Trigeminal neuralgia — a chronic disease spine, the main symptoms are paroxysmal pain in the area of innervation of one, two, or all branches of the nerve. Pain with trigeminal neuralgia often reaches a pronounced degree. Often during an attack of pain in the trigeminal nerve on the affected side of the face observed in vegetative symptoms as sweating, redness, swelling, tearing, salivation. Sometimes with trigeminal neuralgia pain occurs jerk facial muscles with its clonic contraction.
In between bouts of trigeminal neuralgia pain absent or mild. Stimulation of certain areas in a conversation or a meal, respectively, the anatomical direction of the branches of the trigeminal nerve provokes an attack of pain, so the patient beware cause irritation of the area.
In those cases, trigeminal neuralgia, which can clearly identify the pathological process is localized in the brain, cranial cavity, extracranial in the surrounding tissues or to the nerve in the nerve and causes irritation of the nerve, talking about the form of symptomatic trigeminal neuralgia.
Symptomatic trigeminal neuralgia is a manifestation of intracranial tumor localization, inflammation of the paranasal sinuses, diseases of the teeth and jaws. However, most often seen so-called idiopathic (essetsialnaya) form of trigeminal neuralgia in which you can sometimes suggest an inflammatory etiology of the disease, but often the etiological factor can not be identified.
With symptomatic trigeminal neuralgia should strive to eradicate the underlying disease. In unclear cases, trigeminal neuralgia, or if there is reason to believe the inflammatory nature of the disease, first resorted to medication and physiotherapy.
Surgical treatments for trigeminal neuralgia have to interrupt the conduction of nerve trunk and can be divided into two groups: extracranial and intracranial. By the methods of surgical treatment of extracranial trigeminal neuralgia include transection (neurotomy), or twisting of the peripheral branches of the trigeminal nerve and their alcoholism.
Innervated by the trigeminal nerve area of sensitivity on the skin of the face.
Neurotomy trigeminal nerve (transection of the peripheral branches) - is easily doable operation leading to the cessation of pain associated with trigeminal neuralgia. However, after trigeminal neurotomy is often observed relatively rapid regeneration of the nerve with restoration of sensitivity and recurrent pain attacks.
The best results in trigeminal neuralgia allows operation of twisting of the nerve, called nevroekzeresys, where possible excised portion of the peripheral branches of 2-4 cm in length, however, and after the operation of twisting of the nerve (nevroekzeresys) is usually 6-12 months after nerve regeneration and pain returned.
To prevent the regeneration of the trigeminal nerve, after surgery nevrekzeresys resort to sealing the holes bony canals through which the nerve branches, with the help of wood, bone, metal, tight pins, muscle, wax, paraffin, etc., but it often does not lead to permanent cure, and after a certain time, often relapse of pain.
For access to the branches of the first branch of the trigeminal nerve conduct an incision in the medial nadorbitalnoy area. To detect the infraorbital nerve (a branch of the second branch of the trigeminal nerve), there extraoral approach by making an incision of soft tissue in the medial division under the bottom edge of the orbit, while avoiding injury to the facial nerve branches innervating the lower eyelid and intraoral access, which is cut to the bone a little below the fold transition from canine to first molar, and after separation raspatory mucosa together with the periosteum is exposed and isolated nerve, which is captured by Pean forceps, the peripheral end of it is cut off, and the central slowly gets out of the infraorbital canal to the bone as long as he does not come off.
Photo of tongue piercing causing atypical trigeminal neuralgia.
Sensory divisions of the trigeminal nerve.
When nervekzeresys mental nerve (a branch of the third branch of the trigeminal nerve) through the intraoral incision is made over from canine to first molar on 0,5-0,75 cm below the gingival margin, ie slightly above the mental foramen. Most neyrohirrugov relate negatively to the operations of transection or twisting of the peripheral branches of trigeminal neuralgia with and prefer a simple and often highly effective therapeutic measure in the form of alcoholism nerve trunk, which is widespread.
Break the conduction of nerve trunk with a rack of anesthesia for trigeminal neuralgia, is achieved by chemical nerve block injections intranevralnoy 1-2 ml 80% alcohol with novocaine. Blockade in trigeminal neuralgia with novocaine alcohol most often an outpatient, and no complications.
The introduction of a needle into the nerve trunk of the trigeminal nerve initially injected with 2.1 ml of 2% novocaine solution. A few minutes after the nature of conduction anesthesia convinced of the correctness of the needle, make alcoholization trigeminal nerve.
