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TRIGEMINAL NEURALGIA
DR DEBJYOTI DUTTA MD. FIPP.

Trigeminal Neuralgia is a disease causing intense facial pain. The pain

is characterized by sharp electric shock like feeling in one side of the
face along the distribution of one or more division of trigeminal nerve.
The attacks are short lasting i.e., seconds to minutes. Sometimes there
may be successive attacks.
The attack s may be triggered by speak ing, chewing , to uching th e area.
In severe cases even blow of air on the affected side of face may be
painful.

I NTR ODU CTION

The first Description of a disease like trigeminal neuralgia we get from the
writings of Ibn Sina (980-1073) in an Arabic text. The first attempt to treat
trigeminal neuralgia was done by John Locke in 1677, who applied sulphuric
acid to the face to treat trigeminal neuralgia' Trigeminal neuralgia successfully
treated for the first time by alcohol injection by Pitres in 1902. First RF
lesioning for this ganglion was described by Sweet and Vepsic in 1965, First
Retro-gasserian glycerol injection was done by Hakanson in 1981. Percutaneous
balloon compression was performed by Mullan and Lichtor in 1978 for the first
time.

EPIDEMIOLOGY OF TRIGEMINAL NEURALGIA

Trigeminal neuralgia is more common in females. The male: female ratio

is 2:3. The peak incidence is in between 50 and 70 years. If we see the
division wise distribution the most common is the involvement of
V2+V3 division (32%), the next common is isolated maxillary(V2)
division and involving all 3 divisions (V1+V2+V3) of trigeminal nerve
(17% each). Next common is the involvement of isolated
mandibular(V3) division at (15%) patients. Follows the V1+v2 at 14%
cases. Isolated ophthalmic division involvement is the rarest at 4%

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SYMPTOMS OF TRIGEMINAL NEURALGIA

The main symptom of trigeminal neuralgia is unilateral facial pain and

the character typically described as agonizing, paroxysmal and
lancinating in one or more divisions of trigeminal nerve namely V1 -
Ophthalmic Division V2 Maxillary Division and V3 is the mandibular
division. Activities like chewing, speaking, touching the face at the
affected side may trigger the attacks. Trigeminal Neuralgia may be of
two types the first one is idiopathic and the other is secondary to other
diseases like CP angle tumour or Multiple Sclerosis. Trigeminal
neuralgia secondary to multiple sclerosis may be bilateral.

PATHOPHYSIOLOGY OF TRIGEMINAL NEURALGIA

Pathophysiology of idiopathic trigeminal neuralgia still remains

unknown.

One of the proposed mechanisms is the compression of trigeminal nerve

by aberrant blood vessels at the trigeminal root, causing demyelinatio n
and ectopic impulse generation. Though it is not found in all cases of
idiopathic trig eminal neuralg ia.

Secondary Trigeminal neuralgia may be caused by CP Angle tumour,

Multiple sclerosis or injury caused by previous surgeries.

DIAGNOSIS OF TRIGEMINAL NEURALGIA

The diagnosis of trigeminal Neuralgia in mainly based of history of the

patient. The following questions are often asked to the patient. Does the
pain occur in attacks? Are most of the attacks are of small duration
(seconds to minutes)? Are the attacks unilateral? Do the attacks occur in
the region of face? Are there unilateral autonomic symptoms? Unilateral
autonomic features (like lacrimation, nasal stuffiness, conjunctival
congestion, redness in one side of face) are not found in trigeminal
neuralgia. Other diseases that can mimic trigeminal neuralg ia needs to be
excluded as well. They are Temporo-Mandibular Joint (TMJ) Arthritis,
Persistent Idiopathic Facial Pain, Sphenopalatine neuralgia, Migraine,

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Dental Disorders etc. Neurological Examination of all cranial nerve needs

to be done carefully. In idiopathic t rigeminal neuralgia they are no rmal,
in secondary trigeminal neuralgia the features suggestive of CP Angle
tumour or Multiple sclerosis may be found.

MEDICAL MANAGEMENT OF TRIGEMINAL NEURALGIA

The drug of choice f or trigeminal neuralgia is carbamazepine. The starting

dose 100-200 mg in divided dosage, and gradually to be increased to 400-
800 mg\day depending of response and adverse effects.
The best alternative to carbamazepine is Oxcarbazepine usually started at
a dose of 150 to 300 mg, the dose is gradually increased to 900-180
The other alternative is Gabapentin -900- 2400 mg/day, Phenytoin – 300-
500mg/day
Baclofen (5 mg orally 3 times a day for 3 days, then 10 mg orally 3 times a
day for 3 days, then 15 mg orally 3 times a day for 3 days, then 20 mg
orally 3 times a day. Maintenance dose: 40-80 mg/day. 80 mg/day doses
should be administered in 4 divided doses.)

