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Trigeminal Neuralgia Trigeminal Neuralgia can cause extremely severe pain over an area of the face supplied by the Trigeminal Nerve. It is said that the pain can sometimes be so severe that patients may at times consider suicide. The pain can be sudden and can be triggered by anything like touching the face, using a tooth brush or even by sudden changes in the outside temperature. Most often the cause is unknown. Females are more often affected than males. The Trigeminal nerve is one of 12 nerves arising from the brain. The short nerve ends in an expanded mass called the ganglia from which 3 branches exit the skull to supply the different areas of the face. The pathology most often affects either the maxillary or mandibular division of the nerve affecting the particular area supplied by that division (Blue or Brown shades on the picture). It usually affects one side of the face but sometimes both sides can be affected. Quite often the pain involves the jaw or teeth that the person may think that it is a dental problem and may visit a dentist. Once the dentist rules out a dental cause the diagnosis is often made by the person's symptoms alone. Investigation : An MRI scan should be done to rule out other causes of pain like tumours affecting the nerve, sinusitis or occasionally Multiple Sclerosis. Sometimes an enlarged vessel pressing on the ganglion causing the neuralgia may be picked up on the scan. Treatment: Drugs: The drugs normally used for epilepsy often control the acute pain. Carbamazine can be very effective initially but may become less effective later. Gabapentin, Baclofen, Oxacarbazepine, Pregabalin are other drugs that can be tried. With many of these drugs side effects like sickness, drowsiness, double vision, tiredness may occur. To reduce the side effects dossage may need altering. It is however worth persisting with the medication as the side effects usually settle after a while. However you must discuss any side effect with your doctor who will decide if you should continue with the drug. Other procedures: If the medication does not control the symptoms adequately other specialised treatments should be considered.There are a number of procedures available but most of them do not guarantee total cure for the condition. 1. Injection of Glycerol 2. Percutaneous radiofrequency thermocoagulation 3. Baloon compression of the ganglia 4. Gamma Knife Radiosurgery 5. Microvascular Decompression All these procedures except microvascular decompression aim to control symptoms by destroying the ganglion or nerve. Although pain can be controlled, many of the procedures leave a numb area of the face supplied by the nerve. The loss of sensation can sometimes be disabling. Also any procedure where a needle is inserted in to the brain, complications like bleeding in the brain and paralysis of muscles that control eye movements can occur. Injecting glycerol and radiofrequency thermocoagulation are procedures done by inserting a needle or a fine tube into the ganglion under general anaesthetic. The needle or probe is positioned accurately in the brain by using x-rays to guide them. In glycerol injection a small quantity of glycerol is injected in to the ganglion. In radiofrequency coagulation heat is  applied  directly on the ganglion through the needle. In balloon compression, a tiny balloon inserted through a needle is inflated over the ganglion to compress and destroy it. Gamma knife radio surgery otherwise called stereotactic radiosurgery involves directing an accurate beam of radiation at the ganglion. It does not require a general anaesthetic nor does it involve any form of invasive surgery. Patients can usually be discharged home the same day shortly after the procedure. Microvascular decompression:  Many consider vascular compression of the ganglia by an engorged vessel to be the main cause of neuralgia. Decompressing the vessel is a more invasive procedure involving opening the skull under a general anaesthetic. Although this is the only procedure that can be considered to cure the problem without a side effect, it is an invasive procedure involving intracranial surgery and carries a risk of potentially serious complications, such as hearing loss, stroke and even death (in around 1 in every 200 cases). However of all the surgical procedures this is now being considered as the gold standard curative procedure as the cure rate following surgery can be as high as 75%. Experts recommend that you should choose a neurosurgeon who specialises in this field as the complication and failure rate following surgery can be high when undertaken by a less experienced surgeon. All the procedures require highly trained staff working in well equipped hospitals. Among the procedures which one should one choose? Although all of them have the potential to relieve pain, most of them also carry a certain amount of risk. Among all the procedures the one which causes the least complication is Gamma Knife Radio Surgery. The reason is because the patient is neither put to sleep (as no general anaesthetic is used) nor any invasive surgery is involved. This would be the ideal procedure for an elderly patient or for someone who has other medical problems. For a young patient who has not responded well to drugs microvascular decompression undertaken by an experienced surgeon should be considered. K. Badrinath
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