Division Trigeminal Neuralgia Research Articles

Efficacy and Safety of Radiofrequency Thermocoagulation with Different Puncture Methods for Treatment of V1 Trigeminal Neuralgia: A Prospective Study

Radiofrequency thermocoagulation through the supraorbital foramen with a different puncture method is a new approach for the treatment of ophthalmic division trigeminal neuralgia. To compare the efficacy of the vertical puncture method and the transverse puncture method in the treatment of ophthalmic division trigeminal neuralgia during radiofrequency thermocoagulation through the supraorbital foramen. Randomized, longitudinal prospective, clinical research study. Department of Anesthesiology and Pain Medicine, Jiaxing, China. A total of 57 patients with ophthalmic division trigeminal neuralgia were enrolled in the study between October 2011 and April 2018, and prospectively randomized into the vertical puncture group (n = 29) or transverse puncture group (n = 28). All these patients received computed tomography guided radiofrequency thermocoagulation through the supraorbital foramen. Patients in the vertical puncture group were treated with a vertical puncture method; patients in the transverse puncture group received a transverse puncture method. Facial pain was evaluated using the Numeric Rating Scale preoperatively and at 1 day, 6 months, 1 year, and 2 years after treatment; facial numbness degree was analyzed at 1 day and 2 years after the treatments were recorded. The short-term and long-term complications during the period of postoperative follow-up were recorded. All surgical procedures were successfully completed. The Numeric Rating Scale scores at 6 months, 1 year, and 2 years after the treatment were significantly lower in the transverse puncture group compared to the vertical puncture group (P < 0.05), while no difference was observed on day one after the treatment (P > 0.05). The numbness degree at 2 years was significantly decreased compared to day one in both groups (P < 0.05). The radiofrequency thermocoagulation for ophthalmic division trigeminal neuralgia in the transverse puncture group showed better long-term outcomes than those in the vertical puncture group (P < 0.05). No short-term or long-term postoperative complications were observed in any of the groups. Additional clinical data should be collected to preserve the results in future work. The transverse puncture method during radiofrequency thermocoagulation through the supraorbital foramen had better efficacy and fewer complications in comparison with the vertical puncture method when treating ophthalmic division trigeminal neuralgia.

Long‐Term Outcomes of Percutaneous Radiofrequency Thermocoagulation of Gasserian Ganglion for 2nd‐ and Multiple‐Division Trigeminal Neuralgia

The objective of this study was to examine the long-term outcome of percutaneous radiofrequency thermocoagulation (PRT) of the Gasserian ganglion for the 2nd division and multiple division trigeminal neuralgia (TN), compared to the isolated 3rd division TN. One hundred and forty-eight procedures performed in 89 patients with typical TN between April 2004 and September 2011 in a single pain center were retrospectively analyzed. Baseline characteristics of these patients, immediate outcome, duration pain-free, and complications were obtained from their medical records and questionnaires sent in June 2012. Duration pain-free was assessed by Kaplan-Meier analysis. Of the 148 PRT of the Gasserian ganglion, 37 procedures were performed for isolated 2nd-division TN (V2 TN), 67 procedures were for both 2nd- and 3rd-division TN (V2+V3 TN), and 38 procedures were for isolated 3rd-division TN (V3 TN). The remaining 6 procedures were performed for V1+V2 TN and V1+V2+V3 TN. Immediate success rates of PRT for V2 TN, V2+V3 TN, and V3 TN were 100%, 86.6%, and 100%, respectively, whereas the durations pain-free for V2 TN and V2+V3 TN were significantly shorter than that for V3 TN (9, 12, and 36months, respectively: P=0.012). For 2nd-division TN and multiple-division TN, less long-term pain relief after PRT of the Gasserian ganglion can be expected compared with that for isolated trigeminal 3rd-division neuralgia, even if immediate pain relief is achieved.

