Trigeminal Neuralgia

Trigeminal neuralgia (tic doloreaux) is a rare disorder of the fifth cranial (trigeminal) nerve, manifested by sharp, shooting electrical-type pains usually on one side of the face. It is triggered by minor stimuli, often chewing, talking or feeling cold wind on the face. Trigeminal neuralgia is almost always caused by a small blood vessel pushing against the origin of the trigeminal nerve at the brainstem.

This disorder is manifested by sharp, electrical type pain shooting into the face in the distribution of the trigeminal nerve components. It can be remitting and relapsing in nature, and trigger factors include chewing, caffeine, extreme temperatures, talking, or even rubbing of the face. Patients with severe pain can develop “masked facies”, where they keep the affected side of the face extremely still to minimize the pain.

Diagnosis of trigeminal neuralgia is mainly based on clinical history. The most common etiology is compression of nerve at its origin from the brainstem. MRIs are routinely obtained, which may or may not show the offending vessel – the absence of an obvious vessel on MRI does not preclude the diagnosis of trigeminal neuralgia. Additionally, MRI scans occasionally show an unexpected etiology to the patient’s symptoms, such as a tumor or vascular malformation.

The first line of treatment is always medical with antiseizure medication (tegretol or dilantin). Should medical treatment fail, a number of surgical treatments are available. These can be either (1) open surgery consisting of craniotomy with microvascular decompression of the trigeminal nerves (MVD); or (2) percutaneous techniques for the fifth nerve, which involves either radio frequency rhizotomy, balloon compression or glycerol injections. The latter techniques are usually used in older patients who are at a higher risk of open brain surgery. Occasionally, Gamma Knife radiosurgery is utilized in this disorder.

The success rate of all of these procedures is usually 75% to 95%, although recurrent cases may be more difficult to treat long term. The surgeons of Dallas Neurosurgical & Spine are experienced in all of these techniques and tailor surgical treatment to the individual patient.

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