Trigeminal Neuralgia Pain Research Articles

Relationship between trigeminal neuralgia and the C-reactive protein/albumin ratio

Objectives: This study aimed to assess whether the C-reactive protein/albumin ratio (CAR) is a risk factor for trigeminal neuralgia (TN) development and the relationship between the CAR and TN pain frequency. Patients and methods: In this retrospective study, 100 patients (51 females, 49 males; mean age: 58.6±14.1 years; range, 31 to 88 years) with idiopathic TN and 70 healthy controls (38 females, 32 males; mean age: 54.1±15.7 years; range, 21 to 89 years) were included between January 2020 and December 2022. Patients were divided into two groups by weekly and monthly pain frequency. The laboratory findings and CARs were compared. Results: The CAR values were significantly different between the patient and control groups (p<0.05) and were significantly different among TN subgroups divided according to attack frequency (p<0.05). Conclusion: Since there was a significant relationship between TN and CAR as a prognostic predictor, this relationship demonstrated once again that inflammation plays a role in the etiopathogenesis of TN. As opposed to previous studies that investigated the effect of only inflammation, the effects of both inflammation and malnutrition could be investigated by evaluating CAR in this study.

Hippocampus diffusivity abnormalities in classical trigeminal neuralgia

Abstract Introduction: Patients with chronic pain frequently report cognitive symptoms that affect memory and attention, which are functions attributed to the hippocampus. Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder characterized by paroxysmal attacks of unilateral orofacial pain. Given the stereotypical nature of TN pain and lack of negative symptoms including sensory loss, TN provides a unique model to investigate the hippocampal implications of chronic pain. Recent evidence demonstrated that TN is associated with macrostructural hippocampal abnormalities indicated by reduced subfield volumes; however, there is a paucity in our understanding of hippocampal microstructural abnormalities associated with TN. Objectives: To explore diffusivity metrics within the hippocampus, along with its functional and structural subfields, in patients with TN. Methods: To examine hippocampal microstructure, we utilized diffusion tensor imaging in 31 patients with TN and 21 controls. T1-weighted magnetic resonance images were segmented into hippocampal subfields and registered into diffusion-weighted imaging space. Fractional anisotropy (FA) and mean diffusivity were extracted for hippocampal subfields and longitudinal axis segmentations. Results: Patients with TN demonstrated reduced FA in bilateral whole hippocampi and hippocampal body and contralateral subregions CA2/3 and CA4, indicating microstructural hippocampal abnormalities. Notably, patients with TN showed significant correlation between age and hippocampal FA, while controls did not exhibit this correlation. These effects were driven chiefly by female patients with TN. Conclusion: This study demonstrates that TN is associated with microstructural hippocampal abnormalities, which may precede and potentially be temporally linked to volumetric hippocampal alterations demonstrated previously. These findings provide further evidence for the role of the hippocampus in chronic pain and suggest the potential for targeted interventions to mitigate cognitive symptoms in patients with chronic pain.

Causal interactions in brain networks predict pain levels in trigeminal neuralgia

Trigeminal neuralgia (TN) is a highly debilitating facial pain condition. Magnetic resonance imaging (MRI) is the main method for generating insights into the central mechanisms of TN pain in humans. Studies have found both structural and functional abnormalities in various brain structures in TN patients as compared with healthy controls. Whereas studies have also examined aberrations in brain networks in TN, no studies have to date investigated causal interactions in these brain networks and related these causal interactions to the levels of TN pain. We recorded fMRI data from 39 TN patients who either rested comfortably in the scanner during the resting state session or tracked their pain levels during the pain tracking session. Applying Granger causality to analyze the data and requiring consistent findings across the two scanning sessions, we found 5 causal interactions, including: (1) Thalamus → dACC, (2) Caudate → Inferior temporal gyrus, (3) Precentral gyrus → Inferior temporal gyrus, (4) Supramarginal gyrus → Inferior temporal gyrus, and (5) Bankssts → Inferior temporal gyrus, that were consistently associated with the levels of pain experienced by the patients. Utilizing these 5 causal interactions as predictor variables and the pain score as the predicted variable in a linear multiple regression model, we found that in both pain tracking and resting state sessions, the model was able to explain ∼36 % of the variance in pain levels, and importantly, the model trained on the 5 causal interaction values from one session was able to predict pain levels using the 5 causal interaction values from the other session, thereby cross-validating the models. These results, obtained by applying novel analytical methods to neuroimaging data, provide important insights into the pathophysiology of TN and could inform future studies aimed at developing innovative therapies for treating TN.