Lacrimal neuralgia: So far, a missing cranial neuralgia

The lacrimal nerve supplies the lacrimal gland, the lateral upper eyelid, and a small cutaneous area adjacent to the external CANTHUS . First division trigeminal neuralgia, supraorbital/supratrochlear neuralgia, and infraorbital neuralgia have been acknowledged as neuralgic causes of pain in the forehead and periorbit. However, the lacrimal nerve has never been identified as a source of facial pain. Here we report two cases of lacrimal neuralgia. A 66-year-old woman had continuous pain in the lateral aspect of her left superior eyelid and an adjacent area of the temple since age 64. A 33-year-old woman suffered from continuous pain in a small area next to the lateral CANTHUS of her left eye since age 25. In both patients the superoexternal edge of the orbit was tender. In addition, sensory dysfunction could be demonstrated within the painful area. Anaesthetic blockades of the lacrimal nerve with lidocaine 2% resulted in complete but short-lasting relief. Pregabalin provided a complete response in the first patient. The second patient was refractory to various oral and topical drugs and different radiofrequency procedures, but she eventually obtained partial relief with pregabalin. Lacrimal neuralgia should be considered among the neuralgic causes of orbital and periorbital pain.

Refractory periods in SUNCT

Sir, The refractory period in patients with SUNCT is studied by Pareja JA and group, and we deeply appreciate their contribution in today’s understanding of SUNCT. SUNCT has a resemblance with first division trigeminal neuralgia, but SUNCT can be distinguished by the presence of marked autonomic symptoms like conjunctival injection and tearing. However, we do not have clear understanding of the underlying pathophysiological divide between trigeminal neuralgia and SUNCT. Trigeminal autonomic reflex with central disinhibition of variable extent is believed to bring autonomic symptoms in an otherwise trigeminal neuralgia-like illness. So, the trigeminal neuralgia, SUNA and SUNCT may actually be a continuum [1]. It may still be worthwhile to differentiate trigeminal neuralgia from SUNCT, as the presence or absence of autonomic symptoms may actually point towards the underlying pathophysiology. However, trigeminal neuralgia (ophthalmic division) with florid autonomic features irrespective of refractory period as in our cases represents a spectrum of SUNCT [2]. Over a period of time, these patients may show variable attack severity and fluctuating duration of refractory period. Therefore, we referred to Cohn et al. [3] in our paper, not mistakenly though, as they recommended the application of absent refractory period to diagnostic criteria of SUNCT. We believe that refractory period may be present/relative in milder disease and may become absent with severe disease (saw tooth pattern or very frequent spontaneous attacks) [4, 5]. Once, refractory period is studied in a large cohort of SUNCT patients in respect to attack severity, disease chronicity, primary versus secondary disease or natural course versus on-medication course, it would be more authentic to apply absent refractory period to the diagnostic criteria of SUNCT.

The importance of autonomic symptoms in trigeminal neuralgia

Autonomic symptoms can occur in association with the facial pain of trigeminal neuralgia (TN). The distinction between first division (V1) TN and trigeminal autonomic cephalgias, particularly short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), can be difficult. The goal in this study was to investigate the frequency of autonomic symptoms with TN and to determine their effect on surgical outcome. The authors sent questionnaires and reviewed the records of 92 patients who underwent surgical procedures for TN to obtain visual analog scale scores for pain before and after surgery and to determine the location of the pain and the presence of autonomic symptoms. Sixty-seven percent of patients had at least 1 autonomic symptom, and 14% had 4 or more autonomic symptoms associated with their pain. With V1 pain, the most common autonomic symptoms were conjunctival injection, ptosis, and excessive tearing. With pain involving the second division (V2), facial swelling was the most common autonomic symptom. Excessive salivation occurred most often when the pain involved the third division (V3). In patients who underwent microvascular decompression (MVD), visual analog scores for pain showed significantly greater improvement postoperatively in those who had no preoperative autonomic symptoms than in those who reported autonomic symptoms. There was also a significantly greater number of patients who were pain free postoperatively in the group without autonomic symptoms. There were 3 patients with V1 facial pain associated with conjunctival injection and tearing who, in retrospect, fulfilled all the current diagnostic criteria for SUNCT. These patients underwent MVD, during which a vessel was found to compress the trigeminal nerve. Postoperatively, the 3 patients experienced complete and long-lasting pain relief. The presence of autonomic symptoms in TN correlated with a worse prognosis for pain relief after MVD. First division TN with autonomic symptoms can present identically to SUNCT but can respond to MVD if there is a compressive vessel. Neurosurgeons should be aware of SUNCT, especially in patients with V1 TN and autonomic symptoms, to ensure that all potential medical therapies have been tried prior to surgical treatment.

