Imaging of Trigeminal Neuralgia and Other Facial Pain

BackgroundTrigeminal neuralgia (TN) has the highest incidence of disorders causing facial pain. TN is provoked by benign stimuli, like shaving, leading to severe, short-lasting pain. Patients are initially treated using antiepileptic drugs; however, multiple invasive options are available when conservative treatment proves insufficient. Percutaneous radiofrequency treatment of the trigeminal, or gasserian, ganglion (RF-G) is a procedure regularly used in refractory patients with comorbidities. RF-G involves complex needle maneuvering to perform selective radiofrequency heat treatment of the affected divisions. We present a unique case of cranial nerve 4 (CN4) paralysis after RF-G.Case presentationA male patient in his 60s presented with sharp left-sided facial pain and was diagnosed with TN, attributed to the maxillary and mandibular divisions. MRI showed a vascular loop of the anterior inferior cerebellar artery without interference of the trigeminal complex. The patient opted for RF-G after inadequate conservative therapy. The procedure was performed by an experienced pain physician and guided by live fluoroscopy. The patient was discharged without problems but examined the following day for double vision. Postprocedural MRI showed enhanced signaling between the trigeminal complex and the brainstem. Palsy of CN4 was identified by a neurologist, and spontaneous recovery followed 5 months after the procedure.ConclusionsMention of postprocedural diplopia in guidelines is brief, and the exact incidence remains unknown. Different mechanisms for cranial nerve (CN) palsy have been postulated: incorrect technique, anatomical variations, and secondary heat injury. We observed postprocedural hemorrhage and hypothesized that bleeding might be a contributing factor in injury of CNs after RF-G.

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A novel method to treat recurrent facial pain: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02888-1 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Jintakorn Kuvatanasuchati ◽

Karoon Leowsrisook

Keyword(s):

Case Report ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Case Presentation ◽

Facial Movements ◽

Novel Treatment ◽

Effective Cost ◽

Novel Method

Abstract Background Chronic facial pain is a serious condition affecting millions of people worldwide. The reasons for chronic facial pain vary, and currently, the methods of treating chronic facial pain are expensive, invasive, and, based on current findings, ineffective. The purpose of this study is to develop and test an effective, cost-friendly method to treat patients with chronic facial pain. This study will examine the effectiveness of a novel treatment of a patient suffering from trigeminal neuralgia. Case presentation A 70-year-old Thai female visited the advanced general dentistry clinic at the Faculty of Dentistry, Mahidol University, Bangkok, Thailand. She was suffering from facial pain on her left side and was diagnosed by a physician as having trigeminal neuralgia. She experienced a sharp shooting pain that was triggered by facial movements such as chewing, speaking, or brushing teeth, and touching certain areas of her face. Bouts of pain lasted from a few seconds to several minutes, and episodes of several attacks lasted days, weeks, months, or longer prior to her visit to the advanced general dentistry clinic at Mahidol University. Physician designed an occlusal equilibration appliance for treating the patient by inserting the appliance in the mouth for dental occlusal equilibration (deprogram). The patient used this appliance by placing it in the mouth continuously (day and night) and removed it only when eating. After using the appliance for 2 weeks, the patient appeared to feel and look better prior to taking medication and was able to eat normally. The patient was pain free after treatment for a duration of 9 months. However, after 9 months, the pain reoccurred and manifested itself. Conclusion This novel treatment of recurrent facial pain showed an improvement of the patient’s chronic facial pain and serves as evidence to being a novel method for treating those suffering from trigeminal neuralgia.

