Facial Pain can be a devastating disease. It can lead to years of frustration, changes in lifestyle, and at times isolation, becoming house bound or even suicide. Many times this facial pain is called Trigeminal Neuralgia or Tic Douloureux. This special type of facial pain has the characteristics of episodic, lancinating, debilitating pain. The pain initially lasts a few seconds but over time it may feel that a pain is there all the time. The sharp, shooting pain can be triggered with many things from touch to eating, cold weather or even the wind blowing. The pain is usually one -sided affecting the forehead, cheek or chin or any combination. There is usually no neurological deficit. Trigeminal neuralgia is usually seen slightly more common in females (1.8:1) and those over fifty. It is more often on the right and in the cheek and chin. Trigeminal neuralgia affects 4/100,000 people. The symptoms can go into remission for weeks or months. This severe facial pain is usually due to the irritation of the Trigeminal nerve at the brain stem where the insulating covering changes from thick to thin. This is at the root entry zone. The irritation is often from a blood vessel lying in the root entry zone. The blood vessel most commonly is the Superior Cerebellar Artery, but may be a persistent primitive trigeminal artery or even a vein. Other conditions may mimic trigeminal neuralgia. When multiple sclerosis is involved patients may have bilateral disease 18% of the time. Individuals may have brain tumors, herpes zoster, dental disease, orbital disease or temporal arteritis that mimics trigeminal neuralgia. It is very important to determine the cause of the facial pain and therefore an MRI is performed. The MRI may even demonstrate the blood vessel irritating the trigeminal nerve, multiple sclerosis or tumors.
Trigeminal Neuralgia can be managed initially with carbamazepine (Tegretol), working in as little as 24 hours. The initial response, possibly do to increased segmental inhibition, also supports the diagnosis. If patients do not tolerate carbamazepine or develop break through pain they may benefit from phenytoin Dilantin), baclofen (Lioresal), gabapentin (Neurontin), pimozide (Orap), clonazepam (Klonopin), amitriptyline (Elavil) or even topical creams such as capsaicin (Zostrix) or lidocaine.
If patients fail medical therapy they may be candidates for the Neurosurgeon to perform percutaneous balloon compression. Other treatments include percutaneous radiofrequency rhizotomy, gamma knife radiosurgery, and rootlet, ganglion or nerve sectioning or even simple injection of the branch. These procedures may decrease the abnormal pain transmission or increase segmental inhibition but do not necessarily alleviate the cause.
PERCUTANEOUS BALOON COMPRESSION
This outpatient procedure can be performed in individuals who cannot tolerate a brain operation but can be sedated slightly. A small nick is made in the skin away from the edge of the mouth. Then using constant fluoroscopic x-ray a needle is inserted into the hole aiming at the opening in the base of the skull where a branch of the trigeminal nerve exits. A balloon catheter is placed through the needle, through the opening into the skull and the balloon inflated with radiopaque dye for 1 to 11/2 minutes, allowing visualization of the nerve and the balloon. This compression modulates the abnormal pain transmission. The balloon and needle is removed and after a
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