Wallenberg’s syndrome and symptomatic trigeminal neuralgia

Symptomatic trigeminal neuralgia due to a brainstem infarction is said to be rare. However, facial pain is not uncommon in Wallenberg’s syndrome. Facial pain related to a Wallenberg’s syndrome may be either persistent of intermittent, and occasionally occurs in brief attacks. Here, we report a patient with a right lateral medullary infarction who started having first division trigeminal neuralgia 1 month after the stroke. The pain paroxysms were suppressed with gabapentin.

Trigeminal Neuralgia: Role and Neurosurgical Indications of Peripheral Alcohol Injections, Controlled Radiofrequency Thermocoagulation, Gasserian Ganglion Compression with Balloon and Microvascular Decompression in Posterior Cranial Fossa. Experience in 437 Patients

Introduction: Trigeminal neuralgia is a common cause of facial pain. Many therapies are accomplishable; purpose of the study is to evaluate the role and the indications, in our experience, of peripheral alcohol injections, controlled radiofrequency thermocoagulation, gasserian ganglion compression with balloon and microvascular decompression in posterior cranial fossa. Methods: A series of 437 patients treated with various surgical methods for idiopathic trigeminal neuralgia refractory to medical therapy is presented. The treatments were performed according to the interested trigeminal division, the gravity of the neuralgia, the age and the general conditions of the patients. Moreover, the role of radiosurgery is underlined. Results: Peripheral alcohol injections resulted very effective for temporary control of dolorific attacks. Thermocoagulation resulted a very effective and stable method for isolated III division trigeminal neuralgia; balloon compression was very effective for pain control but entire hemifacial anesthesia was necessary to obtain a good outcome; microvascular decompression resulted affective but was reserved for young healthy patients (trigeminal neuralgia is predominant in advanced age). Conclusions: In our opinion, each treatment should be indicated according to neuralgia (interested trigeminal division, gravity) and patient (age, general conditions) characteristics, to perform the best treatment for each patient.

Microvascular decompression in patients with isolated maxillary division trigeminal neuralgia, with particular attention to venous pathology

The authors have the clinical impression that patients with isolated V2, or maxillary division, trigeminal neuralgia (TN) are most often women of a younger age with atypical pain features and a predominance of venous compression as the pathology. The aim of this study was to evaluate a specific subgroup of patients with V2 TN. Among 120 patients who underwent microvascular decompression (MVD) for TN in 2007, data were available for 114; 6 patients were lost to follow-up. Patients were stratified according to typical (Burchiel Type 1), mixed (Burchiel Type 2a), or atypical (Burchiel Type 2b) TN. A pain-free status without medication was used to determine the efficacy of MVD. All patients were contacted in June 2008 and again in January 2009 at 12-24 months after surgery (median 18.4 months) and asked to rate their response to MVD as excellent (complete pain relief without medication), fair (complete pain relief with medication or some relief with or without medication), or poor (continued pain despite medication; that is, no change from their preoperative baseline pain status. Of 114 patients, 14 (12%) had isolated V2 TN. Among these 14 were 2 typical (14%), 1 mixed (7%), and 11 atypical cases (79%) of TN. Among the remaining 100 cases were 37 typical (37%), 14 mixed (14%), and 49 atypical cases (49%) of TN. In the isolated V2 TN group, all patients were women as compared with 72% of women in the larger group of 100 patients (p = 0.05, chi-square test). The average age in the isolated V2 TN group was 51.2 years (median 48.1 years) versus 54.2 years (median 54.0 years) in the remainder of the group (p = NS, unpaired Student t-test). In the isolated V2 TN group, there was a predominance of atypical pain cases (79%) versus 49% in the remainder of the group, and this finding trended toward statistical significance (p = 0.07, chi-square test). Venous contact or compression (partly or wholly) was noted in 93% of the patients with isolated V2 versus 69% of the remainder of the group (p = 0.13, chi-square test). The likelihood of excellent outcomes in the patients with V2 TN (71%) was compared with that in typical pain cases (79%) among patients in the rest of the group (that is, the bestoutcome group), and no difference was found between the 2 groups (p = 0.8, chi-square test). The authors confirmed that patients with isolated V2 TN were more likely to be female, tended toward an atypical pain classification with venous pathology at surgery, and fared just as well as those presenting with typical pain.

