Revisiting the Corneal and Blink Reflexes for Primary and Secondary Trigeminal Facial Pain Differentiation

Trigeminal neuralgia is often misdiagnosed at initial presentation due to close connotation with dental pain and is often over diagnosed for the very same reasons leading to numerous unnecessary surgical procedures such as peripheral neurectomy and alcohol injections, while the actual cause may remain elusive for decades. Evaluation of the neurosensory system may disclose the correct anatomical location of the etiology. The neurological examination may be clouded by the sensory deficits subsequent to previous peripheral surgical procedures. The corneal and blink reflexes are integral measures of the trigeminal and facial neurosensory assessment, and their abnormal function may facilitate the identification of intrinsic disease of the brain stem. These reflexes can be employed to discover pathological lesions including intracranial space-occupying trigeminal, lateral medullary, cerebral hemispheric lesions, and degenerative diseases of the central nervous system. Dental surgeons and oral and maxillofacial surgeons should consider corneal reflex in neurological assessment of patient presenting with trigeminal neuralgia-like symptoms. Failure to evaluate corneal sensitivity may lead to delayed or inaccurate diagnosis and unsuitable or redundant treatment interventions. This simple noninvasive reflex can be performed by chair-side and may provide significant information regarding the origin of facial pain and is an invaluable part of clinical methods especially in remote and peripheral healthcare center practitioners where sophisticated radiographic investigations such as computed tomography and magnetic resonance imaging may not be available.

The Role of Selective Peripheral Neurectomy in the Treatment of Upper Limb Spasticity

Background: Management of upper limb spasticity remains challenging. Selective peripheral neurectomy (SPN) is a relatively recent intervention for cases refractory to medical therapy. The aim of this study was to conduct a systematic review looking at the efficacy and outcomes of SPN, in order to clarify the patient selection criteria and surgical technique. Methods: A search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Open Grey and CINAHL was conducted. Inclusion criteria included studies comparing pre- and post-operative outcomes for SPN, neurectomy, fasciculotomy and upper limb spasticity. Results: Only case series were reported with no randomised controlled trials found. 7 studies met the inclusion criteria with a total of 174 patients. A meta-analysis was not possible due to the degree of baseline heterogeneity. All studies had no control arm for comparison of outcomes, with a high risk of bias due to poor internal and external validity, as well as design and performance bias. Surgical techniques differ vastly between studies, with percentage of fascicles ablated between 30–80% and length of neurectomy between 5–10 mm. Some advocated removing end branches while others performed fascicular SPN proximally. 13 patients underwent orthopaedic or neurosurgical procedures, which are both confounding factors. All studies reported an improvement in spasticity although functional outcomes were reported with non-standardized measures. Recurrence rates were reported to be 0–16.1% (mean 3.72%). Conclusions: From this systematic review, SPN appeared to be a useful technique in selected cases, but overall no firm conclusions can be drawn regarding the best surgical technique, or the extent of functional improvement.