Outcomes of Trigeminal Ganglion Sparing Surgical Resection of Nonacoustic Cerebellopontine Angle Tumors Causing Trigeminal Neuralgia

ObjectiveTumors may be responsible for up to 5% of trigeminal neuralgia (TN) cases. Predictors of long-term pain relief after surgical resection of various cerebellopontine angle (CPA) tumor types are not well understood. Previous studies found that size and extent of resection predict long-term pain status, although resection of tumor involving the trigeminal ganglion (TG) may be associated with high morbidity. This study evaluated predictors of TN pain freedom after resection of a non-acoustic CPA tumor, with avoidance of any portion involving the TG. MethodsIn a retrospective cohort study, we evaluated clinical outcomes and complications after surgical resection of non-acoustic CPA tumors with purposeful avoidance of the TG causing trigeminal neuralgia. The primary outcome was pain-freedom. We performed logistic regression analyses to examine the relationship between pain-freedom at last follow-up and age, side of symptoms, pre-operative symptom duration, tumor diameter, tumor type, and concurrent neurovascular compression (NVC). ResultsOf 18 patients with non-acoustic CPA tumors causing TN treated with surgical resection, 83.3% were pain-free at last follow-up (mean 44.6 months). Age(p=0.12), side (p=0.41), pre-operative symptom duration(p=0.85), tumor diameter(p=0.29), tumor type(p=0.37), and NVC presence (p=0.075) were not associated with long-term pain freedom. ConclusionsThis study provides additional evidence that various tumor types causing trigeminal neuralgia may safely undergo surgical resection and decompression of the trigeminal nerve to treat TN. This study presents a cohort of patients that underwent resection of a non-acoustic CPA tumor, with purposeful avoidance of the TG to minimize complications, demonstrating high rates of long-term pain freedom.

The influence of prior percutaneous rhizotomy on outcomes following microvascular decompression for trigeminal neuralgia.

Microvascular decompression (MVD) is an effective intervention in patients with trigeminal neuralgia (TN). How prior rhizotomy can impact long-term pain outcomes following MVD is not well understood. In this study, the authors sought to compare pain outcomes in patients who had undergone primary MVD versus those who had undergone secondary MVD after a single or multiple rhizotomies. The authors retrospectively reviewed the data on all patients who had undergone MVD at their institution from 2007 to 2020. Patients were included in the study if they had undergone primary MVD or if their surgical history was notable for past rhizotomy. Barrow Neurological Institute (BNI) pain scores were assigned at preoperative and final follow-up appointments. Perioperative complications were noted for each patient, and evidence of pain recurrence was recorded as well. A history of rhizotomy as well as other variables that might influence TN pain recurrence were evaluated using a Cox proportional hazards model. The impact of prior rhizotomy on TN pain recurrence following MVD was further assessed using Kaplan-Meier survival analysis. Of 1044 patients reviewed, 947 met the study inclusion criteria. Of these, 796 patients had undergone primary MVD, 84 had a history of a single rhizotomy before MVD, and 67 had a history of ≥ 2 rhizotomies prior to MVD. Patients in the single rhizotomy and multiple rhizotomies cohorts exhibited a greater frequency of preoperative numbness (p < 0.001), higher preoperative BNI pain scores (p < 0.005), and higher rates of postoperative numbness (p = 0.04). However, final follow-up BNI pain scores were not significantly different between the primary MVD and prior rhizotomy groups (p = 0.34). Cox proportional hazards analysis revealed that younger age, multiple sclerosis, and female sex independently predicted an increased risk of pain recurrence following MVD. Neither a history of a single prior rhizotomy nor a history of multiple prior rhizotomies independently increased the risk of pain recurrence. Furthermore, Kaplan-Meier analysis of pain-free survival among the 3 groups revealed no relationship between a history of prior rhizotomy and pain recurrence following MVD (p = 0.57). Percutaneous rhizotomy does not complicate outcomes following subsequent MVD for TN pain. However, patients undergoing rhizotomy before MVD may have an increased risk of postoperative facial numbness compared to that in patients undergoing primary MVD.

