I. Diagnosis and treatment of trigeminal neuralgia and misconceptions
Trigeminal neuralgia is a common clinical disease, mostly seen in middle and old age, especially in people with atherosclerotic hypertension and diabetes mellitus. Once the disease is diagnosed, it is difficult to cure and the pain is severe and affects daily life. Due to the lack of adequate medical knowledge and medical information, most patients often seek medical treatment blindly, which makes it difficult to get timely and correct treatment, and not only delays the disease, but also causes loss of confidence in disease treatment due to repeated ineffective treatment, in fact, most patients are still suffering from pain. In order to make the majority of patients understand the knowledge about trigeminal neuralgia and get rid of the pain as soon as possible, this article makes a general explanation on the relevant issues.
The main manifestations of trigeminal neuralgia
The trigeminal nerve, as its name implies, includes three branches, namely the ophthalmic nerve, maxillary nerve and mandibular nerve. Pain can occur in one or more branches. Ophthalmic neuralgia is distributed in the frontal and parietal regions; maxillary neuralgia is distributed in the cheek region below the fissure of the eye and above the corner of the mouth; mandibular neuralgia is distributed in the cheek region below the corner of the mouth. The most characteristic feature of trigeminal neuralgia is the pain in the face, which comes and goes without aura, like lightning, and the pain is severe and unbearable, like cutting, burning, needling or electric shock, and there are often particularly sensitive areas in the upper lip, corners of the mouth, nose, palate or buccal mucosa (medically called “trigger points or board points”). Therefore, in order to prevent painful attacks, patients are often afraid to talk, eat, brush their teeth and wash their faces, which seriously affects their daily life.
Causes of trigeminal neuralgia
Many causes can cause trigeminal neuralgia, which can be divided into primary trigeminal neuralgia and secondary trigeminal neuralgia according to the different causes.
1, secondary trigeminal neuralgia refers to trigeminal neuralgia caused by organic diseases, common causes include trigeminal radiculitis, skull base arachnoiditis, skull base malformation, skull base tumor (cholesteatoma, meningioma, auditory neuroma, trigeminal neuroma), etc.
2.Primary trigeminal neuralgia refers to trigeminal neuralgia of unknown etiology, which is also the most common type in clinical practice. However, it was later found that most of this kind of trigeminal neuralgia is caused by the compression of intracranial blood vessels, and the pain can be relieved by using the method of decompression of blood vessels, so some people also classify trigeminal neuralgia caused by blood vessel compression as secondary trigeminal neuralgia.
In conclusion, according to the current examination methods, the cause of most trigeminal neuralgia can be clearly identified – the nerve root in the brainstem section is caused by vascular compression, which makes the radical treatment of trigeminal neuralgia possible.
IV. Diagnosis of trigeminal neuralgia
The effective treatment of any disease depends on the correct diagnosis. Similarly, before choosing the treatment method, it must be clear whether this facial pain is the real trigeminal neuralgia and what is the cause of the pain? Otherwise, it is easy to seek medical help in a hurry, and eventually no satisfactory results will be achieved. The diagnosis of trigeminal neuralgia is mainly based on the typical clinical manifestations: a short, sharp, lightning-like and severe pain in the face, not daring to press with the hand during the pain attack, or even not daring to wash the face, shine the teeth, speak or eat in order to prevent the pain from attacking. Based on these characteristics, it is easy to distinguish migraine, cervical spine headache, tension headache, headache caused by oral and five sensory diseases. For example, migraine is a throbbing headache that occurs in the head and face, with a predominantly distending pain, a long duration of each attack, ranging from minutes, hours or days, and often accompanied by nausea and vomiting in severe cases. All odontogenic pains have clear dental disease, pain episodes are clearly related to the activity of the teeth, and an oral examination can make a clear diagnosis. Paranasal sinusitis, for example, can also cause facial pain, although this pain is often persistent and patients have a history of paranasal sinusitis, and the pain mostly does not interfere with face washing, tooth shining, speech, or eating. Before treatment, the cause of trigeminal neuralgia also needs to be clarified. Currently, it is mainly based on MRI. Conventional MRI can clarify the presence or absence of cholesteatoma, meningioma, trigeminal neuroma, auditory neuroma, etc., but cannot show vascular compression, while 3D TOF MRA MRI can clearly show the presence or absence of vascular compression, and can even suggest the origin of the blood vessels, so a detailed MRI examination is required before treatment.