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Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers

Journal of Neurosurgery ◽

10.3171/jns.1974.40.2.0143 ◽

1974 ◽

Vol 40 (2) ◽

pp. 143-156 ◽

Cited By ~ 447

Author(s):

William H. Sweet ◽

James G. Wepsic

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain ◽

Electrical Heating ◽

Gasserian Ganglion ◽

Foramen Ovale ◽

Content Type ◽

Corneal Scarring ◽

Radiofrequency Heating ◽

Neurological Morbidity ◽

Fine Print

✓ The authors report their experience in the treatment of trigeminal neuralgia with controlled increments of radiofrequency heating from an electrode placed in the Gasserian ganglion or its posterior rootlets. Touch is preserved in some or all of a trigeminal zone rendered analgesic. The electrode tip is introduced through the foramen ovale and placed among the desired rootlets with the help of a combination of radiographs and the conscious patient's response to electrical stimulation with a square wave signal and gentle electrical heating. The degree of heat is measured by a thermister at the electrode tip. The patient's cooperation is maintained by the use of the neurolept anesthetic Innovar and the production of brief unconsciousness for the painful parts of the operation by methohexital (Brevital). Of 274 patients with facial pain so treated, 214 had trigeminal neuralgia; 91% of the latter group experienced relief of pain and 125 followed for 2½ to 6 years had a recurrence rate of 22%. In a total of 353 procedures, there has been no mortality and no neurological morbidity outside the trigeminal nerve. Only six of the patients with trigeminal neuralgia have complained significantly of postoperative paresthesias. The most serious undesired result has been the production of an anesthetic cornea in 28 patients, one of whom lost the sight of one eye due to corneal scarring. Correlating findings in our patients with those in studies by other authors, we conclude that the preservation of some touch is due to resistance to heating by the heavily myelinated A-beta fibers.

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Neuralgias of the Trigeminal Nerve

Pain Research and Management ◽

10.1155/2000/517683 ◽

2000 ◽

Vol 5 (1) ◽

pp. 107-113 ◽

Cited By ~ 2

Author(s):

Allan S Gordon

Keyword(s):

Neuropathic Pain ◽

Differential Diagnosis ◽

Trigeminal Neuralgia ◽

Clinical Features ◽

Trigeminal Nerve ◽

Postherpetic Neuralgia ◽

Facial Pain ◽

The Other ◽

Atypical Facial Pain ◽

Trigeminal Neuropathic Pain

Practitioners are often presented with patients who complain bitterly of facial pain. The trigeminal nerve is involved in four conditions that are sometimes mixed up. The four conditions - trigeminal neuralgia, trigeminal neuropathic pain, postherpetic neuralgia and atypical facial pain - are discussed under the headings of clinical features, differential diagnosis, cause and treatment. This article should help practitioners to differentiate one from the other and to manage their care.

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Patterns of opioid use in patients with trigeminal neuralgia undergoing neurosurgery

Journal of Neurosurgery ◽

10.3171/2018.8.jns1893 ◽

2019 ◽

Vol 131 (6) ◽

pp. 1805-1811

Author(s):