352 Outcomes After Microvascular Decompression for Sole Arterial Versus Venous Compression in Trigeminal Neuralgia

INTRODUCTION: In most cases of trigeminal neuralgia (TN), the trigeminal nerve is compressed by the arterial vasculature. METHODS: We retrospectively reviewed all patients undergoing microvascular decompression at our institution, identifying patients with either sole arterial or venous compression. We dichotomized patients into arterial or venous groups and obtained demographics and postoperative complications for each case. Barrow Neurological Index (BNI) pain scores were collected preoperatively, postoperatively, and at final follow-up, as well as recurrence of pain. Differences were calculated via Chi-squared tests and t-tests. Ordinal regression was used to account for variables known to influence TN pain. Kaplan-Meier analysis was used to determine recurrence-free survival. RESULTS: Of 1044 patients, 642 (61.7%) had either sole arterial or venous compression. 472 of these cases demonstrated arterial compression, and 170 displayed sole venous compression. Patients in the venous compression group were significantly younger (p &lt; 0.001). Patients with sole venous compression demonstrated worse preoperative (p = 0.04) and final follow-up (p &lt; 0.001) pain scores. Patients with sole venous compression had significantly higher rate of pain recurrence (p = 0.02) and BNI score at pain recurrence (p = 0.04). On ordinal regression, venous compression was found to independently predict worse BNI pain scores (OR = 1.66, p = 0.003). Kaplan-Meier analysis demonstrated a significant relationship between sole venous compression and increased risk of pain recurrence (p = 0.03). CONCLUSIONS: TN patients with sole venous compression demonstrate worse pain outcomes following MVD compared to those with only arterial compression.

The white matter characteristic of the genu of corpus callosum coupled with pain intensity and negative emotion scores in patients with trigeminal neuralgia: a multivariate analysis.

Trigeminal neuralgia (TN) is a chronic neuropathic pain disorder that not only causes intense pain but also affects the psychological health of patients. Since TN pain intensity and negative emotion may be grounded in our own pain experiences, they exhibit huge inter-individual differences. This study investigates the effect of inter-individual differences in pain intensity and negative emotion on brain structure in patients with TN and the possible pathophysiology mechanism underlying this disease. T1 weighted magnetic resonance imaging and diffusion tensor imaging scans were obtained in 46 patients with TN and 35 healthy controls. All patients with TN underwent pain-related and emotion-related questionnaires. Voxel-based morphometry and regional white matter diffusion property analysis were used to investigate whole brain grey and white matter quantitatively. Innovatively employing partial least squares correlation analysis to explore the relationship among pain intensity, negative emotion and brain microstructure in patients with TN. Significant difference in white matter integrity were identified in patients with TN compared to the healthy controls group; The most correlation brain region in the partial least squares correlation analysis was the genus of the corpus callosum, which was negatively associated with both pain intensity and negative emotion. The genu of corpus callosum plays an important role in the cognition of pain perception, the generation and conduction of negative emotions in patients with TN. These findings may deepen our understanding of the pathophysiology of TN.

Efficacy of Laser Therapy in Trigeminal Neuralgia: a Systematic Review.

Trigeminal neuralgia is the most common and disabling type of neuralgia in craniofacial region. Because of adverse effects of first and second lines of treatment, new modalities including laser therapy have been investigated for treatment of trigeminal neuralgia. The aim of this study was to review the effect of laser in trigeminal neuralgia. PubMed, Scopus, Web of Science, Science Direct, and Embase databases from December 1983 to August 2020 were searched using keywords "trigeminal neuralgia" and "laser". Our inclusion criteria were interventional studies with a randomized clinical trial design, which used laser for treatment of trigeminal neuralgia. In this systematic review, a total of 269 records were identified through systematically searching aforementioned databases among which, 30 were from PubMed and 44 were from Web of Science. A total of 111 records were duplicated and were therefore removed. Only 17 records were considered relevant after reading title and abstracts. After reading full texts of the articles, 13 met the eligibility criteria and were included in our review. This review revealed that low-level laser therapy reduces pain in trigeminal neuralgia specially diode lasers, although there are no standardized protocols for laser procedures.

