What Is Trigeminal Neuralgia Radiosurgery?

There is no clear conclusion on the etiology and pathogenesis of trigeminal neuralgia, and no theory can explain its clinical symptoms. What is currently supported is the theory of trigeminal nerve microvascular compression leading to neurodemyelination and epilepsy-like neuralgia.

Bao Yuhai	(Chief physician)	Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
Liang Jiantao	(Deputy Chief Physician)	Department of Neurosurgery, Xuanwu Hospital, Capital Medical University

Trigeminal neuralgia is the most common cerebral neurological disease. It is mainly manifested by recurrent paroxysmal severe pain in the trigeminal nerve distribution area on one side. The domestic statistical incidence rate is 52.2 / 10 million. Females are slightly more than males. The incidence is May grow with age. Trigeminal neuralgia occurs in middle-aged and elderly people, with the right side more than the left side. The disease is characterized by sudden onset, sudden arrest, lightning-like, knife-like, burning-like, intractable, unbearable severe pain in the trigeminal nerve distribution area of the head and face. Speaking, washing your face, brushing your teeth or breeze, even walking can cause severe pain during paroxysmal episodes. The pain lasts for a few seconds or minutes. The pain occurs periodically, and the interval between attacks is the same as that of normal people.

Ni Jiayu

President of China Branch of World Association of Pain Physicians and Director of Pain Treatment Center of Beijing Xuanwu Hospital More details

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Western Medicine Name

Trigeminal neuralgia

Affiliated Department

Surgery-Neurosurgery

Multiple groups

Middle-aged and elderly

Contagious

Non-contagious

Whether to enter health insurance

Yes

Etiology and pathogenesis of trigeminal neuralgia

There is no clear conclusion on the etiology and pathogenesis of trigeminal neuralgia, and no theory can explain its clinical symptoms. What is currently supported is the theory of trigeminal nerve microvascular compression leading to neurodemyelination and epilepsy-like neuralgia.

Clinical manifestations of trigeminal neuralgia

Trigeminal neuralgia sex and age

Most are over 40 years old, mostly middle-aged and elderly. More women than men, about 3: 2;

Trigeminal neuralgia pain site

The right side is more than the left side, and the pain spreads from one point of the face, mouth, or jaw to one or more branches of the trigeminal nerve. The second and third branches are most common, and the first branch is rare. The pain range does not exceed the midline of the face, nor does it exceed the trigeminal nerve distribution area. Occasional bilateral trigeminal neuralgia, 3%;

Trigeminal neuralgia pain nature

Such as severe cuts, acupuncture, tearing, burning, or electric shock, and even painful;

The law of trigeminal neuralgia pain

The onset of trigeminal neuralgia is often unpredictable, and the onset of pain is generally regular. The duration of each pain episode suddenly stopped from only a few seconds to 1 to 2 minutes. The number of episodes is small at the onset of the onset, and the interval is long, ranging from minutes and hours. As the disease progresses, the episodes become more frequent, the interval gradually shortens, and the pain gradually increases and becomes severe. Pain episodes are reduced at night. No discomfort during the interim period; 5. Inducing factors: Talking, eating, washing the face, shaving, brushing teeth, and wind blowing can all induce painful episodes, resulting in the patient's loss of energy. Act cautiously, and even dare not wash his face, brush his teeth, eat or speak Also be careful lest you cause an attack;

Trigeminal neuralgia trigger point

The trigger point is also known as the "trigger point" and is often located on the upper lip, nose, gums, corner of mouth, tongue, eyebrow, etc. Touching or stimulating the trigger point can trigger a painful episode;

Trigeminal neuralgia expression and facial changes

When you have an attack, you often stop talking, eating, and other activities. The painful side can show cramps, that is, "painful cramps." , Tears and salivation. The expression is nervous and anxious;

Trigeminal neuralgia neurological examination

There were no abnormal signs, and a few had reduced facial sensation. Such patients should further inquire about their medical history, especially if they have a history of hypertension, and conduct a comprehensive neurological examination, including lumbar puncture, skull base and internal auditory radiography, brain CT, MRI and other examinations to help Identification of secondary trigeminal neuralgia.

Trigeminal neuralgia classification

Trigeminal neuralgia can be divided into two categories: primary (symptomatic) trigeminal neuralgia and secondary trigeminal neuralgia, of which primary trigeminal neuralgia is more common.

Primary trigeminal neuralgia refers to clinical symptoms, but no organic lesions related to the onset were found by various examinations.