SHORT CLINICAL PRACTICE ALGORITHM

Patients suspected having trigeminal neuralgia with Intense paroxysmal

unilateral facial pain from history, are subjected to through clinical
examination. MRI Scanning of brain is recommended for ruling out other
disorders and identifying aberrant vessels if present. Medical Management
is usually recommended first with medicines. If the medical managements
fail or patients are unable to tolerate the medicines due to adverse
effects, patients are selected for interventional or surgical management.
MVD is the treatment of choice in young patients, whereas for older
patients Percutaneous Radiofrequency Lesioning around the Gasserian
Ganglion is treatment of Choice.

INTERVENTIONAL TREATMENT OPTIONS OF

TRIGEMINAL NEURALGIA

Percutaneous Glycerol Rhiz olysis

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This is the simplest technique in which 50- 90 % glycerol in injected at

trigeminal ganglion. The average duration of pain relief is 6 months to 1 year.
The procedure can be repeated. Foraminal Fibrosis may occur by repeated
injection.

Percutaneous Radiofrequency (RF) Rhiz olysis

This is the treatment of choice for trigeminal neuralgia in aged and can also be
done in young individual. The pain relief period is much longer compared to
other techniques. This procedure may be done as day care procedure.

Percutaneous Balloon Micro-Compression

In this technique 4 Fr Fogarty catheter is inserted through 14G, 10 cm needle.

The balloon is kept inflated there for 60 seconds to 120 seconds to selectively
block a delta and c fibers. Pain relief period is 2- 74 months in different
studies,

Stereotactic Radiation Therapy (Gamma knife)

Stereotactic Radiation Therapy is one of the non-invasive treatments for

trigeminal neuralgia. Pain, Pain relief is not immediate, it takes around 3
months for onset. Only one third of patients gets complete pain relief. Number
of studies is still limited regarding efficacy though the procedure is safe.

Trigeminal Ganglion Cryotherapy

A comparatively newer mode of neurolysis, Showing good results in trigeminal

neuralgia.

Gasseria n Ganglion Stimulation. (Experim ental)

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Trigeminal Ganglion Stimulation can be tried when other modalities are not
effective.

Surgical Microvascular Decompres sion

Microvascular Decompression is a surgical technique in which the ganglion is

separated from the aberrant vessel with sponge after doing craniotomy.

RADIOFREQUENCY
THERMOCOAGULATION OF GASSERIAN
GANGLION
Radiofrequency Thermocoagulation of the Gasserian Ganglion is a
minimally invasive treatment for Trigeminal Neuralgia. It is safe and
can be done in day care.

UNDERSTANDING THE ANATOMY RROUND GASSERIAN GANGLION

For performing the Gasserian Ganglion Radiofrequency Ablation it is very
important to understand the anatomy around the Gasserian ganglion.
Gasserian Ganglion is situated within the cranium, in an area called the
Meckel's cave at the posteromedial part of middle cranial fossa, which is
close to the apex of petrous part of the temporal bone.

Relations of The Gasserian Ganglia - The Cavernous sinus, Internal carotid

artery, trochlear and optic nerves lie medial to the ganglia. Superiorly
lies the te mporal lobe of the brain. Posteriorly it is related to brain stem
and anteriorly it divides into its three branches, Ophthalmic(V1)
Maxillary (V2) and Mandibular(V3) branches.

These three branches come out of the cranium through 3 foramens, they
are Superior orbital fissure, Foramen Rotundum and Foramen Ovale
respectively. For the Gasserian ganglion RF our RF needle should enter
from below through foramen ovale.

The structures that pass-through foramen ovale are Mandibular nerve,

Lesser petrosal nerve (branch of the glossopharyngeal nerve), Accessory
meningeal artery Emissary vein (connecting the cavernous sinus with the
pterygoid plexus of veins)

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IMPORTANT RADIOLOGICAL LANDMARKS

Identification of below radiological landmarks are important for the procedure.

FORAMEN OVALE

For successfully performing trigeminal ganglion block the most important radiological landmark is
foramen oval. Foramen ovale can be seen from the submental view. To see the foramen ovale c arm
should be tilted caudally and at an ipsilateral oblique direction. It is seen between maxilla &
mandible.