Trigeminal neuralgia pain outcomes following microsurgical resection versus stereotactic radiosurgery for petroclival meningiomas: a systematic review and meta-analysis.

Petroclival meningiomas (PCMs) are challenging lesions to treat because of their deep location and proximity to critical neurovascular structures. Patients with these lesions commonly present because of local mass effect. A symptom that proves challenging to definitively manage is trigeminal neuralgia (TN), which occurs in approximately 5% of PCM cases. To date, there is no consensus on whether microsurgical resection or stereotactic radiosurgery (SRS) leads to better outcomes in the treatment of TN secondary to PCM. In this systematic review and meta-analysis, the authors aimed to evaluate the available literature on the efficacy of microsurgical resection versus SRS for controlling TN secondary to PCM. The Embase, MEDLINE, Scopus, and Cochrane databases were queried from database inception to May 17, 2022, using the search terms "(petroclival AND meningioma) AND (trigeminal AND neuralgia)." Study inclusion criteria were as follows: 1) reports on patients aged ≥ 18 years and diagnosed with TN secondary to PCM, 2) cases treated with microsurgical resection or SRS, 3) cases with at least one posttreatment follow-up report of TN pain, 4) cases with at least one outcome of tumor control, and 5) publications describing randomized controlled trials, comparative or single-arm observational studies, case reports, or case series. Exclusion criteria were 1) literature reviews, technical notes, conference abstracts, or autopsy reports; 2) publications that did not clearly differentiate data on patients with PCMs from data on patients with different tumors or with meningiomas in different locations (other intracranial or spinal meningiomas); 3) publications that contained insufficient data on treatments and outcomes; and 4) publications not written in the English language. References of eligible studies were screened to retrieve additional relevant studies. Data on pain and tumor outcomes were compared between the microsurgical resection and SRS treatment groups. The DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction was used to pool estimates from the included studies. Two comparative observational studies and 6 single-arm observational studies describing outcomes after primary intervention were included in the analyses (138 patients). Fifty-seven patients underwent microsurgical resection and 81 underwent SRS for the management of TN secondary to PCM. By the last follow-up (mean 71 months, range 24-149 months), the resection group had significantly higher rates of pain resolution than the SRS group (82%, 95% CI 50%-100% vs 31%, 95% CI 18%-45%, respectively; p = 0.004). There was also a significantly longer median time to tumor recurrence following resection (43.75 vs 16.7 months, p < 0.01). The resection group showed lower rates of pain persistence (0%, 95% CI 0%-6% vs 25%, 95% CI 13%-39%, p = 0.001) and pain exacerbation (0% vs 12%, 95% CI 3%-23%, p = 0.001). The most common postintervention Barrow Neurological Institute pain score in the surgical group was I (66.7%) compared with III (27.2%) in the SRS group. Surgical reintervention was less frequently required following primary resection (1.8%, 95% CI 0%-37% vs 19%, 95% CI 1%-48%, p < 0.01). Microsurgical resection is associated with higher rates of TN pain resolution and lower rates of pain persistence and exacerbation than SRS in the treatment of PCM. SRS with further TN management is a viable alternative in patients who are not good candidates for microsurgical resection.