V. Treatment of trigeminal neuralgia
The evaluation of a treatment method is mainly based on the following points.
(1) Cure rate of the disease
The higher the cure rate, the better.
(2) Relapse rate of the disease
The lower the recurrence rate, the better.
(3) Incidence of complications
The lower the complication rate, the better. As far as trigeminal neuralgia is concerned, there are various clinical treatments available, and all the publicity reports, large and small, glorify it as the best treatment plan. Here is a brief introduction to some of the main treatment measures that exist in clinical practice.
VI. The treatment measures for trigeminal neuralgia are usually divided into two main categories.
1. Etiological treatment.
The main purpose of treatment is to remove the real cause of trigeminal neuralgia, so this treatment measure is expected to obtain a cure of the disease, but this treatment presupposes that the cause of trigeminal neuralgia has been clarified, so it is mainly applied to secondary trigeminal neuralgia with a clear cause, such as posterior cranial fossa cholesteatoma, meningioma, auditory neuroma or trigeminal neuroma resection, trigeminal nerve microvascular decompression, etc.
2.Minimally invasive treatment.
It is mainly suitable for patients with advanced age and frailty, combined with multi-system diseases or poor compliance with open surgery, such as percutaneous trigeminal hemimelia balloon compression, percutaneous trigeminal hemimelia glycerol injection destruction, trigeminal hemimelia radiofrequency thermocoagulation and stereotactic radiosurgery, etc.
3.Symptomatic treatment.
That is, the treatment is mainly aimed at the pain symptoms themselves, such as oral analgesic drugs carbamazepine (Delidos), wild papaya, phenytoinamide, depigmentation tablets, Sanli pain, etc., Chinese medicine, herbal medicine, acupuncture, physiotherapy, massage, drug local closure, radiofrequency thermal coagulation therapy, gamma knife radiation therapy, etc. All these treatments may provide temporary relief of pain, but since the cause of the pain is not removed, it is impossible for the patient to obtain a cure, and recurrent attacks of pain and repeated treatments are inevitable. For example, when the pain is mild, you can choose symptomatic treatment, when the patient is too old to undergo surgery, and when the patient is generally well and the pain is severe, you can choose etiologic treatment to cure the disease completely. Since more than 90% of trigeminal neuralgia is caused by vascular compression, microvascular decompression is a treatment measure that is expected to cure the disease while preserving the function of the trigeminal nerve, so the following is an introduction to microvascular decompression, the most clinically used treatment technique.
Principles, efficacy, advantages and risks of microvascular decompression
1.Rationale of microvascular decompression
Long-term compression of the trigeminal nerve root by blood vessels can lead to demyelination of the nerve root, resulting in the occurrence of pain. Microvascular decompression is to separate the blood vessel (cause) that compresses the nerve root from the nerve root, then relocate and fix it at a site far away from the nerve root to achieve complete decompression of the nerve root and obtain the purpose of treatment. Therefore, this is a treatment method that targets the cause of the disease and is expected to completely cure trigeminal neuralgia.