Trigeminal nerve branches.
Varicella zoster virus reactivates in the ophthalmic division of the trigeminal nerve. Complications from this type of herpes zoster ophthalmicus can be critical. Herpes zoster virus may cause noticeable eyelid edema or skin wounds around the eye. The cornea or other parts of the eye may be changed. Other complications include glaucoma, retinal necrosis, and blindness, as well as an increased risk of stroke.
When the second branch of trigeminal neuralgia nerve of this injection, depending on the location trigger zone can be done through the infraorbital, incisive, and the greater palatine skulolitsevoe holes. When the third branch of the trigeminal neuralgia nerve, depending on the localization of injection pain or make a mental foramen, or resort to the mandibular, lingual or buccal anesthesia.
The best results were observed when the blockade alcohol neuralgia second and third branches of the trigeminal nerve. Often, during the absence of pain associated with trigeminal neuralgia lasts 0,5-1 year or more. After this period, no pain is shown to re-alcoholism trigeminal nerve. Alcoholism at the first branch neuralgia of the trigeminal nerve in most cases ineffective.
In severe trigeminal neuralgia after failed attempts to medication and physical therapy, extracranial Novocain and alcohol blockades, sometimes taken pererezok and ekzeresys peripheral branches arise indications for intracranial operations.
Injections of various substances in the Gasser's ganglion or in the intracranial branches of the trigeminal nerve divisions, or coagulation gasserova node puncture access through a skin holding the needle through the foramen ovale in trigeminal neuralgia were fairly widespread.
The introduction of novocaine or alcohol directly into the Gasser's ganglion in trigeminal neuralgia often gives a good result, but when returning pain is re-injected. However, this method is associated with the risk of damage to adjacent brain structures, as injectable alcohol is distributed in the cranial cavity. Even after successfully produced by injection of alcohol in the Gasser's ganglion in his circle may be formed seam, if necessary intracranial surgery are caused great difficulties for the neurosurgeon.
Deep injection of alcohol in the trunks of the second and third branches of the trigeminal nerve in the round and oval holes were used by some surgeons, but the exact hit in the trunks requires a thorough pre-training on cadavers, and even in experienced hands, because individual features of the skeleton skull is sometimes impossible.
To achieve the hydrothermal destruction of the sensitive root of trigeminal nerve resort to percutaneous puncture of the oval hole (using the principle of stereotactic neurosurgery). After the needle under X-ray control into the cavity of the skull to the spine sensitive trigeminal nerve produce its thermal destruction by the introduction of hot water in a small dose in the trigeminal cistern mekkelevoy sinus.
Percutaneous radiofrequency rhizotomy for patients with trigeminal neuralgia performing under light sedation.
Electrocoagulation gasserova site by introducing the needle through the foramen ovale applied even in 1931, Kirchner with a specially designed apparatus. In 1936 this author reported that the treatment by this method 250 patients trigeminal neuralgia pain relapse occurred in only 4% of cases. Shmehel (1951) reported the results of electrocoagulation gasserova site by Kirchner in 118 patients: half of patients with trigeminal neuralgia pain disappeared after a single electrocoagulation, while the rest managed to succeed after repeated or multiple applications of the method.
Hensess (1957) recommends the use of electrocoagulation gasserova site for trigeminal neuralgia in elderly patients: at 229 coagulation held 171 patients, with 62.5% recovery was observed, in 15,8% - improved, and there were no deaths. Only 25 patients with trigeminal neuralgia had to resort to intracranial surgery.
The idea of removing gasserova node in severe trigeminal neuralgia was carried out Rose (1890), which, after resection of the upper jaw has penetrated through the oval hole on the base of the skull and scraped by parts Gasser uzel.Metod not get distribution because of its difficulty and non-radical. Intracranial access gasserovu site to remove it with trigeminal neuralgia have described the Hartley (1882) and Kruse (1882). After osteoplastic trepanation scales and temporal bone, peeling of the dura mater from the base of the middle cranial fossa and the lifting of the temporal lobe can be obtained ample access to gasserovu site. However, extirpation gasserova site, which gives a satisfactory result in terms of getting rid of pain is difficult and dangerous interference, especially in view of the subtleties of the wall of the cavernous sinus adjacent to the site, and now no longer applicable.