Unusual Presentation of Trigeminal Neuralgia and its Surgical Management

Trigeminal neuralgia (TN) is a debilitating neuropathic condition characterized by excruciating, lancinating pain attacks. The standard first-line treatment of TN is carbamazepine medication, but some patients do not experience relief from this drug. For cases that do not respond to medication, surgical procedures that cut or remove portions of the peripheral nerves, such as the inferior alveolar and mental nerves, can be attempted. However, these neurectomysurgeries often have high rates of severe facial pain recurring over time. A 40-year-old man suffered from chronic, debilitating trigeminal neuralgia. He underwent multiple tooth extractions and took carbamazepine, but neither provided improvement in his agonizing facial pain. He then had surgical neurectomies of the mental and inferior alveolar nerves, which provided only partial pain relief. The patient was not relieved, so he underwent a surgical neurectomy of the lingual nerve. This third procedure successfully provided a significant reduction in his trigeminal neuralgia pain. Lingual neurectomy emerges as a potentially definitive treatment modality for trigeminal neuralgia refractory to medication or alternative neurectomy procedures. This minimally invasive surgical approach offers a valuable option for patients seeking sustained pain relief, particularly those who are not suitable candidates for or desire to avoid, more extensive or resource-intensive interventions.

History of Trigeminal Neuralgia:Before the Era of Modern Treatment

Descriptions of what appears to be trigeminal neuralgia(TN)appear in medical literature from around the 2nd century AD. Aretaeus of Cappadocia is believed to be the first person in history to have specifically described TN. TN or TN-like facial pain was once known as Fothergill's disease, following a detailed description of the symptoms by Fothergill in the 18th century. For a long time, no effective oral therapy for TN was available, and only surgical treatments were used, such as severing of the trigeminal nerve or resection of the Gasserian ganglion. In the 19th and 20th centuries, Hartley, Krauss, Cushing, Spiller and Frazier developed techniques for approaching the Gasserian ganglion through the middle cranial fossa, and Dandy pioneered trigeminal nerve transection through the posterior fossa. Also at this time, Harris introduced nerve block using alcohol. Later, various oral medications, such as phenytoin(1942)and carbamazepine(1962), were introduced and these became effective treatments. Modern surgical treatment began in the mid-20th century, when Taarnhøj, Gardner and Jannetta introduced nerve decompression.

An accurately supervised motion-aware deep network for non-contact pain assessment of trigeminal neuralgia mouse model

Pain assessment in trigeminal neuralgia (TN) mouse models is essential for exploring its pathophysiology and developing effective analgesics. However, pain assessment methods for TN mouse models have not been widely studied, resulting in a critical gap in our understanding of TN. With the rapid advancement of deep learning, numerous pain assessment methods based on deep learning have emerged. Nonetheless, these methods have some limitations: (1) insufficiently objective supervision signals for training, (2) failure to account for the dynamic behavioral characteristics of mouse models in the constructed models and (3) inadequate generalization ability of the models. In this study, we initially constructed an objective pain grading dataset as the ground truth for model training, which remedy the limitations of prior studies that relied on subjective evaluation as supervisory signals. Then we proposed a novel deep neural network, named trigeminal neuralgia pain assessment network (TNPAN), which fuses the static texture characteristics and dynamic behavioral characteristics of mouse facial expressions. The promising experimental results demonstrate that TNPAN exhibits exceptional accuracy and generalization capability in pain assessment.

Association of concomitant continuous pain in trigeminal neuralgia with a narrow foramen ovale.

The pathogenesis of concomitant continuous pain remains unclear and is worthy of further study. In this clinical study, we aimed to explore the potential role of a narrow foramen ovale in the development of concomitant continuous pain. A total of 108 patients with classical trigeminal neuralgia affecting the third branch of the trigeminal nerve and 46 healthy individuals were enrolled in this study. Three-dimensional reconstructed computerized tomography images of all participants were collected, and the morphometric features of the foramen ovale were examined by two investigators who were blinded to the clinical data of the patients. In this cohort, patients with concomitant continuous pain suffered from more sensory abnormalities (18.4% vs. 2.9%, p = 0.015) and responded more poorly to medication (74.3% vs. 91.9%, p = 0.018) than patients without concomitant continuous pain. While no significant differences regarding the mean length (5.02 mm vs. 5.36 mm, p > 0.05) and area (22.14 mm2 vs. 23.80 mm2, p > 0.05) were observed between patients with and without concomitant continuous pain, the mean width of the foramen ovale on the affected side in patients with concomitant continuous pain was significantly narrower than that in patients without concomitant continuous pain (2.01 mm vs. 2.48 mm, p = 0.003). This neuroimaging and clinical study demonstrated that the development of concomitant continuous pain was caused by the compression of the trigeminal nerve owing to a narrow foramen ovale rather than responsible vessels in classical trigeminal neuralgia.

