Facial Pain: Diagnosis and treatment Ahmed M. Raslan, MD Assistant Professor Department of Neurological Surgery OHSU, Portland, OR, USA

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Diagnosis of Facial Pain Clinical ! Imaging

Classification of Facial Pain Trigeminal distribution Other cranial Nerves Cluster Migraine TMJ

Classification of Facial Pain Trigeminal distribution Other cranial Nerves TN1 TN2 Symptomatic Neuropathic Postherpetic Deafferentation Atypical Rare syndromes

Classification of Facial Pain Trigeminal distribution Other cranial Nerves Glossopharyngeal Nervus Intermedius Ramsy-Hunt

Other Cranial Neuralgia Glossopharyngeal Nervus Intermedius Ramsy-Hunt Unilateral Throat pain Syncope/ Swallow-syncope Base of tongue-tonsillar fossa-angle of mandible, ear pain

Other Cranial Neuralgia Glossopharyngeal Nervus Intermedius Ramsy-Hunt Unilateral Sharp episodic pain deep in the EXTERNAL ear

Other Cranial Neuralgia Glossopharyngeal Nervus Intermedius Ramsy-Hunt Sudden onset Retroauricular and facial pain Followed 2 days later by facial palsy Vesicular eruptions ?

Trigeminal Neuralgia IASP IHS Sudden , usually unilateral, severe brief stabbing recurrent pains in the distribution of one or more branches of the Vth cranial nerve Painful unilateral affliction, characterized by brief electric shock like pain limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination and may remit for varying periods

Classification of facial pain TN1 TN2 Symptomatic Neuropathic Post-Herpetic De- afferentation Atypical Sharp stabbing episodic pain for more than 50 % of the time. Constitute the typical TN Sharp stabbing pain < 50 with predominant component of dull aching or burning pain. Advanced from of TN Due to: 1-MS 2-Tumour 3-AVM 4-Aneurysm Etc….. Un-intentional injury 1- surgical ENT, Ophth. Plastic…. 2- traumatic Herpes Zoster out-break Severe neuro-pathy Intentional neuro-surgical injury for treatment of TN 1-Rhizotomy 2-RF 3-Radio-surgery Somato-form Pain disorder Can not be diagnosed By history only Burchiel K. A new classification of facial pain. Neurosurgery 53 (5) 2003: 1164-1176 Eller J, Raslan A, Burchiel K. Trigeminal Neuralgia: Definition and classification. Neurosurg Focus 18 (5) 2005: E3

1- TN1 Represents the classic TN Severe abrupt stabbing , electric or shock-like pains is the hallmark Dull aching or burning pain is absent or present for less than 50 % of the time the patient experience the pain Presence of pain free intervals Straight forward diagnosis May progress to TN2 ..?

2- TN2 Still the patient experience sharp pains, but the hallmark is dull aching, burning pain or back ground pain that constitute more than 50 % of the time Constant back ground pain is the most significant attribute with the absence of any structural abnormality

TN2 Type A Type B Progressed from prior TN1 Started de novo a TN2 ; ? Trigeminal ganaglion dysfunction

3- Symptomatic TN Represents what is usually called secondary TN There is another disease or diagnosis that causes demyelination of the trigeminal nerve Trigeminal nerve can be still compressed and sometimes can be treated by treatment of the cause Broggi et al. Operative findings and outcome of microvascular decompression for trigeminal neuralgia in 35 patients affected with multiple sclerosis. Neurosurgery 55(4) 2004: 830-839

4- Neuropathic TN Patients complain of pain of constant nature, with areas of numbness as a hallmark Due to un-intentional injury to the trigeminal nerve during surgery or trauma, could be spontaneous *Johnson M, Burchiel K. Peripheral stimulation for treatment of trigeminal post herpetic neuralgia and trigeminal post-traumatic neuropathic pain: A pilot study. Neurosurgery 55(1) 2004 : 135-142

5- Post Herpetic TN Constitutes a severe form of neuropathy to the trigeminal nerve Easily diagnosed by history of eruptions

6- Deafferentation facial pain Anesthesia Dolorosa Means “ Painful Anesthesia” Doctors’ induced pain syndrome Follows destructive procedures for trigeminal neualgia Surgical rhizotomy RF procedures, Balloon, rarely Glycerol Radiosurgery Very severe and difficult to treat

7- Atypical Facial Pain We use this term to describe patients who complain of facial pain as a part of somatoform pain disorder Can be diagnosed by Neuro-psychological evaluation Patients usually describe the following symptoms Bilateral pain, or pain that cross the midline Pain outside the distribution of trigeminal nerve Multiple complaints in multiple body parts Patients often carries diagnoses like “chronic fatigue syndrome”, “Fibromyalgia” . Surgical treatment is contra-indicated

Pre-operative Imaging TOF MRA

TOF MRA + 3D SPGR + gad

Steady state sequences CISS, FIESTA, BFFE

DTI imaging

Virtual Endoscopy

Surgical Management of Facial Pain Non- Ablative Possibly Curative MVD Modulation of Pain MCS Trigeminal Stimulation DBS Vent. Opioids Ablative Surgical Rhizotomy Caudalis DREZ Percutanous RF Rhizotomy Balloon Glycerol Tractotomy Radiosurgical Gamma Knife Lin-Ac

Treatment of facial pain TN1 TN2 Symptomatic Neuropathic Post-Herpetic De- afferentation Atypical -MVD -RF --Radio-surgery -Radio-surgery -Surgery -MCS -Trigeminal stimulation -Caudalis DREZ -Tractotomy -As neuro-pathic + -Intra-vent. opioids -No Surgery

Hartel Technique

Trigeminal Rhizotomy

Meckel’s Cave

Motor Cortex Stimulation

Motor Cortex Stimulation

Trigeminal Tractotomy

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