Validity of percutaneous controlled radiofrequency thermocoagulation in the treatment of isolated third division trigeminal neuralgia

Background Of 756 percutaneous controlled radiofrequency thermocoagulations of gasserian ganglion and/or retrogasserian rootlets for idiopathic trigeminal neuralgia or for trigeminal neuralgia in multiple sclerosis, the results in 158 patients who had isolated third division trigeminal neuralgia were reviewed. Methods In 129 patients, percutaneous thermocoagulation was fluoroscopic guided, whereas in the last 29 the procedure was performed under CT control. In all cases, the goal was to achieve selective anesthesia limited to the third trigeminal division. Results Complete pain relief was obtained immediately after the procedure in all patients and selective anesthesia in the third division was achieved in all of them, except for 2 patients in whom unwanted first and second division anesthesia/hypoesthesia also occurred. Other significant complications were transient sixth cranial nerve palsy in 1 patient and masseter muscle dysfunction, which improved during follow-up, in another one. The selected sensory impairment was well tolerated in all patients. During an average follow-up period of 8.8 years, recurrences occurred in 12 patients, together with a partial regression of the anesthesia: in 10 patients the procedure was repeated successfully. In 2 patients with multiple sclerosis, the procedure was repeated twice and 3 times, respectively. Conclusions Percutaneous controlled radiofrequency thermocoagulation is quite easy to perform under fluoroscopic or CT control, and it involves no mortality and very low morbidity; it is an immediately effective procedure and the rate of recurrence is low. Last, but not least, if the anesthesia is limited to the third division, no anesthesia dolorosa occurs and patients are very grateful.

Duration of Attacks of First Division Trigeminal Neuralgia

Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 +/- 11.4 years, and the mean age at onset 64.0 +/- 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 +/- 6.1 s. The unweighted mean was 8.8 +/- 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.

Computerized tomography cisternography of the trigeminal nerve for stereotactic radiosurgery

✓ A-60-year-old man with medically intractable left-sided maxillary division trigeminal neuralgia had severe cardiac disease, was dependent on an internal defibrillator and could not undergo magnetic resonance imaging. The patient was successfully treated using computerized tomography (CT) cisternography and gamma knife radiosurgery. The patient was pain free 2 months after GKS. Contrast cisternography with CT scanning is an excellent alternative imaging modality for the treatment of patients with intractable trigeminal neuralgia who are unable to undergo MR imaging.