Comparison of the Efficacy of Percutaneous Balloon Compression and Extracranial Non gasserian Ganglion Radiofrequency Thermocoagulation for Primary Multibranch Trigeminal Neuralgia

BACKGROUND: Both computed tomography-guided extracranial nongasserian ganglion radiofrequency thermocoagulation (RFT) and percutaneous balloon compression (PBC) have significant clinical efficacy in the treatment of trigeminal neuralgia, but a comparison of the efficacy of the 2 methods for pain in primary multibranch trigeminal neuralgia (TN) has not been studied clinically. OBJECTIVE: To compare the efficacy and safety of PBC with extracranial nongasserian ganglion RFT in the treatment of primary multibranch TN. STUDY DESIGN: This is a single-center, retrospective, observational study. SETTING: This study was conducted at the Pain Department of the Affiliated Hospital of Jiaxing College in Jiaxing, People’s Republic of China. METHODS: A total of 202 patients, including 112 patients in the RFT group and 90 patients in the PBC group, with multi-branch TN who visited the pain department of Jiaxing First Hospital for percutaneous minimally invasive surgery from April 2016 through June 2021 were retrospectively analyzed. Patients in both groups were followed-up regularly after surgery, and the Numeric Rating Scale, recurrence-free survival rate, Barrow Neurological Institute facial numbness score, and other postoperative complications were recorded before surgery (T0), immediately after surgery (T1) and at 3 months (T2), 6 months (T3), 12 months (T4), and 15 months (T5) postoperatively. RESULTS: All patients completed the operation successfully. No significant difference was found between the two groups in terms of gender, age, pain duration, preoperative Numeric Rating Scale (NRS-11), lateralization of pain and affected branches, and preoperative underlying disease (P &gt; 0.05). There was a significant difference in preoperative and immediate postoperative NRS-11 scores between the 2 groups (P &lt; 0.01). NRS-11 scores decreased at each time point (T1-T5) and were significantly different from preoperative scores (P &lt; 0.001). Meanwhile, no significant difference was found in NRS-11 scores at T0, T1, and T2 between the RFT and PBC groups (P &gt; 0.05). However, the differences were statistically significant at T3 (P &lt; 0.05), T4 (P &lt; 0.001), and T5 (P &lt; 0.001). BNI-N scores decreased in both groups at T2, T3, T4, and T5 after surgery and were significantly different from preoperative scores (P &lt; 0.05). BNI-N scores were significantly lower in the PBC group than in the RFT group at all time points (P &lt; 0.05). In the long-term treatment of multibranch trigeminal neuralgia, the PBC group exhibited a lower recurrence rate than the RFT group. No severe complications or deaths were observed in either of the 2 groups. LIMITATIONS: A small sample size and being conducted at a single center are limitations of our study. CONCLUSION: Both RFT and PBC were effective in relieving primary multibranch TN, but patients in the PBC group had a lower recurrence-free survival rate, fewer complications, and a better safety profile. Follow-up studies with a larger patient sample held at multiple locations should be conducted. KEY WORDS: Radiofrequency thermocoagulation, percutaneous balloon compression, trigeminal neuralgia, extracranial nongasserian ganglion, multibranch pain

The role of multiple sclerosis subtype in microvascular decompression outcomes for patients with trigeminal neuralgia

