Trigeminal Neuralgia

Same day relief from Trigeminal Neuralgia at the Skull Base Institute

Trigeminal Neuralgia is universally acknowledged as one the most painful afflictions known to adults and affects thousands of Americans each year. For this reason, Skull Base Institute’s founder, Dr. Shahinian developed a revolutionary endoscopic “keyhole” procedure to treat it. Feel free to call or Contact Us at any time for answers to your questions or to schedule a treatment consultation.

The procedure is typically completed within one hour and most patients experience same day and permanent relief from trigeminal neuralgia. The Skull Base Institute has successfully treated over 6,000 patients.

To help our visitors understand this difficult condition, we encourage you to continue reading about trigeminal neuralgia below. You can even see Dr. Shahinian on The Ellen Degeneres and The Doctors Shows at our Videos & Animations page! The entire staff at Skull Base Institute is passionate about treating trigeminal neuralgia and we know how painful it can be, so please Contact Us if we can help you.

Overview
Trigeminal neuralgia creates episodes of intense, stabbing, electric shock-like facial pain which are caused when a blood vessel comes in contact with the fifth cranial (trigeminal) nerve, applying pressure to the nerve. Patients with neurovascular problems such as trigeminal neuralgia, hemifacial spasm, intractable vertigo and spasmodic torticollis benefit from the Skull Base Institute’s innovative endoscopic “keyhole” approach to these disorders.

The endoscope is being used at the Skull Base Institute to treat trigeminal neuralgia. At the Institute, surgeons perform this delicate microvascular decompression procedure through a dime-size opening behind the ear. Through this opening, surgeons insert a 2.7 mm endoscope. They can then identify the problem and perform the procedure – meticulously separating the nerve and blood vessel, and inserting a Teflon disk between them. Once the pressure has been relieved, patients often report immediate and complete relief from the pain.

In many cases, the endoscopic “keyhole” surgery is the preferred approach to traditional methods, in which instruments are inserted in a larger opening behind the ear, and the brain pushed aside to reach the nerve compression area.

Since the introduction of the endoscopic keyhole approach, numerous presentations have been made nationally and internationally to both colleagues in the field and patients suffering from neurovascular compression syndromes such as Trigeminal Neuralgia. Video tapes of the procedure have also been requested by both the National Trigeminal Neuralgia Association and several of the regional support groups and have been made available.

3-D Endoscopy of the Posterior Fossa
Of all the exciting advances within the field of microvascular nerve compression syndromes, the near future advent of 3-D endoscopy will be the next refinement in the surgical management of these disorders. We are currently experimenting with new technology that once again will revolutionize the way the keyhole endoscopic decompression procedure is performed. Of all the current procedures that are being performed at the base of the skull we are confident that the surgical treatment for Trigeminal Neuralgia and Hemifacial Spasms will be one of the first to benefit from the application of 3-D endoscopy.

Trigeminal neuralgia (TN) is a pain syndrome characterized by intermittent, shooting pain in the face along the distribution of the fifth (trigeminal) cranial nerve. The trigeminal nerve is the largest of twelve cranial nerves and has three divisions (ophthalmic, maxillary, and mandibular), also known as (V1, V2 and V3) respectively. These three branches are the major carrier of sensory information from the face to the brain.

Neuralgia, simply means pain; the pain is characteristically intense, sharp, episodic, periodical, excruciating, stabbing and short lasting and often accompanied by a brief facial spasm or tic, hence the French term “tic doulourex”. The distribution of pain is typically unilateral i.e. restricted to one side of the face, and follows the sensory distribution of cranial nerve V, typically along the (V2) and/or the (V3) divisions. Rarely TN may manifest as “status trigeminus”, a rapid successtion of tic-like spasms triggered by seemingly minor stimuli.

The condition is the most frequently occurring of all the nerve pain disorders, TN can occur at any age but usually has its onset in women over fifty, male-to-female ratio is 2:3, and its annual incidence is 4/100,000.

TN is distinct but may often be confused and should be differentiated from other closely similar conditions such as atypical facial pain, glossopharyngeal neuralgia, temporomandibular joint pain, sinusitis, migraine headache, other forms of neuritis, and dental problems. These clinical conditions have to be ruled out to establish the diagnosis of TN.

Causes
The condition occurs due to an abnormality that exists both at the level of the inner nerve fibers which carry nerve sensation and at the lining covering the trigeminal nerve (myelin sheath). The nerve fibers behave like an electrical cable leading to electric, shock-like pain induced by a stimulus consisting of a touch or jerk. TN is observed to run in families suggesting a genetic liability for the disease.