In place of this operation was less traumatic, more easily workable and least efficient operation of the sensitive root transection behind gasserova site, which was first successfully performed Spiller and Frazier (1901).
This operation was proposed after experiments on dogs showed that after crossing the dorsal root of trigeminal nerve fibers show no signs of regeneration. The essence of this operation lies in the fact that after the formation of a small trepanation window in the temporal region raise the dura mater of skull base and reach gasserova site. After opening the capsule mekkelevoy cut the knot behind the sensitive part of the root of trigeminal nerve, leaving intact its motor part.
This operation is to nasoyaschego time the safest and most reliable of all surgical treatments for trigeminal neuralgia. Frazier found that the three parts gasserova retrogasseralny sensitive site in the spine come separately from each other by three groups of fibers corresponding to the three peripheral branches of the trigeminal nerve, with bundles of fibers are more or less parallel, and only a few anastomosing.
Among the various improvements in temporal rhizotomy for trigeminal neuralgia is to preserve the basic motor root and partial transection of the sensitive root, ie preservation of the first branch in the absence of its involvement in the pathological process in order to prevent nerve keratitis. If, after a total transection of the trigeminal nerve root keratitis, in some cases, ending the death of his eyes, there is a 16,7%, after a partial transection of the spine is observed in 4.4% of patients.
Transection of the sensitive branches of the trigeminal nerve root directly in the pons of the posterior fossa was first successfully performed Dandy (1925), who stressed the advantages of this approach compared with the temporal. When crossing the root of trigeminal nerve in the pons off pain sensitivity, but in most cases preserved tactile than eliminated the unpleasant sensation of numbness on the side of the operation, often observed in the temporal domain.
In this operation the neurosurgeon Dandy gave good results. With a 1921 experience of 200 operations, dissection of the spine with occipital neuralgia by, he said that the recent series of 150 operations have not been a single fatality. However, published further contributions from other authors show that the approach from the posterior fossa tend to have higher mortality rates (3-5%) compared with the temporal approach (0,8-1,9%).
Recurrences of pain after retrogasseralnoy transection of the trigeminal nerve root, according to different authors, varies between 5-18%. Quite often (according to different authors, in 10-20% of cases) in patients undergoing surgery Spiller-Frazier at trigeminal nerve in the anesthetized area of the face appear paresthesias, sometimes reaching painful degree.
Given that the temporal extradural approach to perform retrogasseralnoy rhizotomy been a number of complications associated with damage gasserova host surface for greater petrosal nerve, oculomotor nerve, the tympanic cavity, the average shell artery, proposed a method for intradural access for retrogasseralnoy sectioning the trigeminal nerve root, eliminating the traumatism above education. After opening the dura mater and the lifting of the temporal lobe of the brain performed the autopsy mekkelevoy cavity, and the intersection of the sensitive spine. Since the method described above was operated on 51 patients with fairly good results, but with two fatalities.
In the literature, have been described cases of neuralgia of the third branch of the trigeminal nerve in patients with epidermoidami located in the bridge-cerebellar angle. This allowed Taarnhoyu suggests that although under normal conditions because of the anatomical location of the sensitive root of trigeminal nerve compression can not be, however even with the development in the lining of the brain of minor changes of vascular or inflammatory disorders may occur compression of the spine in a narrow channel formed by the dura mater in of acute upper edge of the rocky bones.
In 1952 he made an unexpected Taarnhoy for neurosurgeons reported that the pain of trigeminal neuralgia disappeared after a simple "decompression" of trigeminal ganglion, producing a wide incision of the dura mater over gasserovym node and spine. For this is also subject to further expand the opening in the tentorium through which the spine is out of the posterior fossa in the middle. Of the 10 operated by this method in patients with trigeminal neuralgia in 7 patients no pain, and three effects of the operation was incomplete.
In 1954 Taarnhoy made a further message about the good results of its operations in 76 patients with trigeminal neuralgia. According to Love and piles (1954), Taarnhoya operation was performed at the Mayo Clinic in 100 patients. In this case, a complete success immediately after the intervention has been achieved in half the cases trigeminal neuralgia, but in 31 patients relapse occurred within 1-22 months after surgery.