ObjectivesWhile patients with concomitant trigeminal neuralgia (TN) and multiple sclerosis (MS) are understood to experience a more intractable pain phenotype, whether TN pain outcomes differ by the presenting MS subtype is not well characterized. This study’s objective is to compare post-operative pain and numbness outcomes following microvascular decompression (MVD) in TN patients with either relapsing-remitting MS (RRMS) or progressive MS. MethodsWe retrospectively reviewed all TN patients who underwent MVDs at our institution from 2007 to 2020. Of the 1044 patients reviewed, 45 (4.3%) patients with MS were identified. Patient demographics, procedural characteristics, and post-operative pain and numbness scores were recorded and compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions. ResultsOf the resulting 45 MS patients, 34 (75.6%) patients presented with the RRMS subtype, whereas 11 (24.4%) patients exhibited progressive MS. Using an adjusted multivariate ordinal regression, the subtype of MS was not significantly associated with the Barrow Neurological Institute (BNI) pain score at final follow-up. Using a Kaplan-Meier survival analysis and a multivariate Cox proportional hazards regression, respectively, RRMS was significantly associated with a shorter post-operative pain-free interval (p = 0.04) as well as a greater risk for pain recurrence (p = 0.02). ConclusionsAlthough the degree of pain at final follow-up may not differ, RRMS patients are at increased risk for pain recurrence following MVD for TN. These results align with a growing understanding that neuroinflammation may play a significant role in TN pain.

Management of trigeminal neuralgia: A multi-centre case study in general practice

Background and aims Patients often first present with symptoms of trigeminal neuralgia (TN) to primary care. However, there has been little research to determine whether the diagnosis and management of this condition is carried out according to current guidelines. Furthermore, there is little up-to-date information regarding the prevalence of TN in the UK. The aim is to estimate the prevalence of TN and to audit the diagnosis and management process of TN in primary care. Methods Between 2019 and 2020 a search was made at five UK GP practices with a total patient population of 55,842 using EMIS and SystmOne patient record systems to review patient consultations to identify patients coded with TN or facial pain (FP). These records were reviewed to ascertain the basis for diagnosis, management in primary care and referral to secondary care. Results 157 patients were identified; 54 coded with FP and 103 with TN. These results indicate a prevalence of 22.3 in 10,000. There was no difference in documented symptoms between the two groups. Seven patients had all ICDH3 criteria recorded, with two meeting the requirements for TN diagnosis. 58.8% of patients with TN were started on carbamazepine, the current gold standard treatment, compared with 16.7% in the FP group. 38.2% of TN patients were referred to a range of different specialities. Conclusion The prevalence of TN may be higher than previously thought. Key diagnostic criteria are often omitted, leading to potential misdiagnosis or delays in diagnosis. Relatively few referrals are made, though all patients should be considered for imaging.

Effect of lesion temperature on the durability of percutaneous radiofrequency rhizotomies to treat trigeminal neuralgia.

Percutaneous radiofrequency rhizotomy is a common procedure for trigeminal neuralgia (TN) that creates thermocoagulative lesions in the trigeminal ganglion. Lesioning parameters for the procedure are left to the individual surgeon's discretion, and published guidance is primarily anecdotal. The purpose of this work was to assess the role of lesioning temperature on long-term surgical outcomes. This was a retrospective analysis of patients who underwent percutaneous radiofrequency rhizotomy from 2009 to 2020. Patient data, including demographics, disease presentation, surgical treatment, and outcomes, were collected from medical records. The primary endpoint was the recurrence of TN pain. Univariate and multivariate Cox proportional hazards regressions were used to assess the impact of chosen covariates on pain-free survival. A total of 280 patients who had undergone 464 procedures were included in the analysis. Overall, roughly 80% of patients who underwent rhizotomy would have a recurrence within 10 years. Lower lesion temperature was predictive of longer periods without pain recurrence (HR 1.05, p < 0.001). The inclusion of lesion time, postoperative numbness, prior history of radiofrequency rhizotomy, surgeon, and multiple sclerosis as confounding variables did not affect the hazard ratio or the statistical significance of this finding. Postoperative numbness and the absence of multiple sclerosis were significant protective factors in the model. The study findings suggest that lower lesion temperatures and, separately, postoperative numbness result in improved long-term outcomes for patients with TN who undergo percutaneous radiofrequency rhizotomies. Given the limitations of retrospective analysis, the authors suggest that a prospective multisite clinical trial testing lesion temperatures would provide definitive guidance on this issue with specific recommendations about the number needed to treat and trial design.