Precise Cannulation of the Foramen Ovale in Trigeminal Neuralgia Complicating Osteogenesis Imperfecta with Basilar Invagination: Technical Case Report

Trigeminal neuralgia is a rare feature of basilar invagination, which is itself a complication of osteochondrodysplastic disorders. Microvascular decompression is an unattractive option in medically refractory cases. The conventional percutaneous approach to the trigeminal ganglion is anatomically impossible because the foramen ovale points inferiorly and posteromedially. We report a new technique for image-guided trigeminal injection in a patient with basilar invagination complicating osteogenesis imperfecta. A 26-year-old woman with osteogenesis imperfecta presented with a 3-year history of typical left maxillary division trigeminal neuralgia, which was poorly controlled by carbamazepine at the maximum tolerated dose. She had obvious cranial deformities, left optic atrophy, delayed left eye closure, tongue atrophy, but normal facial sensation and corneal reflexes. A computed tomographic scan and magnetic resonance imaging confirmed severe basilar invagination. Frameless stereotactic glycerol injection of the left trigeminal ganglion was performed under general anesthesia using the infrared-based EasyGuide Neuro system (Philips Medical Systems, Best, The Netherlands) with magnetic resonance imaging and computed tomographic registration. The displaced and distorted left foramen ovale was cannulated via a true frameless stereotactic method with the trajectory determined by virtual pointer elongation. The needle placement was confirmed with injection of contrast medium into the trigeminal cistern. The path needed to enter the foramen traversed the right cheek, soft palate, and left tonsil. The patient went home pain-free with a preserved corneal reflex and no complications. Frameless stereotaxy allows customization to individual patient anatomy and may be adapted to a variety of percutaneous procedures used in areas where the anatomy is complex.

The long lasting effects of peripheral nerve blocks for trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine

The management of trigeminal neuralgia in older patients who do not want neurolytic block and/or surgical treatment may be problematic. This paper describes three patients who had first and/or second division trigeminal neuralgia. The analgesic effects of infraorbital nerve block using 0.5% bupivacaine or 1% mepivacaine dissipated within a few days, however, the effects of nerve blocks using 4% tetracaine dissolved in 0.5% bupivacaine continued for more than 3 months. Hypesthesia was observed in two patients within a week following the block, but sensory level returned to normal within 2 weeks and there were no further complications in any patient.

SUNCT syndrome: duration, frequency, and temporal distribution of attacks.

Duration, frequency, and temporal distribution of attacks have been objectively estimated in 11 SUNCT patients (3 women and 8 men). The mean age at the time of the study was 69 years (range 52 to 81). The duration of a total of 348 attacks was measured from videotape records, polygraphic tracings, or by stopwatch. The duration of attacks ranged from 5 to 250 seconds, with an unweighted mean of 61 seconds. Both frequency and exact timing of attacks were assessed in four patients who filled in a time chart with the exact onset of 585 consecutive attacks. The majority of attacks occurred during daytime, with a bimodal distribution; ie, morning and afternoon/evening peaks, and only a few attacks were noted at night (ie, 1.2% of the attacks). The unweighted mean frequency of attacks was 28 per day (range 6 to 77). Duration and timing of attacks in SUNCT syndrome may be of help in the differential diagnosis versus other disorders with the same localization, especially first division trigeminal neuralgia.

SUNCT Syndrome: A Hungarian Case

A Hungarian patient with short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is presented in this paper. This male patient was first diagnosed as having first division trigeminal neuralgia. The location and duration of the attacks and the prominent accompanying autonomic features on the symptomatic side, such as conjunctival injection, lacrimation, nasal stuffiness, and the inefficacy of drugs, led to a reconsideration of the diagnosis. The pain paroxysms occurred frequently during a 3- to 4-month period, followed by a longer remission phase. Mechanical precipitating maneuvers were observed during bouts of pain. The clinical picture is reminiscent of the SUNCT syndrome, first described by Sjaastad et al in 1978. SUNCT and trigeminal neuralgia are in many ways similar, although, some decisive differences have also been noted. Further observations are needed to distinguish the two disorders and to clarify this syndrome as a new headache type or as a trigeminal neuralgia variant.

Trigeminal neuralgia due to cholesteatoma of Meckel's cave. Case report.

✓ A young man with typical symptoms of third division trigeminal neuralgia, without sensory impairment, was found to have a small localized cholesteatoma in Meckel's cave. Removal of the tumor resulted in immediate cure.