ANGLE OF CLIVUS WITH THE PETROUS TEMPORAL

THE ANGLE OF CLIVUS WITH THE SHADOW OF THE PETROUS PART OF TEMPORAL BONE IN TRUE
LATERAL VIEW OF SKULL This angle is our direction at which the RF canula needs to be inserted, The
tip of the needle should not cross this junction

FORMATION OF ANGLE OF CLIVUS WITH PETROUS

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Clivus and the petrous part of temporal bone lies in different planes. when seen from laterally the
shadows of petrous of both the sides merges with one another to form the angle.

GASSERIAN GANGLION RF PROCEDURE

I ndications

The indications for Gasserian ganglion RF are Trigeminal neuralgia and

Secondary neuralgia due to cancer or multiple sclerosis, when Conservative
Therapy is not having adequate response or the patient is unable to tolerate
medications.

Contraindications

Contraindications are local infection, sepsis, coagulopathy, increased

intracranial pressure, major psychopathology.

Equipment Required

Equipment that are required for the procedure are 25-gauge needle (for skin
infiltration), 5-ml syringe (for local anesthetic solution),RF generator and
cables,16-gauge intravenous catheter (for introducing the RF needle) RF
needles, 10 cm in length 2-mm or 5-mm RF active tip

Preparation

An informed consent should be taken. Prophylactic Antibiotic injected 1/2 hour

before the procedure after proper skin test. The patient is asked to fast for
sedation during the procedure.

Patient Positioning

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The procedure is done in supine position, with a pillow below the shoulder, so
that the neck is extended.

Technique

After positioning the patient ipsilateral portion of the face to be painted with
antiseptic solution carefully , as pain may be triggered by painting. The area is
draped with surgical drape.
C-arm positioning should start from AP view then the fluoroscope position will
me changed to cranio-caudal direction to get the submental-view. The
Fluoroscope to be rotated to ipsilateral direction so that the foramen ovale can
be seen in between the maxilla and mandible.
The Surface point that corresponds to the foramen ovale should be determined
by putting a opaque pointer. The point of entry usually lies 2-3 cm lateral to
angle of mouth. Local anesthesia (1% lignocaine) injected at the entry point.
After the area is anesthetized an 16-gauge intravenous catheter is first inserted
followed by the RF cannula 10 cm in length 2-mm or 5-mm RF active tip by
needle through needle technique. While introducing the needle, care should be
taken so that it should not passes through oral cavity.

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Needle is progressed towards the foramen ovale under tunnel view. Intermittent
checking under lateral fluoroscopic view is to be done to make sure that the
needle direction is towards the junction of clivus and the coincided shadow of
petrous part of temporal bone of left and right side in true lateral view of the
skull. The needle tip is not visible at the lateral view unless the tip has crossed
the junction. And it should be remembered the tip should not cross more than
2mm above the junction. and in most cases the desired sensory and motor
stimulation is usually find before that. Once close to the ganglion sensory and
motor stimulation checked. Sensory stimulation is usually done at 0.5V and
50Hz, but in some patients we can get stimulation in lower voltage. The area of
paresthesia should match with the area of pain for the best results. Motor
stimulation is usually done at 2Hz and the voltage is the double of that of motor
stimulation to up to 2 volt. Ophthalmic and maxillary do not have motor part so
on motor stimulation we will get the contraction of masseter muscle.
After stimulation careful aspiration is done to avoid position in blood vessel.
Once the needle position is confirmed by stimulation 0.2 - 0,5ml of local
anaesthetic in injected, alternatively sedation can be given, to make the
lesioning time pain free.
Usually, three conventional RF lesions are done successively at 65, 70 and 75
degrees centigrade and for 60-90 seconds.
Case should be taken for ophthalmic division, to not to lesion at high
temperature, that may lead to corneal anaesthesia leading to exposure keratitis.
The needle is taken out post lesioning. The patient is shifted to post procedure
care unit. And monitored for vitals, corneal reflex is checked and ice is applied
in cheek to avoid hematoma formation.

Complications

1. Hematoma in Cheek - Common after percutaneous procedures at

Gasserian ganglion.
2. Loss of corneal reflex - May occur following Gasserian ganglion
neurolysis. Among the percutaneous procedures chance of loss of corneal
reflex is highest with RF procedure 7%, followed by Glycerol Rhizolysis
3.7%, and least with balloon Compression 1.5%.
3. Motor Deficit - Motor deficit is found to be highest following balloon
compression 66%, followed by RF rhizotomy 24%, and least with glycerol
injection - 1.7%
4. Carotid Artery Puncture. Retrobulbar Hematoma and Meningitis are
rare but serious complications

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