Atlas orthogonal chiropractic management of trigeminal neuralgia: A series of case reports

ContextTrigeminal neuralgia is a debilitating facial pain condition. Upper cervical chiropractic care has been mentioned as a possible solution ObjectiveTo determine the effects of Atlas Orthogonal upper cervical chiropractic technique adjustments on trigeminal neuralgia sufferers DesignCase series SettingA private chiropractic practice ParticipantsFive persons with chronic, severe, daily trigeminal neuralgia pain, radiological findings of significant head tilt, pain upon upper cervical palpation, and supine leg length inequality InterventionsUp to two consultations and/or Atlas Orthogonal adjustments a week for eight weeks Outcome measuresSelf-reported reduction in trigeminal neuralgia pain and changes in radiological findings, sensitivity to upper cervical palpation, and leg length inequality ResultsFour participants reported reduced trigeminal neuralgia pain, including two with complete cessation of pain. Three participants reduced medication dosages. One reported no change

The potential role of a narrow foramen rotundum and foramen ovale in the development of concomitant continuous pain in trigeminal neuralgia

The most characteristic symptom of trigeminal neuralgia (TN) is paroxysmal and lancinating pain along the sensory distribution of the trigeminal nerve. Notably, a proportion of TN patients also experience persistent throbbing or burning in the same territory as their paroxysmal pain, termed concomitant continuous pain (CCP). The neurovascular compression (NVC) theory has been regarded as the primary cause of paroxysmal pain in TN. In contrast, the mechanisms underlying CCP can hardly be explained by NVC and have yet to be clearly elucidated. Both the foramen rotundum (FR) and foramen ovale (FO) are substantial bony apertures in the middle cranial fossa, through which the second (V2) and third divisions (V3) of the trigeminal nerve pass, respectively. Prior studies have proposed that a narrow FR and FO on the right side may result in a greater incidence of right-sided symptoms and be involved in the development of TN. However, given the nature of CCP and certain anatomical findings, we postulate that secondary compression of V2 and V3 by narrow foramina is more likely to be the primary cause of the persistent pain instead of the paroxysmal pain in cases of TN with CCP. TN with CCP may be the combination of trigeminal neuralgia induced by NVC and trigeminal neuropathic pain resulting from constant entrapment of V2 and V3. Therefore, considering that microvascular decompression cannot resolve all causes of TN with CCP, percutaneous ablative procedures and stereotactic radiosurgery may be more appropriate for patients with narrow foramina.

Preoperative Characteristics and Postoperative Pain Outcomes in Trigeminal Neuralgia With Concomitant Autoimmune Disease.

Although the association between multiple sclerosis and trigeminal neuralgia (TN) is well established, little is known about TN pain characteristics and postoperative pain outcomes after microvascular decompression (MVD) in patients with TN and other autoimmune diseases. In this study, we aim to describe presenting characteristics and postoperative outcomes in patients with concomitant TN and autoimmune disease who underwent an MVD. A retrospective review of all patients who underwent an MVD at our institution between 2007 and 2020 was conducted. The presence and type of autoimmune disease were recorded for each patient. Patient demographics, comorbidities, clinical characteristics, postoperative Barrow Neurological Institute (BNI) pain and numbness scores, and recurrence data were compared between groups. Of the 885 patients with TN identified, 32 (3.6%) were found to have concomitant autoimmune disease. Type 2 TN was more common in the autoimmune cohort ( P = .01). On multivariate analysis, concomitant autoimmune disease, younger age, and female sex were found to be significantly associated with higher postoperative BNI score ( P = .04, <0.001, and <0.001, respectively). In addition, patients with autoimmune disease were more likely to experience significant pain recurrence ( P = .009) and had shorter time to recurrence on Kaplan-Meier analysis ( P = .047), although this relationship was attenuated on multivariate Cox proportional hazards regression. Patients with concomitant TN and autoimmune disease were more likely to have Type 2 TN, had worse postoperative BNI pain scores at the final follow-up after MVD, and were more likely to experience recurrent pain than patients with TN alone. These findings may influence postoperative pain management decisions for these patients and support a possible role for neuroinflammation in TN pain.