2.The therapeutic effect of microvascular decompression
The treatment effect of trigeminal neuralgia is divided into four types: immediate complete relief (the pain is completely relieved immediately after the surgery), delayed complete relief (the pain is not immediately relieved after the surgery, but gradually relieved after a period of time, but eventually can be completely relieved), obvious relief (the pain level can be significantly reduced after the surgery, and the amount of oral analgesic drugs is significantly reduced) and ineffective. Overall, the probability of complete pain relief after microvascular decompression is over 90%, and the cure relief rate in our department is around 98%, with very low inefficiency, which is the best treatment option in terms of efficacy compared with other treatment measures. Moreover, the long-term efficacy of microvascular decompression is also better, with a cure rate of more than 85% and an effective rate of more than 92% 5 years after surgery, and a cure rate of more than 80% and an effective rate of more than 90% 10 years after surgery.
Many patients are in severe pain because of trigeminal neuralgia, glossopharyngeal neuralgia, or because facial muscle spasm seriously affects their daily work and life and urgently request to cure the disease, but they are always worried and afraid when it comes to surgery, and always think that the surgery has to open the skull – “to make an incision in the brain “, and eventually often do not dare to accept surgical treatment, especially for patients with relatively mild symptoms.
In fact, this is a misconception. Microvascular decompression surgery is a very mature surgical technique for treating trigeminal neuralgia, glossopharyngeal neuralgia, facial muscle spasm and other cranial nerve diseases, and has been used in clinical practice for nearly 60 years. Moreover, the surgery is not performed inside the brain, but is performed using the gaps in human tissues, in the subarachnoid space between the brain tissue and the skull, and microvascular decompression is the procedure of compressing the nerve root Microvascular decompression is a treatment method that separates the blood vessel (the cause of the disease) from the nerve root, relocates and fixes it at a site far away from the nerve root, and achieves complete decompression of the nerve root.
Therefore, in theory, the risk of surgery is not high for an experienced neurosurgeon. Especially in recent years, the progress of microsurgery technology, the application of minimally invasive surgical techniques and the update of surgical equipment have not only significantly improved the surgical efficacy, but also greatly reduced the surgical risk. Microvascular decompression surgery is currently the international first choice for the radical treatment of trigeminal neuralgia and facial spasm, and its greatest advantages are the treatment for the cause, high rate of complete cure and efficiency of pain, low recurrence rate, few complications, and the ability to The normal function of the nerve can be preserved after surgery.
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 roots. Therefore, the higher the number of compressed vessels, the thicker the vessels, and the heavier the adhesions between the vessels and the nerve roots, especially in a few patients with anatomical variations, are the main factors that increase the risk of surgery. Therefore, detailed pre-numerical evaluation and skillful surgical techniques are the keys to improve the surgical efficacy and reduce the surgical risk.
Eight, trigeminal neuralgia patients are prone to misunderstandings
Myth 1: Failure to recognize having trigeminal neuralgia delays diagnosis and treatment.
It is easy to identify and diagnose trigeminal neuralgia with typical characteristics – trigeminal neuralgia is characterized by recurrent paroxysmal severe pain in facial areas such as lips, corners of the mouth, nose, palate or oral mucosa, without aura, coming and going rapidly, resembling lightning, with severe pain, such as cutting, burning, needling or electric shock. Often there are some particularly sensitive areas (“trigger points or trigger points”) that can trigger severe pain in the face with slight contact. Due to the fear of pain attacks, patients often dare not speak, eat, brush their teeth and wash their faces, which seriously affects the quality of life of patients, and some patients even tell that it feels worse than death when the pain attacks.
For early mild trigeminal neuralgia or atypical trigeminal neuralgia, it is often mistaken for toothache, migraine, sinusitis or other stomatological and quintuplegia diseases, and even wrongly treated with tooth extraction. A patient once had several teeth on the painful side extracted and still had pain, but was later diagnosed by a neurologist as suffering from trigeminal neuralgia, and the pain was cured after treatment by microvascular decompression.
Myth 2: Trigeminal neuralgia is an incurable disease.
