NEURALGIAS

BY

S.MALLIKARJUN

BDS IV YR

NEURALGIA Pain of severe throbbing or stabbing

character in the course of distribution of a nerve.

TYPES OF NEURALGIAS• TRIGEMINAL NEURALGIA

• PARATRIGEMINAL NEURALGIA

• SPHENOPALATINE NEURALGIA

• GLOSSOPHARYNGEAL NEURALGIA

• GENICULATE NEURALGIA

• OCCIPITAL NEURALGIA

• POST HERPETIC NEURALGIA

TRIGEMINAL NEURALGIA

Trigeminal neuralgia (TN) is sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve.

SYNONYMS

• Trifacial neuralgia

• Fothergill’s disease

• Tic-doloureux (painful jerking)

ETOIOLOGY• INTRACRANIAL CAUSES1. Petrous ridge compression-internal carotid artey

pulsations

2. Multiple sclerosis

3. Intracranial tumors- at the cerebellopontine angle

4. Intracranial vascular abnormalities-basilar artery aneurysm, superior cerebellar artery abnormality

• EXTRACRANIAL CAUSES1. Vascular factors

2. Dental etiology

3. Post traumatic neuralgia

4. Infections

5. Viral etiology

• Neuralgias and neuritis• Syphilis • Tuberculosis• Tumor of the brain • Basilar meningitis • Pontine diseases .

• Skull fracture• Aneurysm of the carotid

artery or circle of willis• Psychoneuroses,and • Cavernous sinus

thrombosis

Other disorders that may affect the trigeminal nerve include :

PATHOPHYSIOLOGY

Atherosclerotic blood vessel pressing on the root of Trigeminal nerve

Focal demyelination

Hyperexcitability of nerve fibres

Episodes of intense pain

TYPES OF TRIGEMINAL NEURALGIA

• Pre Trigeminal neuralgia

• Idiopathic Trigeminal neuralgia

• Symptomatic neuralgia

• Pre trigeminal neuralgia: dull aching pain usually observed before appearance of trigeminal neuralgia

• Idopathic neuralgia: where the etiology remains unknown

• Symptomatic neuralgia: the type in which the etiology is known

CLINICAL FEATURES• Incidence : 4 in 1,00,000• Age : 4th to 5th decade• Sex : F>M• 60% on the right side, 3%

bilateral.• Mean age of onset-52-58yrs

Involvement : maxillary-60%

mandibular-49%

ophthalmic-16%

all 3 divisions-1%

• Manifests as sudden, unilateral, intermittent, paroxysmal, sharp, shooting, lancinating pain, elicited by slight touch.

• Patient usually complains of electric shock/lightening like pain

• Usually confined to one part.• Lasts for few seconds to

minutes.• Motionless or mask like face.

• Rarely crosses the midline.• Trigger points - Spontaneous attack or

triggered by trigger zone or movement of the face as in chewing, talking, brushing or yawning

• This leads patient frequently go unshaven or unwashed

• Paroxysms occur in cycles.• Depression and weight loss

Trigger zones are usually located on vermillion border of lip, ala of the nose, cheek, chin, and

around the eye.

• There is generally no evidence of sensory or motor impairment

• Apart from pain the other features are itching & sensitivity of the face

• Rarely trigeminal neuralgia is associated with hemi facial spasm- a condition called TIC CONVULSIF that involves both V & VII cranial nerves

DIAGNOSIS

• History• Trigeminal nerve examination• Diagnostic nerve blocking• MRI (brain)• EEG• Microneurography

DIFFERENTIAL DIAGNOSIS• Post herpetic neuralgia• Dental pain• Post traumatic neuralgia• Multiple sclerosis• Glossopharyngeal neuralgia• Migraine • SUNCT syndrome (sudden unilateral neuralgia type of

pain with conjunctival involvement)• Migraine• Tumors of nasopharynx( trotter`s syndrome)

MANAGEMENT

• PHARMACOLOGICAL

• SURGICAL

• OTHERS

PHARMACOLOGICAL• FIRST LINE OF APPROACH

Carbamazepine 100, 200mg..• SECOND LINE OF APPROACH

Phenytoin 100mg

Baclofen 5-80 mg/day

Lamotrigine 25 mg/day• THIRD LINE OF APPROACH

Clonazepam 4-8 mg

Valproic acid 250-500 mg

Oxcarbazepine 1200mg/day

Other methods used are• Trichloro ethylene inhalation• Topical capsaicin cream application• Proparacaine 0.5% anaesthetic drops in eye• Anti inflammatory drug-Indomethacin & short

courses of steroids are found useful in some cases

Review of Treatments – Medical• Carbamazepine

(Tegretol)• Gabapentin (Neurontin)• Baclofen• Clonozepam• Lamotrigin• Oxcarbamazepine• Phenytoin

• Amitriptyline• Nortriptyline (Pamelor)• Protriptyline• Sumatriptan (cluster

headaches)

• NSAIDS / Opoids• Capsaisin (topical)

SURGICAL• Stereo tactically controlled thermo coagulation of

V cranial nerve• Vascular decompression( through posterior

fossa craniotomy)• Repositioning of the basilar artery( compressing

the V nerve)• Micro vascular decompression• Gamma knife radio surgery• Cryotherapy

• Injection of the nerve with alcohol• Local anaesthetic injection of the nerve• Nerve sectioning & avulsion• Percutaneous radiofrequency trigeminal

neurolysis• Bulbar trigeminal tractotomy• Glycerol rhizotomy

MICRO VASCULAR DECOMPRESSION

VASCULAR DECOMPRESSION

Review of Treatments – Surgical

• MVD• Radio Frequency

Rhizotomy• Balloon Compression• Glycerol Rhizotomy• Gamma Knife

Radiosurgery

• Nerve Blocks• Neurotomy • NICO Surgery

• DREZ (Dorsal Root Entry Zone)