Andrew I. Yang ◽

Brendan J. McShane ◽

Frederick L. Hitti ◽

Sukhmeet K. Sandhu ◽

H. Isaac Chen ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain ◽

Opioid Use ◽

Exact Test ◽

Fisher's Exact Test ◽

Fisher’S Exact Test ◽

Long Term Follow Up ◽

Neurosurgical Intervention

OBJECTIVEFirst-line treatment for trigeminal neuralgia (TN) is pharmacological management using antiepileptic drugs (AEDs), e.g., carbamazepine (CBZ) and oxcarbazepine (OCBZ). Surgical intervention has been shown to be an effective and durable treatment for TN that is refractory to medical therapy. Despite the lack of evidence for efficacy in patients with TN, the authors hypothesized that patients with neuropathic facial pain are prescribed opioids at high rates, and that neurosurgical intervention may lead to a reduction in opioid use.METHODSThis is a retrospective study of patients with facial pain seen by a single neurosurgeon. All patients completed a survey on pain medications, medical comorbidities, prior interventions for facial pain, and a validated pain outcome tool (the Penn Facial Pain Scale). Patients subsequently undergoing neurosurgical intervention completed a survey at the 1-month follow-up in the office, in addition to telephone interviews using a standardized script between 1 and 6 years after intervention. Univariate and multivariate logistic regression were used to predict opioid use.RESULTSThe study cohort consisted of 309 patients (70% Burchiel type 1 TN [TN1], 18% Burchiel type 2 [TN2], 6% atypical facial pain [AFP], and 6% TN secondary to multiple sclerosis [TN-MS]). At initial presentation, 20% of patients were taking opioids. Of these patients, 55% were receiving concurrent opioid therapy with CBZ/OCBZ, and 84% were receiving concurrent therapy with at least one type of AED. Facial pain diagnosis (for diagnoses other than TN1, odds ratio [OR] 2.5, p = 0.01) and facial pain intensity at its worst (for each unit increase, OR 1.4, p = 0.005) were predictors of opioid use at baseline. Neurosurgical intervention led to a reduction in opioid use to 8% at long-term follow-up (p < 0.01, Fisher’s exact test; n = 154). Diagnosis (for diagnoses other than TN1, OR 4.7, p = 0.002) and postintervention reduction in pain at its worst (for each unit reduction, OR 0.8, p < 10−3) were predictors of opioid use at long-term follow-up. On subgroup analysis, patients with TN1 demonstrated a decrease in opioid use to 5% at long-term follow-up (p < 0.05, Fisher’s exact test), whereas patients with non-TN1 facial pain did not. In the nonsurgical group, there was no statistically significant decrease in opioid use at long-term follow-up (n = 81).CONCLUSIONSIn spite of its high potential for abuse, opioid use, mostly as an adjunct to AEDs, is prevalent in patients with facial pain. Opportunities to curb opioid use in TN1 include earlier neurosurgical intervention.

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Comparison of Clinical Symptoms and Magnetic Resonance Angiographic (MRA) Results in Patients with Trigeminal Neuralgia and Persistent Idiopathic Facial Pain. Medium-Term Outcome after Microvascular Decompression of Cases with Positive MRA Findings

Cephalalgia ◽

10.1111/j.1468-2982.2005.01030.x ◽

2006 ◽

Vol 26 (3) ◽

pp. 266-276 ◽

Cited By ~ 41

Author(s):

A Kuncz ◽

E Vörös ◽

P Barzó ◽

J Tajti ◽

P Milassin ◽

...

Keyword(s):

Magnetic Resonance ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Facial Pain ◽

Clinical Symptoms ◽

Vascular Compression ◽

Term Outcome ◽

Persistent Idiopathic Facial Pain ◽

Venous Compression ◽

Imaging Results

To evaluate whether NC could be demonstrated preoperatively, high-resolution magnetic resonance angiography (MRA) was performed in 287 consecutive patients with TN and persistent idiopathic facial pain (PIFP) on a 0.5-T and a 1-T MR unit. Depending on the clinical symptoms, the TN cases were divided into typical TN and trigeminal neuralgia with non-neuralgic interparoxysmal pain (TNWIP) groups. Microvascular decompression (MVD) was performed in 103 of the MRA-positive cases. The patients were followed up postoperatively for from 1 to 10 years. The clinical symptoms were compared with the imaging results. The value of MRA was assessed on the basis of the clinical symptoms and surgical findings. The outcome of MVD was graded as excellent, good or poor. The clinical symptoms were compared with the type of vascular compression and the outcome of MVD. The MRA image was positive in 161 (56%) of the 287 cases. There were significant differences between the clinical groups: 66.5% of the typical TN group, 47.5% of the TNWIP group and 3.4% of the PIFP group were positive. The quality of the MR unit significantly determined the ratio of positive/negative MRA results. The surgical findings corresponded with the MRA images. Six patients from the MRA-negative group were operated on for selective rhizotomy and no NC was found. Venous compression of the trigeminal nerve was observed in a significantly higher proportion in the background of TNWIP than in that of typical TN on MRA imaging (24.1% and 0.8%, respectively) and also during MVD (31.2% and 1.2%, respectively). Four years following the MVD, 69% of the patients gave an excellent, 23% a good and 8% a poor result. The rate of some kind of recurrence of pain was 20% in the typical TN and 44% in TNWIP group. The rate of recurrence was 57% when pure venous compression was present. The only patient who was operated on from the PIFP group did not react to the MVD. The clinical symptoms and preoperative MRA performed by at least a 1-T MR unit furnish considerable information, which can play a role in the planning of the treatment of TN.