The most common triggering cause of TN is an enlarged looping artery or vein pressing on the trigeminal nerve at the base of the brain close to the pons (a part of the brainstem).

Other causes such as aneurysms, tumors, chronic meningeal inflammation, or other lesions may irritate trigeminal nerve roots at the pons and cause symptoms of TN to occur, these can be identified and ruled out by MRI scan of the brain.

Symptoms
There are 3 branches of the trigeminal nerve: the ophthalmic (V1), maxillary (V2), and mandibular (V3). Most commonly TN occurs along the distribution of the maxillary branch (V2), manifesting itself as a sharp pain which runs along the cheekbone, most of the nose, upper lip, and upper teeth. The next most commonly affected division of the trigeminal is the mandibular branch (V3), affecting the lower cheek, lower lip, and jaw.

Patients become plagued by intermittent severe pain which interferes with common daily activities such as eating and brushing teeth. The condition can lead to irritability, severe anticipatory anxiety, depression, and life-threatening malnutrition.

TN is typically described by the patients as extremely severe episodes of pain. Probably the most painful condition known to the human race! The pain is described as stabbing, excruciating, periodic, as if electric shock is given to certain areas of the face. The pain may appear suddenly, may last for a fraction of second or for a few minutes. In rare cases it may last for a couple of hours, making the patient almost immobile and he/she may not be able to do any other activity until the pain subsides.

The pain may get triggered either without any cause or by certain motions involving the facial muscles. Various “triggers” such as washing the face, brushing the teeth, shaving, applying facial make-up, touching the face, blowing, kissing, chewing etc. may precipitate a pain attack. The most minor stimuli such as a mild light breeze may provoke pain in some patients. The degree and character of pain may vary from patient to patient depending on which of the three divisions of the trigeminal nerve is affected, if medication for pain is being used, the individual pain threshold etc. In almost all cases (97%), pain is restricted to one side of the face.

There is a tendency in TN for spontaneous remission, with pain free intervals of weeks or even months, followed by exacerbations, which makes it difficult to judge the effectiveness of any specific treatment. Exacerbations most commonly occur in fall and spring.

Diagnosis
Although TN is diagnosed by clinical symptoms in the majority of cases, all patients should have an MRI scan of the brain to evaluate for any intracranial abnormality. The conventional MRI scans are not always sufficient to visualize the trigeminal nerve or diagnose the offending blood vessel and a 3-dimensional MRI neuro-imaging technique with contrast injection and thin cuts is often required. Of note that some patients may limit their clinical examination for fear of stimulating a trigger point that will precipitate an episode of pain.

Treatment
The initial treatment for TN is medical and directed toward control of the pain. Anti-convulsive medication is used, the most effective drugs are carbamazepine (Tegretol®) and gabapentin (Neurontin®). They should be started at a low dose and gradually increased with the ideal dosage being that which controls the pain but does not cause side effects. Once the initial pain is controlled it is important to consider the natural history of TN. If during therapy the pain subsides completely for four weeks, it is reasonable to gradually reduce the dosage and see if the TN has gone into remission. If the pain recurs the drug can be re-administered.

Treatment with anticonvulsive medication does not help all patients and has its own shortcomings. It needs to be taken for a long period of time and can have many side effects. For those patients whose symptoms cannot be controlled medically without side effects such as nausea, ataxia, physical sluggishness or mental dullness, or who desire long term relief without medication, surgery is indicated.

Surgical options for TN can be divided into two categories: non-destructive procedures and destructive procedures.

Non-Destructive Procedures
The only non-destructive procedure which reliably relieves the symptoms of TN is surgical decompression of the trigeminal nerve, which can be performed either by open surgery or endoscopically. The procedure involves surgical exploration with direct visualization of the trigeminal nerve at its junction with the pons, followed by moving away any compressing blood vessels and padding the nerve with a small piece of Teflon. The advantage is pain relief without numbness in the majority of patients and usually lasts indefinitely.

Destructive Procedures
There are multiple destructive procedures which are utilized in the treatment of TN. The most common of which are glycerol injections, gamma knife radiation, electrocoagulation, and balloon compression. These procedures are all based on interrupting the pain by way of damaging the trigeminal nerve fibers. Generally the more numbness they produce, the longer they last and the numbness created due to nerve destruction may be permanent.

Prognosis
Over time the pain of TN usually becomes more severe and more frequent, requiring higher dosage and more continuous usage of medications. As a result, many patients whose pain was initially well controlled with medication find over time that they must increase to toxic levels in order to control their pain. At this point, they require surgical intervention.

If you or someone you love has questions about Trigeminal Neuralgia, please Contact Us and we will be happy to help you.