OTHERS

• TENS – Transcutaneous Electric Nerve Stimulation

• Acupuncher

• Psychological approach

Review of Treatments - Alternative• Acupuncture• Ayurvedic Medicine• Botulinum Toxin (Botox)• Cervical Chiropractic• Exercise / Running• Homeopathy• Hot / Cold Compresses

• Hypnosis• Low Intensity Laser• Lidocaine Cream / Patch• Myotherapy• Osteopathy• TENS (Postherpetic N.)• Vitamin B12• Yoga / Biofeedback

PARATRIGEMINAL NEURALGIA• Also called as raeder’s syndrome

• Characaterised by severe headache or pain in the distribution of trigeminal nerve with signs of ocular sympathetic paralysis

• Homolateral pain in the head or eye

• Sudden appearance of signs and symptoms

• Most common in males

• Generally occurs in middle aged people

• It can be differentiated from horners syndrome by presence of pain and no change in sweating activity

SPHENOPALATINE NEURALGIA• Also called as vidian nerve neuralgia or

hortons’s syndrome

• An idiopathic sydrome consisiting of recurrent brief attack of sudden severe unilateral periorbital pain.

• Typical periodicity has been attributed to hypothalamic harmonal influences

• Pain is thought to be generated at the level of pericarotid/ cavernous sinus complex

• Characterized by unilateral paroxysms of intense pain in the region of the eyes, maxilla, ear , mastoid, base of the nose, and beneath the zygoma.

• Sometimes the pain extends intothe occipital area as well.

• The paroxysms of pain hava a rapid onset, persist for about 15 min, and to several hours, and then disappears asrapidly as they begin

• There is no trigger zone

• The attacks develop regularly, usually atleast once a aday, over a prolonged period of time

• The onset of paroxysm occur exactly in the same time of the day, and for this reason, the disease is referred to as “alarm clock headache”

• Aftersome weaks or months, the trauma disappears completely and this period of freedom and may persist for month or even for years

• Sneezing , swelling of nasal mucosa and severe nasal discharge often appears simultaneously with the painful attacks as epiphohra or wattereing of eyes and blood shoot eyes

• Paraesthestic senstation over the skin of lower half of the face also are reported

• Men are more effected more commonly than women (5:1)

• Treatment:

• Cocainization of sphenopalatine ganglion or alcohol injection of this structure

• Resection of ganglion

• Surgical corrections of septal defects

GLOSSOPHARYNGEAL NEURALGIA

• It is a pain similar to trigeminal neuralgia

• Not as common as trigeminal neuralgia, but when it occurs, the pain may be as severe

• The pain is sharp, shooting pain in the ear, commonly in the nasopharynx, tonsils, posterior portion of the tongue

• Etiology is unknown

• It occurs at any age period without age predilection

• Numerous mild attacks may be interspreaded by occassional severe one

• The patient usually has trigger zone in the posterior oropharynx or tonsillar fossa

• Treatment:

• Resection of extra carnial portion of nerve or intra cranial portion

• Injection of alcohol is not widely accepted

GENICULATE NEURALGIA• Also called as nervous intermedius neuralgia

• It is uncommon paroxysmal neuralgia of cranial nerve VII

• Characeterized by the pain in ear, anterior part of tongue and soft palate

• This type of pain has a trigger zone

• The location of pain runs alsong the distribution of neve(external auditory canal, small area of soft palate, posterior auricular region)

• The pain is not as sharp and intense as trigeminal neuralgia and often sometimes facial paralysis, indicating the involvement of motor root

• This pain results commonly from herpes zoster of geniculate ganglion and nervus intermedius of cranial nerve vii

• This condition is also referred to as ramsay hunt syndrome

• Virus vesicles may be observed in the ear canal or tympanic membrane

• Acyclovir significantly reduces the duration of pain

• Symptoms result from nflammatory neural degeneration and short course(2 to 3 weks) of high steroid therapy

• Patient may also be treated with carbamazepine and antidepressants

• Patient may also undergo surgery of nervous intermidius if he doesn’t respond to the above medication

OCCIPITAL NEURALGIA• Rare neuralgia in the distribution of the

sensory branches of cervical plexus

• The most common cause are trauma, neoplasms, infections and aneurysms of effected nerves

• Palpation below the superior nuchal line may reveal an exquisitely tender spot

• Treatment has included corticosteroids, neurolysis, avulsion and blocking the nerve with local anesthetic solution

POST HERPETIC NEURALGIAIt is caused by reactivation of varicella-

zoster virus infection

15-20% of cases of herpes zoster invoule trigeminal nerve

Majority cases affect ofhthalamic division of 5th nerve

Characterized by pain and lesions in the region of eyes and forehead

Infection of maxiilary and mandibilar divisions cause facial and oral pain

Pain resolves within month after the lesions heal

Mostly affects elderly people.

Pathogenesis • The vz virus injures the periphral nerve by

demyelination, wallerian degeneration and sclerosis

• Atrophy of dorsal horn cells in the spinal cord

• Patient exhibits painfull response to non painfull stimuli

Clinical features

• Pain paresthesia. Hyperesthasia and alodynia persists months to years after zoster lesions have healed

• Pain is accompanied by a sensory deficit in the region of nerve distrubtion

TREATMENT• Topical therapy: lidocaine,

capsaicin,EMLA cream.

• Tricyclic antidepressants: amitriptyline, nor triptyline, doxepin, desiprimine

• Others: gabapentin, carbamazepine, phenytoin

• Surgery: nerve blocks peripheral nerve sresection, dorsal root surgery

• Prevention:antiviral drug (famciclovir) and corticosteroids

THANK YOU