In addition to the clinical symptoms of secondary trigeminal neuralgia, clinical and imaging examinations can reveal organic diseases such as tumors, inflammation, and vascular malformations. Secondary trigeminal neuralgia is more common in young and middle-aged people under the age of 40. There is usually no trigger point, inducing factors are not obvious, and the pain is often persistent. Some patients can find other manifestations of the primary disease. Brain CT, MRI, and nasopharyngeal biopsy are helpful for diagnosis. ^[1]

Differential diagnosis of trigeminal neuralgia

Trigeminal neuralgia toothache

Trigeminal neuralgia is often misdiagnosed as toothache, often pulling out healthy teeth, and even removing all teeth is still ineffective. The pain caused by dental disease is persistent pain, which is mostly limited to the gums, with local dental caries or other lesions. X-ray and dental examination can confirm the diagnosis.

Trigeminal neuralgia parasinusitis

For example, frontal sinusitis, maxillary sinusitis, etc., are localized persistent pains, which may include fever, stuffy nose, thick nose and local tenderness.

Trigeminal neuralgia glaucoma

Acute exacerbation of unilateral glaucoma is misdiagnosed as the first trigeminal pain, glaucoma is a persistent pain, does not emit radiation, may have vomiting, is accompanied by conjunctival membrane congestion, anterior chamber shallowness, and increased intraocular pressure.

Trigeminal neuralgia temporomandibular arthritis

The pain is confined to the temporomandibular joint cavity, and is persistent. There is tenderness at the joints, joint movement disorders, and pain are closely related to mandible movements. X-rays and specialist examinations are available to assist diagnosis.

Trigeminal neuralgia migraine

The pain site is beyond the range of the trigeminal nerve, and there are many visual threats before the attack, such as blurred vision and dark spots, which can be accompanied by vomiting. Pain is persistent and long, often half a day to 1-2 days.

Trigeminal neuralgia

The history is short, the pain is persistent, and the trigeminal nerve distribution area is hypersensitive or diminished, which may be accompanied by dyskinesia. Neuritis usually develops after a cold or paranasal sinusitis.

Trigeminal neuralgia cerebellar pontine angle tumor

The onset of pain may be the same or atypical as trigeminal neuralgia, but it is more common in young people under the age of 30. Most of them have hyposensory trigeminal nerve distribution and gradually produce other symptoms and signs of the cerebellar pontine angle. Cholelipoma is more common, followed by meningiomas and auditory schwannomas. The latter two have other cerebral nerve involvement, and ataxia and increased intracranial pressure are more obvious. X-rays, CT intracranial scans, and MRI can help confirm the diagnosis.

Trigeminal neuralgia tumor invades skull base

The most common is nasopharyngeal carcinoma, which is often accompanied by nasal nasal congestion and nasal congestion. It can invade most of the brain nerves and cervical lymph nodes. It can be confirmed by nasopharyngeal examination, biopsy, skull base X-ray examination, and CT and MRI examinations.

Trigeminal neuralgia glossopharyngeal neuralgia

It is easy for the third branch of the trigeminal nerve to be mixed, and the parts of the glossopharyngeal neuralgia are different, such as the soft palate, the tonsils, the pharyngeal tongue wall, the root of the tongue, and the external auditory meatus. Pain is induced by swallowing. The pain disappeared after spraying the throat area with 1% cocaine.

Trigeminal neuralgia

It can be seen that ganglion cell tumors, chordomas, and Meningioma meningioma, etc., may have persistent pain, and the patient's trigeminal nerve sensory and motor disorders are obvious. The skull base X-ray may have changes such as bone destruction.

Trigeminal neuralgia facial neuralgia

More common in young people, the pain is beyond the scope of the trigeminal nerve, which can extend behind the ears, the top of the head, the occipital neck, and even the shoulders. The pain lasts for several hours, has nothing to do with movement, is not afraid of touching, can be bilateral pain, and can be heavy at night. ^[2]

Trigeminal neuralgia treatment

Trigeminal neuralgia medication

1, carbamazepine (carbamazepine): effective for pain relief in 70% of patients, but about 1/3 of patients can not tolerate side effects such as drowsiness, dizziness, digestive tract discomfort. Start 2 times a day, and later 3 times a day. 0.2 to 0.6 g daily, divided into 2 to 3 times, daily extreme amount of 1.2 g.

2, sodium phenytoin (sodium phenytoin): less effective than carbamazepine.

3, Chinese medicine treatment: have a certain effect.