Historically, the overall trend in the displacement of interventions for trigeminal neuralgia from the periphery to the center. Starting with resection of the peripheral branches, and then going to the transection of the spine (directly behind the first gasserova site, and then at the entrance to the pons), the surgeons then took transection of the bulbo-spinal tract of trigeminal nerve. In 1931 the anatomist Kuntz suggested cutting the descending tract of trigeminal nerve in the medulla oblongata. In this case, one would expect off the pain of keeping the sensitivity of the face and oral mucosa and the motor portion of the spine. In 1936 NN Burdenko proved the possibility of crossing pathways in the medulla oblongata person performing a bulbotomii with hyperkinesis.
Treatment of trigeminal neuralgia chosen individually in each case. It includes a set of conservative procedures:
- stimulation of nerve and muscle
- vitamin B, "C" and "E"
- antiviral drugs
- homeopathic remedies
- surgery (neurolysis, nerve trunk cross-linking, etc.)
Operation tractotomy for trigeminal neuralgia was first made Shikvistom (1937) and lies at the intersection of the sensitive tract of the trigeminal nerve on the lateral surface of the medulla oblongata. Near the lower corner 4 ventricle in close proximity to nerve bundles 10 traktotom injected to a depth of 2-3,5 mm and produce incision 2,5-4 mm.
According to the summary statistics covering 583 tractotomy on Shokvistu about trigeminal neuralgia, postoperative mortality was 1.5%. At 124 tractotomy noted a large number of relapses (37%), which is 5 times higher than the number at retrogasseralnoy transection of the spine temporal approach. This circumstance forces reluctant to tractotomy for trigeminal neuralgia, with limited evidence.
This surgery is indicated in cases of neuralgia, which previously produced retrogasseralnaya transection of the spine proved to be ineffective or some time after her recurrence of pain. Sam Shokvist (1957) considered this operation more shown at the first branch neuralgia of young people (to avoid constant tactile anesthesia during later life), and "large" trigeminal neuralgia, in combination with pain caused by multiple sclerosis, neuralgia and is contraindicated in the third branch, as in its area of innervation of anesthesia can not be guaranteed.
The use of acupuncture is a complementary treatment for trigeminal neuralgia.
According to Dalessio (1982), 25-50% of patients with trigeminal neuralgia does not respond to pain medication. Such patients with drug-resistant trigeminal neuralgia is need to resort to surgery to alleviate the suffering. According Tatli (2008) Different surgical methods of treating pain of trigeminal neuralgia have both their advantages and limitations. Microvascular decompression of the trigeminal nerve in the area of its release in mostomozhechkovom recognized at the corner of today's most long-term eliminates the pain of trigeminal neuralgia.
Thus, at present there are two main surgical access to the intracranial trigeminal divisions of
- Temporal access to the spine and gasserovomu node in the middle cranial fossa
- Suboktsipitalny access through the posterior cranial fossa, which can be performed transection of the sensitive part of the root or descending tract of trigeminal nerve
- Microvascular decompression of the trigeminal nerve in the area of its release in mostomozhechkovom corner
It should be pointed out that as the supply of new effective medication indications for surgical treatment of trigeminal neuralgia in some patients reduced. In particular, we noted a pronounced therapeutic effect in this disease Tigretol, lyrica, Suksilep.
Removal of burning and pain (neuralgia), on the face and teeth in the treatment of trigeminal neuralgia is accelerated by the use of physiotherapy.
Call now and sign up for diagnosis or treatment of trigeminal neuralgia by phone: +7 (926) 988-14-23 (neurosurgeon, neurologist)
- Carpal tunnel syndrome
- Cubital tunnel syndrome
- Peripheral neuropathies (neuritis):
- Facial nerve neuropathy (neuritis), Bell's palsy
- Median nerve neuropathy (neuritis)
- Peroneal nerve neuropathy (neuritis)
- Radial nerve neuropathy (neuritis)
- Sciatic nerve neuropathy (traumatic neuritis)
- Tibial nerve neuropathy (neuritis)
- Trigeminal nerve neuropathy (traumatic neuritis)
- Ulnar nerve neuropathy (neuritis)
- Neuropathy and polyneuropathy (alcoholic, diabetic)
- Optic nerve and retina diseases:
- Opto-chiasmatic arachnoiditis (optic chiasm)
- Pain in the arm and neck (trauma, osteochondrosis)
- Sciatica, leg pain (hernia and protrusion of the disc)
- Traumatic neuropathies (neuritis)
- Trigeminal neuralgia
- Tumors of peripheral nerves
+7 (926) 988-14-23