I have wanted to write such a popular article for a long time because I have been asked by patients more than once: “Director, how should I treat trigeminal neuralgia? If you had trigeminal neuralgia, what would you do? I think my advice may be useful for patients.
The first thing is to clarify whether I have trigeminal neuralgia?
There are a lot of articles on trigeminal neuralgia, so you can look up and learn about trigeminal neuralgia on the internet and see if my symptoms match up with this disease. Am I suffering from trigeminal neuralgia? In fact, the diagnosis of trigeminal neuralgia is generally easy, and the diagnosis is mainly based on clinical manifestations, not on special examinations such as CT, MRI and other means, so the clinical diagnosis generally does not require special auxiliary examinations, and the main points of diagnosis are as follows: Yu Wenhua, Department of Neurosurgery, Hangzhou First People’s Hospital 1. More than 95% of patients with trigeminal neuralgia are one-sided, and the painful areas are mainly the following trigeminal nerve branches Most patients have “trigger points”, i.e., trigger points, and there is an area that they dare not touch, and stimulating these areas can easily cause pain attacks. In addition, it is especially easy to trigger when talking, eating, brushing teeth or washing face.
Sometimes it is difficult to distinguish trigeminal neuralgia from toothache, which refers to the pain caused by dental diseases such as caries, root and crown remnants. Toothache is persistent pain, aggravated by hot and cold stimulation, deep pain site, no discharge-like pain, no trigger point of facial skin, no pain attack is induced when speaking, brushing teeth, washing face, and dental disease can be detected by examination of the oral cavity.
If the diagnosis is still not clear, it is recommended to go to a regular large hospital neurosurgery or neurology department to assist in clear diagnosis. Once the diagnosis of trigeminal neuralgia is confirmed, you must overcome the fear in your heart and find ways to calm yourself down, accept the reality and face it bravely, because this disease can be treated.
Secondly, we need to understand why do I have trigeminal neuralgia? What is the cause of trigeminal neuralgia?
For now, the exact mechanism of trigeminal neuralgia pathogenesis is not known. However, many causes can cause trigeminal neuralgia, which can be divided into primary trigeminal neuralgia and secondary trigeminal neuralgia according to the different causes. Primary trigeminal neuralgia refers to trigeminal neuralgia of unknown etiology, and conventional neurological examinations including common imaging examinations are not abnormal, so there are often patients who tell me that I have done CT and MRI without any obvious abnormality, but through special magnetic resonance imaging technology (trigeminal root thin layer TOF-MRA examination), it can be found that most of the trigeminal neuralgia is due to long-term compression of the trigeminal nerve root by intracranial blood vessels. Therefore, it can be clinically explained why trigeminal neuralgia mostly occurs in old age, and the pain is like electric shock or pins-and-needles pain; the main reason for the onset of pain in old age is that Older patients may have small displacement of cerebral blood vessels with age, and of course it takes a long time for myelin sheath to destroy at the site of trigeminal nerve root compression. In conclusion, according to the current examination methods, the cause of most trigeminal neuralgia can be clearly identified – the nerve roots are compressed by blood vessels in the exiting brainstem segment, which makes the radical treatment of trigeminal neuralgia possible. Secondary trigeminal neuralgia refers to trigeminal neuralgia caused by organic diseases, common causes include trigeminal radiculitis, skull base arachnoiditis, skull base malformation, skull base tumors (cholesteatoma, meningioma, auditory neuroma, trigeminal neuroma), etc. This is relatively rare in clinical practice, but secondary trigeminal neuralgia is relatively common in young trigeminal patients.
Therefore, once trigeminal neuralgia is diagnosed, a special MRI imaging must be done to clarify the cause. If the responsible blood vessel is clear or the vascular compression of the trigeminal nerve root is very serious, it indicates that the general treatment may not be ideal if the cause of vascular compression cannot be removed, and of course, if it is caused by a tumor, it should be treated early.
How should trigeminal neuralgia be treated?
