder that causes intense pain, generally on one side of the face. Since this nerve has three divisions, ophthalmic, maxillary and mandibular, it is referred to as trigeminal.

Also called Tic Dolereau, patients suffer from excruciating stabs of pain in any or all three parts of the face that shoots up with activities like brushing, chewing or talking. Even the mere act of touching the face can trigger terrifying streaks of pain, almost like lightening.

So extreme is the pain that patients often stop talking, eating and brushing for several days on end. They are known to suffer from depression that may even, at times, drive them to attempt suicide. However, with proper diagnosis and early treatment this condition can be completely cured.

Incidence: Though the nature, severity and location of the pain are characteristic, trigeminal neuralgia is often mistaken for a dental problem. Many patients, as a result, arrive at a neurosurgeon’s clinic after having had several teeth extracted!Trigeminal neuralgia is neither gender nor age specific, but it is more common among women, particularly those over 60, than men and occurs more often on the right than the left side of the face. It can be very active for a time, and then seem to disappear, sometimes for long periods; but it always recurs later, often with more intensity.

Cause: It is now believed that this condition is caused by a blood vessel, either a vein or an artery that sit on the trigeminal nerve at the point where it emerges from the brain. If these blood vessels cause pressure on the nerve or irritate it, severe pain can occur. Besides, the constantly pulsating blood vessels can sometimes lead to the loss of myelination (coating of the nerve)making it hyper-excitable. The disorder can be diagnosed through an MRI scan. If a vascular anomaly is suspected then an angiogram may be required.

Treatment: There are several drugs known to be effective in the treatment of trigeminal neuralgia; but these need to be taken regularly over extended periods of time and may have some side-effects. There are patients who cannot tolerate these medicines.

Micro Vascular decompression: Since we know that the condition is caused by vascular compression, this has emerged as the most acceptable surgical therapy worldwide. During the procedure, surgeons aim to separate the nerve from overlapping vessels and place an intervening substance layer of muscle or Teflon to keep them apart. The relief is instantaneous. BGS-GIN has performed more than 300 such microsurgical procedures with an 88% success rate resulting in complete relief from pain.

Radiofrequency lessoning: This involves thermo coagulation of the ganglion where in painfibres are selectively destroyed. It is a painful procedure usually associated with some degree of impairment of sensations over the face and high recurrence. However this procedure can be used in those who are not fit for surgery.

Radiosurgery: The pain can be reduced by delivering high dose radiation through a selected beam to the trigeminal nerve. Though it is non-invasive, this course of treatment is often considered palliative.

Trigeminal tractotomy: A destructive procedure that removethe trigeminal nerve, tractotomy is resorted to only in extreme cases, generally among patients with malignancy that involves the trigeminal nerve.

Recurrence: Despite the best of treatment, the disease is known to recur in 6-10% of patients. In cases of such a relapse, a combination of the treatment procedures may have to be used again.

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