Facial Pain Trigeminal Neuralgia

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MANAGEMENT (contd) Operative therapy

Peripheral nerve techniques: Nerve block with alcohol or phenol provides temporary relief (up to two years). Avulsion of the supra- or infraorbital nerves gives more prolonged pain relief.

Trigeminal ganglion/root injection: Alcohol or phenol injection into the trigeminal ganglion effectively produces pain relief, but area control is limited and the risk of corneal anaesthesia, ulceration and scarring is high. Now rarely used. Glycerol injection into Meckel's cave usually produces good pain relief with less sensory damage.

Trigeminal Nerve Headache Injection

Microvascular decompression:

Exploration of the cerebellopontine angle reveals blood vessels in contact with the trigeminal nerve root or root entry zone in the majority of patients. Separation of these structures and insertion of a non absorbable sponge produces pain relief in most patients, without the associated problems of nerve destruction.

Trigeminal root section: Through either a subtemporal (extra- or intradural) or posterior fossa approach, the appropriate trigeminal root is identified and divided.

Microvascular decompression:

Exploration of the cerebellopontine angle reveals blood vessels in contact with the trigeminal nerve root or root entry zone in the majority of patients. Separation of these structures and insertion of a non absorbable sponge produces pain relief in most patients, without the associated problems of nerve destruction.

Radiofrcquency thermocoagulation: The site of facial 'tingling' produced by electrical stimulation of a needle inserted into the trigeminal ganglion, accurately identifies the location of the needle tip. When the site of tingling corresponds to the trigger spot or site of pain origin, radiofrcquency thermocoagulation under general anaesthetic, produces a permanent lesion -usually resulting in analgesia of the appropriate area with retention of light touch.

Results and complications

Pain relief - accurate comparison of the wide variety of techniques used for trigeminal neuralgia is difficult; all but peripheral nerve avulsion appear to produce similar results. Approximately 80-85% of patients remain pain free for a 5-year period. Results of peripheral nerve avulsion are less satisfactory with pain recurring in 50% within 2 years.

DysaesthesialAnaesthesia dolorosa - this troublesome sensory disturbance follows any destructive technique to nerve or root in 5-30% of patients. Microvascular decompression avoids this problem and the risk of a severe deficit is low with glycerol injection.

Corneal anaesthesia - this occurs most frequently following phenol or alcohol injection into the trigeminal ganglion, but is also a problem when root section or thermocoagulation involves the first division.

Mortality - microvascular decompression and open root section carry a very low mortality (about 1%), but this must not be ignored when comparing results with safer methods.

Treatment selection: This largely depends on the surgeon's personal preference and experience.

In many centres, the absence of sensory complications make microvascular decompression the procedure of first choice, particularly for 1st division pain and for the younger patient.

Frail and elderly patients may tolerate glycerol injection and thermocoagulation more 160 easily than other procedures.

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