Trigeminal Neuralgia

Background

Early Stage squareTrigeminal neuralgia, also known as tic douloureux, is a nerve disorder in which irritation of the trigeminal nerve causes stabbing pain in the face. This pain is usually limited to one side and involves the lower face and jaw. Pain attacks can be triggered by any kind of stimulation to the face, such as touching, drinking, talking, or smiling.

There is no single cause for trigeminal neuralgia; however, the most common cause is when the nerve is irritated by contact with a healthy blood vessel. Tumors and Multiple Sclerosis are other causes.

According to the American Association of Neurological Surgeons, approximately 150,000 people are diagnosed with trigeminal neuralgia each year. An estimated 5 million individuals are affected worldwide. The disorder occurs more commonly among adults older than 50 years.

Current Treatment

Current treatment options for trigeminal neuralgia involve:

Medications

  • Anticonvulsants
  • Antispasmodic agents: These drugs can be used alone or in combination with the anticonvulsants


Invasive Procedures

  • Microvascular decompression: This procedure involves moving aside blood vessels that are in contact with the trigeminal nerve and is considered the gold standard treatment in patients who are healthy enough to undergo surgery.
  • Gamma knife radiosurgery: A focused dose of radiation is aimed at the trigeminal nerve where it enters the brainstem. Damage to the nerve leads to the reduction or elimination of pain.
  • Glycerol injection: A thin needle is used to inject glycerol at the base of the skull. The glycerol damages the insulation of the trigeminal nerve and blocks pain signals. This procedure can be repeated multiple times.
  • Balloon compression: A catheter containing a small balloon is inserted into the cheek using a small needle. The balloon is placed where the trigeminal nerve enters the base of the skull. The balloon is inflated, applying pressure to the nerve and blocking pain signals.
  • Radiofrequency thermal rhizotomy: A catheter containing a small thermal electrode is inserted at the base of the skull. A small electric current is used to create lesions and cause damage to the trigeminal nerve.

Focused Ultrasound Therapy

There are two approaches to using focused ultrasound to treat trigeminal neuralgia. One group believes that focused ultrasound could provide a noninvasive way to heat and destroy the pain fibers of the trigeminal nerve as an alternative to radiofrequency ablation and gamma knife surgery. A recent preclinical study on cadavers has demonstrated the feasibility of focused ultrasound to heat the trigeminal nerve. More work is needed in preclinical models and, eventually, in patients to determine the efficacy and safety of focused ultrasound treatment for trigeminal neuralgia.

Another group of focused ultrasound leaders considers that trigeminal neuralgia is a given localization of neuropathic pain. Therefore, they treat this syndrome like any other form of neuropathic pain, and this approach began prior to focused ultrasound treatments. Currently, they perform a type of medial thalamotomy which has been shown to provide an average pain relief of 60 percent, and which does not bring a risk of iatrogenic pain production nor produce somatosensory deficits. This group is treating trigeminal neuralgia as part of the neuropathic pain CE approval in Europe.

Notable Papers

Monteith SJ, Medel R, Kassell NF, Wintermark M, Eames M, Snell J, Zadicario E, Grinfeld J, Sheehand JP, Elias WJ. Transcranial magnetic resonance-guided focused ultrasound surgery for trigeminal neuralgia: a cadaveric and laboratory feasibility study. J Neurosurg. 2013;118(2):319-28.

Pirrotta R1, Jeanmonod D, McAleese S, Aufenberg C, Opwis K, Jenewein J, Martin-Soelch C. Cognitive Functioning, Emotional Processing, Mood, and Personality Variables Before and After Stereotactic Surgery: A Study of 8 Cases With Chronic Neuropathic Pain. Neurosurgery. 2013 Jul;73(1):121-8. doi: 10.1227/01.neu.0000429845.06955.70.

Daniel Jeanmonod, Beat Werner, Anne Morel, Lars Michels, Eyal Zadicario, Gilat Schiff, Ernst Martin. Transcranial magnetic resonance imaging–guided focusedultrasound: noninvasive central lateral thalamotomy forchronic neuropathic pain. Neurosurg Focus. 2012 Jan;32(1):E1. doi: 10.3171/2011.10.FOCUS11248.

Michels L, Moazami-Goudarzi M, Jeanmonod D. Correlations between EEG and clinical outcome in chronic neuropathic pain: surgical effects and treatment resistance. Brain Imaging Behav. 2011 Dec;5(4):329-48. doi: 10.1007/s11682-011-9135-2.

Stern J, Jeanmonod D, Sarnthein J. Persistent EEG overactivation in the cortical pain matrixof neurogenic pain patients. Neuroimage. 2006 Jun;31(2):721-31. Epub 2006 Mar 9.

Sarnthein J, Stern J, Aufenberg C, Rousson V, Jeanmonod D. Increased EEG power and slowed dominant frequency in patients with neurogenic pain. Brain. 2006 Jan;129(Pt 1):55-64. Epub 2005 Sep 23.

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