Trigeminal neuralgia surgery

1. Trigeminal and semilunar ganglion closure

In 1903, Schosser was the first to treat trigeminal neuralgia with peripheral trigeminal closure. Surgery directly injects drugs into the trigeminal nerve, denatures it, causes conduction block, and relieves pain. Commonly used blocking drugs are absolute alcohol and glycerol. Peripheral branch closure is simple, but the effect cannot be lasting, and it can last for 3-8 months, rarely exceeding 1 year. The operation of semilunar closure is relatively complicated and can cause complications such as neurokeratitis. The total effective rate is 72-99%, the early recurrence rate is 20%, and the recurrence rate in 5-10 years is 50%.

2. Percutaneous radiofrequency thermocoagulation for semilunar ganglia

It is a safe, simple, and easy-to-accept treatment method for patients, with a curative effect of 90%. The theoretical basis is that it can selectively destroy the pain fibers in the trigeminal nerve while retaining the tactile fibers. The method is to insert a radio frequency needle electrode into a semilunar ganglion under the guidance of X-ray or CT, and gradually heat it to 65-75 degrees after being energized to damage the target for 60 seconds. This method is suitable for patients who cannot, or refuse, craniotomy due to advanced age.

3. Microvascular decompression (MVD)

MVD surgery is currently the preferred surgical treatment for primary trigeminal neuralgia. Proposed by Professor Jannetta for the first time in 1967, surgical indications include: confirmed that the trigeminal nerve is vascular compression by imaging examination; other patients with poor treatment results are willing to undergo surgery; the blood vessels that cause pain in the trigeminal nerve are called "responsible blood vessels".

Common responsible vessels are:

Upper cerebellar artery (75%), the upper cerebellar artery can form a blood vessel that extends to the caudal side and contacts the trigeminal nerve into the brain stem, mainly compressing the nerve root above or above.

Anterior inferior cerebellar artery (10%), in general, the anterior inferior cerebellar artery compresses the trigeminal nerve from below, and it can also be clamped together with the superior cerebellar artery to clamp the trigeminal nerve.

Basal artery, with the increase of age and hemodynamics, the basilar artery can bend to both sides and compress the trigeminal nerve root, and generally bend to the side of the smaller vertebral artery.

Other rare responsible vessels include the posterior inferior cerebellar artery, mutated vessels (such as the permanent trigeminal artery), the lateral pontine vein, the lateral vein, and the basal vein plexus. The responsible blood vessel can be one or more, and it can be either an artery or a vein.

The method of microvascular decompression is: under general anesthesia, make a 4cm straight incision behind the affected ear and in the hairline, open the skull, with a diameter of about 2cm, enter the cerebellopontine angle area under the microscope, and perform the trigeminal nerve walking area. Explore, "relax" all blood vessels and arachnoid cords that may cause compression, and isolate these blood vessels from nerve roots with Tefflon gaskets. Once the responsible blood vessels are isolated, the root of the stimulus disappears, and the trigeminal nucleus Your high excitement will disappear and return to normal. In most patients, the pain disappears immediately after surgery, and normal facial sensation and function are retained without affecting the quality of life. ^[3]

Trigeminal neuralgia prevention and routine maintenance

1. Diet should be regular should choose soft, chewy food. Patients who have pain due to chewing should eat liquid food, do not eat fried foods, and not eat irritating, over-sour and sweet foods, and cold foods. The diet should be nutritious and usually eat more vitamin-rich and have Foods that clear fire and detoxify; eat more fresh fruits, vegetables and beans, eat less fat and more lean meat, and light food is better.

2. Mouthwash, talk, brush your teeth, and wash your face gently. So as not to induce trigger points and cause trigeminal neuralgia. Do not eat irritating foods such as onions.

3 Pay attention to keep your head and face warm, avoid local freezing and dampness, and do not wash your face with too cold or too hot water; usually you should keep your mood stable, not excited, not tired to stay up late, listen to soft music, feel calm, and maintain adequate sleep.

4 Keep the spirit happy and avoid mental stimulation; try to avoid touching the "trigger point"; living rules, the indoor environment should be quiet, clean and fresh. At the same time, the bedroom is not affected by wind and cold. Appropriate participation in sports, exercise and improve physical fitness.

Trigeminal neuralgia

Legend of Trigeminal Microvascular Decompression

Trigeminal neuralgia is known as "the first pain in the world." At present, microvascular decompression is recognized as the standard method for curing the disease in the medical community. The surgical technique is mature, simple in operation, low in risk, effective and immediate, and rare recurrence. In order to make it easier for patients without medical background and their families to understand what is microvascular decompression, one of our cases is illustrated to illustrate the surgical process.

Figure one

Figure II

Figure three