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Idiopathic Trigeminal Neuralgia Associated with a Severe Atypical Facial Pain Exacerbated by Hydrocephalus

Anesthesiology ◽

10.1097/00000542-199912000-00063 ◽

1999 ◽

Vol 91 (6) ◽

pp. 1968-1968 ◽

Cited By ~ 2

Author(s):

Masako Iseki ◽

Hiromasa Mitsuhata ◽

Yutaka Tanabe ◽

Toyo Miyazaki

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain ◽

Atypical Facial Pain ◽

Idiopathic Trigeminal Neuralgia

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Pain Psychiatry of Trigeminal Neuralgia

Effective Techniques for Managing Trigeminal Neuralgia - Advances in Medical Diagnosis, Treatment, and Care ◽

10.4018/978-1-5225-5349-6.ch012 ◽

2018 ◽

pp. 243-264

Author(s):

Lily H. Kim ◽

Michael Bret Schneider

Keyword(s):

Transcranial Magnetic Stimulation ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Magnetic Stimulation ◽

Repetitive Transcranial Magnetic Stimulation ◽

Depression And Anxiety ◽

Surgical Interventions ◽

Holistic Treatment ◽

Carbamazepine Therapy ◽

High Incidence

In addition to the repeated episodes of paroxysmal, electrical facial pain classically associated with the disease, many patients with trigeminal neuralgia (TN) suffer from severe emotional distress. At present, there is no universally agreed pathophysiological explanation for the high incidence of depression and anxiety within this patient population. Despite the unclear understanding, the psychiatric comorbidities should be addressed as a part of comprehensive, multi-modal approach. Anticonvulsants or serotonin and norepineprhine reuptake inhibitors are viable pharmacological options that can supplement the currently used carbamazepine therapy. For medically refractory cases, surgical interventions are being suggested as effective alternatives in managing both the pain and the psychiatric complaints of TN. Examples include microvascular decompression, stereotactic radiosurgery, and repetitive transcranial magnetic stimulation. Continued research to understand TN should take into account the psychiatric burden in this population in order to promote a holistic treatment approach.

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TRIGEMINAL NEURALGIA AND OTHER FACIAL PAIN

Neurology and Clinical Neuroscience ◽

10.1016/b978-0-323-03354-1.50068-7 ◽

2007 ◽

pp. 835-843

Author(s):

Alan Stiles ◽

James Evans

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain

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Cranial neuralgias and persistent idiopathic facial pain

Oxford Textbook of Headache Syndromes ◽

10.1093/med/9780198724322.003.0027 ◽

2020 ◽

pp. 237-247

Author(s):

Aydin Gozalov ◽

Messoud Ashina ◽

Joanna M. Zakrzewska

Keyword(s):

Neuropathic Pain ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Orofacial Pain ◽

Treatment Modalities ◽

Management Approach ◽

Trigeminal Neuropathy ◽

Facial Region ◽

Persistent Idiopathic Facial Pain ◽

Chronic Orofacial Pain

Orofacial pain is a complex problem and affects up to 7% of the population. Although trigeminal neuralgia has been considered the prime neuralgic condition in the facial region, other forms of neuropathic pain are now being more frequently recognized and require recognition and a different management approach. Many patients with chronic orofacial pain report numerous comorbidities, such as psychiatric or personality disorders, which significantly affect management. Various pain conditions present in the facial region. Some of them rarely present extra-orally (unless as radiating pain) such as atypical odontalgia or persistent dento-alveolar pain disorder and burning mouth syndrome, whereas others will present in both areas such as classical trigeminal neuralgia, post-traumatic trigeminal neuropathy, trigeminal neuropathy attributed to multiple sclerosis, and persistent idiopathic facial pain. Myofascial pain syndrome related to the muscles of mastication is very common and may also be associated with temporomandibular joint problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are similar in quality and characteristics with specific treatment modalities, but differ in pain location. Trigeminal neuropathic pain is caused most frequently by trauma. If no other diagnostic criteria are fulfilled, a diagnosis of persistent idiopathic facial pain is made. It is crucial for these patients to be managed by multidisciplinary teams.

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