Trigeminal neuralgia has been described as the number one pain in the world, and there are many ways to treat it, but the more ways to treat a disease in medicine, the more difficult it is to cure it. The first-line treatment for trigeminal neuralgia is still drug-based, and the drug of choice for treatment is carbamazepine, 100mg a piece domestically and 200mg a piece imported from Deloitte. Generally, the commonly used dosage is 100 mg each, the starting dose of treatment starts from one, and the frequency of treatment is two to three times a day (100 mg, bid-tid), that is, the least dose to achieve pain control effect, and can be appropriately supplemented with neurotrophic drugs such as methylcobalamin and vitamin B1, most of the clinical cases have good efficacy at the beginning, but as the disease progresses, the symptom control is often worse and worse, even if the dose is increased, it is not satisfactory. However, as the disease progresses, symptom control often becomes worse and worse, even if the dose of drugs is increased, it is not satisfactory, and the side effects of drugs are also greater.
However, the disadvantage is that patients need to take the drugs for a long time, and they can only suppress the pain symptoms, but not treat the cause of the disease, and there will be drug resistance in the long term, so patients must increase the dose of drugs when the pain control is not good for a period of time, in order to achieve the efficacy, but at the same time there will be light and heavy side effects, the most important side effects are dizziness, unstable walking, drowsiness, white blood cell reduction, and drowsiness. The most important side effects are dizziness, unstable walking, drowsiness, decreased white blood cells, liver function impairment, and gastrointestinal discomfort. Carbamazepine is toxic to the liver, kidneys and hematopoietic system, so regular blood tests and blood biochemistry should be done at the hospital every three to six months after taking it. Remember that patients who are allergic to carbamazepine (rash, generalized itching or even blisters) should not take it.
Traditional Chinese medicine is characterized by the overall conditioning of the person, which can not only weaken the causative factors, but also enhance their own repair resistance, which theoretically has a certain efficacy in treatment, especially inflammatory damage type trigeminal neuralgia has the possibility of self-healing at the early stage of the disease through Chinese medicine conditioning and neurotrophic aids. Therefore, most of the trigeminal neuralgia patients tend to have less than ideal results as the disease progresses.
Many patients with trigeminal neuralgia have suffered from trigeminal nerve pain for many years, and after many treatments have failed, they often mistakenly believe in some so-called “partial prescriptions and ancestral secret recipes” for the treatment of trigeminal neuralgia, resulting in money spent, but the pain is not alleviated, but leads to a variety of complications, resulting in The result is that instead of reducing the pain, various complications are caused, resulting in lifelong regrets. The most reliable way is to go to a regular hospital. Even if you want to learn about the treatment information through the Internet, you should pay attention to the information provided by large, regular medical institutions, and you should be cautious about private or purely advertising-based treatment information, especially drugs with excessive exaggerated effects. The real famous hospital, famous department and famous doctor never do advertisement.
What if medication does not work well?
As most of the trigeminal neuralgia patients have progressed, the effect of drug treatment is not satisfactory, so some patients must resort to surgical treatment. The indications for surgical treatment are patients who are not well treated with medication, whose dosage is too high (total daily dose of carbamazepine > 600 mg), whose medication is ineffective, or whose side effects of medication are too great (dizziness, unstable walking, skin allergy, reduced white blood cells, liver function impairment) to sustain treatment; or who are suffering from mental or physical distress caused by the disease, which seriously affects their daily life. or patients who are suffering from mental or physical distress that seriously affects their daily life.
The evaluation of the advantages and disadvantages of a surgical treatment method is based on the following points: (1) the cure rate of the disease, after the treatment the patient is completely back to normal and does not need to receive any further treatment measures, the higher the cure rate the better; (2) the recurrence rate of the disease, that is, the probability of the disease reoccurring within a certain period of time after the operation, the lower the recurrence rate the better; (3) the incidence of complications, that is, the probability of complications arising from the treatment, of course, the lower the recurrence rate the better. The lower the recurrence rate, the better; (3) the incidence of complications, i.e. the probability of complications arising from the treatment received, the less complications the better.
