1. Trigeminal neuralgia (tic douloureux) painful twitch
CT guided interventional treatment
Jalal Jalal Shokouhi- MD ISR Iran
Shahyar Pashaie-MD Tehran. Uni. Iran
Mohammad hossein Herischi Baku Republic Azerbaijan

2. TRIGEMINAL NEURLAGIA

3. Trigeminal Neuralgia What is it?
Fifth cranial nerve pain in the cheek, lips, gums or chin on the one side

4. Function:
Chewing Saliva Tears Facial sensations

5. Topogram: Ophtalmic branch: around eyes and forhead
Maxillary branch: lips, nose, cheek
Mandibular branch: tongue, lower lip

6. TGN-Historical perspective • Fallopius : documented the trigeminal nerve in the 16th century in an anatomical study • John Locke : American physician in Paris – gave a full detailed description of TGN. The patient was the Countess of Northumberland, wife of British Ambassador to the French Court. • Nicolas Andre : called the clinical entity ‘Tic douloureaux’ in 1756 describing 5 patients who suffered from a : ‘cruel and obscure illness which causes in the face some violent motions, some hideous grimaces, which are an insurmountable obstacle to the reception of food, which put off sleep’ • Fothergill’s disease : after eponymous London Physician in • Trousseau : 1853 suggested that the paroxysmal nature of TGN was due to abnormal conduction and called it ‘neuralgia epileptiform’

7. TGN : Clinical features • Female > Male • Incidence : 4
TGN : Clinical features • Female > Male • Incidence : 4.3 / 100,000 • Age group : years • Paroxysmal recurrent pain of short duration • Trigger point(s), allodynia • Periods of remission • Recurrent episodes of pain with progressively shorter periods of remission • Distribution of pain : – localised to Trigeminal nerve – 80% Maxillary / Mandibular combination – Right side > Left side • Clinical examination : Usually normal

8. TGN-Differential diagnosis • Dental / Sinus related pain • Cluster headache / Migrainous neuralgia • Atypical facial pain • Post - herpetic neuropathy • TM joint dysfunction – Degenerative , Rheumatoid arthritis • Trigeminal neuropathy – Demyelination : Multiple sclerosis • Facial myalgia

9. Trigeminal Neuralgia What causes it

10. Pathophysiology
• Compression at root exit zone : at junction of central myelin
(oligodendroglial cells) and peripheral myelin (Schwann cells) : the
Obersteiner-Redlich line
– Vascular cross compression of Root Exit Zone
• Atherosclerotic degeneration causing elongation and tortuosity
– Neoplastic compression
• Meningioma, Schwannoma, Neuroma, Epidermoid
• Focal segmental axonal demyelination with abberant
synaptogenesis resulting in transaxonal ephaptic transmission
• Spontaneous discharge occur at site of compression
• Evoked potentials studies demonstrate increased latency & threshold
consistent with nerve compression

11. Pathophysiology
• Association between multiple sclerosis and
demyelination
– 4% of patients with MS have TGN
• Harris 1950 Rare forms of paroxysmal trigeminal neuralgia
and their relation to disseminated sclerosis BMJ
– 2% of patients with TGN have MS

14. Treatments:
Drug: antiepileptic: carbamazepine or tegretol,phenytoin or dilantin

16. Treatments:
Drug: antiepileptic: carbamazepine or tegretol,phenytoin or dilantin
Surgery of tumor or vascular decompression, microendoscopy (2.7mm)

21. Treatments:
Drug: antiepileptic: carbamazepine or tegretol,phenytoin or dilantin
Surgery of tumor or vascular decompression, microendoscopy (2.7mm)
Radio surgery(γ-knife,RF)

22. Treatments:
Drug: antiepileptic: carbamazepine or tegretol,phenytoin or dilantin
Surgery of tumor or vascular decompression, microendoscopy (2.7mm)
Radio surgery(γ-knife,RF)
Interventional radiology: glycerol, ethanol, RFA

32. 33 Idiopathic (dental operations)?? 16 M.S 14 ?
63 patients
13 Female
50 Male
33 Idiopathic (dental operations)??
16 M.S
14 ?

33. Techniques and drugs:
Needle G22 Spiral CT guidance Local anesthesia (marcaine, pubivicaine cc) Iodine 0.5 cc Ethanol 65-95% 2-3cc

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37. Nerve blockage, if there is no organic lesion in meckle cave, cavernous sinus and parasellar, also mandibular nerve branch
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38. M.S and Pain: 53 to 82% Acute: Neuropathic in acute phase
Chronic: 90% Neuropathic or musculoskeletal
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39. Site of lesions:
Trigeminal entry zone in brain stem: Tri. G. Neuralgia
Brain stem, spinal cord: muscle spasm, pain full cramp
Corticospinal, Corticobulbar, Spasticity, LBP, extremity pain
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44. Results: All patients: pain free immediately after injection
Repeat injection: 2-3
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45. Take home message:
M.S. has diplopia, parestesia, paralysis, vertigo,... Also MS has pain.
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46. Thank you Any Question?