Trigeminal Nerve

The trigeminal nerve or 5th cranial nerve is one of the main nerves of the face. It comes through the skull from the brain in front of the ear. It is called tri geminal as it splits into three main branches. Each branch divides into many smaller nerves.Trigeminal-Neuralgia

  • The upper branch V1 (ophthalmic) – which carries sensory information from the skin above the eye, forehead and front of the head.
  • The middle branch V2 (maxillary) – which carries sensory information from the skin through the cheek, side of the nose, upper jaw, teeth and gums.
  • The lower branch V3 (mandibular) – which carries sensory information from the skin through the lower jaw, teeth and gums.

The branches of the trigeminal nerve take sensations of touch and pain to the brain from your face, teeth and mouth. The trigeminal nerve also controls the muscles used in chewing and the production of saliva and tears.

What is Trigeminal Neuralgia (TN)?

Trigeminal neuralgia (TN), also called tic douloureux, is a condition that is characterized by intermittent, shooting pain in the face. It affects the trigeminal nerve or 5th cranial nerve, one of the largest nerves in the head. The trigeminal nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes.

One may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of searing pain. The time between each pain may be minutes, hours, or days. After an attack of pain you may have a dull ache and tenderness over the affected area, which soon eases. Trigeminal neuralgia affects women more often than men. It usually affects people aged over 50.

Symptoms

Trigeminal neuralgia usually only affects one side of the face, in rare cases it can affect both sides, although not at the same time.

  • Occasional twinges of mild pain
  • Episodes of severe, shooting or jabbing pain that may feel like an electric shock
  • Spontaneous attacks of pain or attacks triggered by things such as touching the face, chewing, speaking and brushing teeth
  • Bouts of pain lasting from a few seconds to several seconds
  • Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain
  • Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
  • Pain affecting one side of your face at a time
  • Pain focused in one spot or spread in a wider pattern
  • Attacks becoming more frequent and intense over time

NOTE: TN diagnosis is based primarily on the person’s history and description of symptoms, along with results from physical and neurological examinations. Because of overlapping symptoms and the large number of conditions that can cause facial pain, obtaining a correct diagnosis is difficult, but finding the cause of the pain is important as the treatments for different types of pain may differ.

Treatment

Treatment with a medicine called carbamazepine usually works well to stop the pains. Surgery is an option if medication does not work, or if side-effects from the medicine are a problem.

  1. Microvascular decompression (MVD): The most common surgical procedure done to treat Trigeminal neuralgia is known as the Janetta Procedure. The Trigeminal nerve is exposed using an open surgical approach. A small incision is made behind the ear and a small hole is drilled in the skull aided visually by a specialized microscope. The exposed trigeminal nerve may reveal being compressed by a blood vessel. This blood vessel is then moved away and interposed by a padding made of Teflon felt. MVD in short as the procedure is called – has a high success rate measured by least damage to the nerve, longest pain free period and best chance of the patient being permanently off medication. An average stay at hospital spans two to three days. Normal daily activities can be resumed in four to six weeks.
  2. Radiosurgery (Gamma Knife): This is the least invasive option for treating trigeminal neuralgia; controlled beams of radiation are delivered precisely to targets inside the skull. The trigeminal nerve is targeted at the place where it enters the brainstem to stop the transmission of pain signals rather than attacking the root cause since the procedure is simple and very targeted, it can be done on an outpatient basis requiring little or no anesthesia. However response time is slower as compared to other treatments. On the positive side it provides significant pain control or pain reduction in about more than 80% of the patients even though response time may vary from 4-6 weeks to 3-8 months. The medications for trigeminal neuralgia are usually expected to continue till required level of pain relief has been achieved which may last 3-6 months on an average.

Outpatient needle procedures

Needle procedures are minimally invasive techniques of reaching the trigeminal nerve through the face without a skin incision or skull opening. They are performed with a hollow needle inserted through the skin (percutaneous) of the cheek into the trigeminal nerve at the base of the skull. The goal of rhizotomy or injection procedures is to damage an area of the trigeminal nerve to keep it from sending pain signals to the brain. Damaging the nerve causes mild to major facial numbness in that area. These outpatient procedures are typically performed under local anesthesia and light sedation.Trigeminal-Neuralgia 1

  1. Radiofrequency rhizotomy, also called Percutaneous Stereotactic Radiofrequency Rhizotomy (PSR), uses a heating current to selectively destroy some of the trigeminal nerve fibers that produce pain. While asleep, a hollow needle and electrode are inserted through the cheek and into the nerve. The patient is awakened and a low current is passed through the electrode to stimulate the nerve. Based on feedback, the surgeon positions the electrode so that tingling occurs where painful attacks are located. Once the pain-causing area is located, the patient is put back to sleep and a heating current is passed through the electrode to damage only that portion of the nerve.
  2. Glycerol injection is similar to PSR in that a hollow needle is passed through the cheek to the nerve. The needle is positioned in the trigeminal cistern (a fluid-filled area in the ganglion). Glycerol is injected into the cistern to damage some of the trigeminal nerve fibers that produce pain. Because the location of the glycerol cannot be controlled precisely, the results are somewhat unpredictable.
  3. Balloon compression is similar to PSR in that a hollow needle is passed through the cheek to the nerve. However, it is performed under general anesthesia. The surgeon places a balloon in the trigeminal nerve through a catheter. The balloon is inflated where fibers produce pain. The balloon compresses the nerve, injuring the pain-causing fibers. After several minutes the balloon and catheter are removed.

These procedures work by deliberately injuring or damaging the trigeminal nerve, which is thought to disrupt the pain signals travelling along it.

 

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