Most patients know that they suffer from trigeminal neuralgia, but they do not know that trigeminal neuralgia can be cured or eradicated. The reasons for this are many: 1) the lack of effective medical information, 2) the lack of proper guidance from doctors, 3) the loss of confidence in the cure because of the ineffectiveness of long-term treatment, and the fact that some patients have been suffering from trigeminal neuralgia for many years, have been transferred to many hospitals, and have tried various treatments such as carbamazepine (Deltamethrin), traditional Chinese medicine, acupuncture, radiofrequency, buried wire, local closure and tooth extraction. The pain was never effectively controlled, and the patient was in pain and lost confidence in the cure. This situation is more common in clinical work.
In fact, trigeminal neuralgia is a completely curable disease, the key is to get the guidance of professional doctors and choose the right treatment method. Trigeminal neuralgia includes two types of primary trigeminal neuralgia and secondary trigeminal neuralgia.1. The common causes of secondary trigeminal neuralgia include tumors (cholesteatoma, trigeminal nerve sheath tumor, auditory neuroma, meningioma, etc.), inflammation, cerebrovascular disease, skull base malformation, etc. Therefore, treatment for the cause is the key to treat secondary trigeminal neuralgia.2. The etiology and pathogenesis of primary trigeminal neuralgia, although Although the cause and pathogenesis of primary trigeminal neuralgia are still controversial, the current academic circles agree that cerebrovascular atherosclerosis, twisted and elongated blood vessels, and compression or stimulation of trigeminal nerve roots are the causes of trigeminal neuralgia attacks, therefore, surgical methods are used to release the compression of blood vessels on nerve roots, that is, “microvascular decompression”.
Since the beginning of trigeminal nerve root microvascular decompression surgery in the 1970s, tens of thousands of patients with trigeminal neuralgia have been effectively treated, and at present, microvascular decompression surgery has become the first choice for the treatment of primary trigeminal neuralgia at home and abroad, with a cure rate of over 95%. Therefore, trigeminal neuralgia is a completely curable disease.
Myth 3: Excessive worry about the risk of surgery and afraid to receive surgical treatment.
Many patients are desperate to cure the disease because of severe pain, but they are always worried and afraid at the mention of surgery, always thinking that surgery will open up the skull – “to open up inside the brain”, and eventually they often dare not undergo surgical treatment, especially for patients with relatively mild symptoms This is especially true for patients with relatively mild symptoms. In fact, this is a misconception. Microvascular decompression surgery for trigeminal neuralgia is a very mature surgical technique that has been used in clinical practice for more than 60 years, and the surgery is not performed inside the brain, but in the subarachnoid space between the brain tissue and the skull, so the risk of surgery is not high. Especially in recent years, the application of minimally invasive surgical techniques has not only significantly improved the surgical efficacy, but also greatly reduced the surgical risk, and microvascular decompression surgery is now the international preferred option for the radical treatment of trigeminal neuralgia.
Of course, not all patients must undergo microvascular decompression surgery, and the general treatment principle is: for patients with relatively mild pain, medication should be applied first, and surgery should be considered only when medication is ineffective; for elderly patients, especially those whose general condition is not suitable for microvascular decompression surgery, it is recommended that balloon compression of the meniscus should be chosen first when medication is ineffective. For patients with severe pain that seriously affects their daily life, microvascular decompression surgery should be preferred to cure trigeminal neuralgia. Therefore, the appropriate treatment plan should be chosen according to the physical condition and severity of pain of different patients.
Myth 4: Misbelief in the so-called “partial and secret prescriptions”.
Many patients with trigeminal neuralgia have been suffering from trigeminal neuralgia for many years, and the treatment has not been effective, so they often mistakenly believe in some so-called “biased and secret recipes” for trigeminal neuralgia. 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 treatment information through the Internet, you should pay attention to the information provided by large medical institutions, and you should be cautious about private or purely advertising-based treatment information.
In conclusion, trigeminal neuralgia is a completely curable disease, the key is to receive regular and professional treatment.