The main purpose of treatment is to remove the real cause of trigeminal neuralgia, that is, to displace the responsible blood vessels compressing the trigeminal nerve root, so this treatment is expected to obtain the root treatment and cure of the disease. In case of secondary trigeminal neuralgia with clear cause, such as posterior cranial fossa cholesteatoma, meningioma, auditory neuroma, etc., it is necessary to remove the tumor and explore whether there are blood vessels compressing the nerve at the same time, because the tumor can also push out the blood vessels compressing the nerve root. 2. Minimally invasive treatment: It is mainly suitable for patients who are old and frail, combined with multi-system diseases or poor compliance with open surgery, such as percutaneous trigeminal hemianopia balloon compression ( mechanical compression injury), percutaneous trigeminal hemi-lunar ganglion glycerol injection destruction (chemical injury), trigeminal hemi-lunar ganglion radiofrequency thermocoagulation (thermal injury) and stereotactic radiation gamma knife treatment (radiological injury), etc. These procedures are relatively less invasive, but all are nerve damage for low price, so it is inevitable that all will have postoperative facial numbness, otherwise they are ineffective, but these methods do not target etiological treatment, the vast majority of postoperative recurrence. In particular, I would like to mention the gamma knife, because the radiation damage effect takes quite a long time, many patients do after the gamma knife treatment symptoms often no relief, the treatment effect is generally, according to my many years of clinical consultation experience, I personally think that gamma knife treatment is not worth recommending.
For a specific patient, should be based on their own characteristics to choose their own treatment plan, when the patient is very old, the general condition is not good, combined with multi-system disease is not suitable for open surgery treatment, should choose minimally invasive treatment. When the patient’s general condition is good but the pain is severe, it is advisable to choose the treatment for the cause of the disease in order to completely cure the disease. Since more than 90% of trigeminal neuralgia is due to vascular compression, microvascular decompression is the only treatment that can cure the disease while preserving the function of the trigeminal nerve.
There is no single method that can replace all the means in the current trigeminal neuralgia treatment program, and the treatment of trigeminal neuralgia should be individualized according to the patient’s condition, and as a qualified trigeminal neuralgia specialist, it is best to master all the above treatment methods.
Is open microvascular decompression surgery scary?
Many patients are always worried and afraid when they mention surgery, and they always think that surgery will open up the skull – “to make an incision inside the brain”, so they often don’t dare to receive surgical treatment in the end, but this is actually a misunderstanding. Microvascular decompression surgery is a very mature surgical technique for the treatment of trigeminal neuralgia, glossopharyngeal neuralgia, facial spasm and other cranial nerve disorders, and has been clinically used for nearly 60 years. Microvascular decompression is a method of treatment that is specific to the cause of the disease, as the nerve root is completely decompressed.
Of course, microvascular decompression is not without any risk. The degree of risk depends on whether there are abnormalities in the development of the local anatomy, the number and thickness of the compressed vessels, and the relationship between the vessels and the nerve root. The greater the number of compressed vessels, the thicker the vessels, the heavier the adhesions between the vessels and the nerve roots, and especially in a few patients, the variation in anatomical development are the main factors that increase the risk of surgery. Therefore, detailed pre-numerical evaluation and skillful surgical technique are the keys to improve the surgical efficacy and reduce the surgical risk.
Therefore, theoretically the risk of surgery is not high for an experienced neurosurgeon. Especially in recent years, advances in microsurgery, the application of minimally invasive surgical techniques and the updating of surgical equipment have not only significantly improved the surgical efficacy but also greatly reduced the surgical risk, with the greatest advantages of cause-specific treatment, high rates of complete cure and efficiency of pain, low recurrence rates, few complications, and preservation of normal nerve function after surgery. In general, this surgery is quite safe.
How about going to find a professional trigeminal neuralgia doctor?
This is very important! It is not necessary to blindly follow some big hospitals, because each doctor will have their own specialties, and finding a doctor who specializes in trigeminal neuralgia will give you the best treatment. At present, there are many websites, such as Medical Search, Xinglin Doctor, etc., from which you can learn about better hospitals and specialist doctors for trigeminal neuralgia treatment in the country, in each province and city, and even in the region. If it is convenient, you can go to the ward to find out how many similar patients there are during the consultation. You can also talk to patients in the ward about their experiences and feelings after trigeminal neuralgia treatment, which will be helpful in choosing the treatment plan.
If I have trigeminal neuralgia, I will do my best to fight with the disease together with my patients, not to say defeat lightly, and to laugh at life. And for now, as a doctor, I want to do my best for my patients, to help, encourage and guide them to overcome this disease.