1.What is the trigeminal nerve?
The trigeminal nerve is the fifth pair of cranial nerves, originating from the posterior cranial fossa at the bridge brain, mainly including three sensory nerve branches, including the ophthalmic branch, the upper jaw branch, and the lower jaw branch, which are responsible for the general sensation of the face, scalp and part of the auricle, external auditory canal, nasal cavity and mouth, teeth and tongue; and a motor nerve branch, which mainly innervates the masticatory muscles.
2.What is trigeminal neuralgia?
Trigeminal neuralgia is a sudden, sharp, tearing, electric shock-like pain in the face; one pain can last for a few seconds, but each attack can last for several times, so the pain can last for several hours. This causes a great deal of pain and inconvenience in work and life. This pain does not last all day, but has a painless period, during which the patient is no different from a normal person, and no other obvious symptoms of nerve deficit occur; the pain is limited to the affected side of the face and the distribution of the trigeminal nerve. It is only when the pain cannot be relieved after the extraction of several teeth that the patient seeks treatment from neurologist or surgeon.
3.What is the cause of trigeminal neuralgia?
The cause of trigeminal neuralgia is mostly spontaneous and has no specific cause.
The trigeminal nerve consists of three sensory nerve branches: the ophthalmic branch, the upper jaw branch, and the lower jaw branch. If the nerves are compared to electrical wires, under normal conditions, the fiber bundles of the three nerves do not interfere with each other. However, if a lesion occurs, the myelin sheath on the surface of the nerve fiber bundles will degenerate, just like the insulation “rubber” outside the “wire” is broken, and the nerve conduction will be short-circuited, thus easily causing abnormal nerve impulses and severe neuralgia. This disease is especially common in middle-aged and elderly people, slightly more women than men, and more on the right than the left side. Because of the rich distribution of facial nerve endings, the pain is often very intense, and trigeminal neuralgia is also known as the “first pain in the world”.
4.What is the diagnosis of trigeminal neuralgia based on?
The diagnosis is mainly based on the patient’s medical history, which focuses on whether the patient can correctly describe the location and extent of pain, the time of pain onset and its duration, and whether there is a pain-free period? Is there a cause of the pain and a pain point? Does the patient have a history of banding? The physical examination is mainly to assess the sensory condition of each branch of the trigeminal nerve on both sides, to assess the function of chewing and mouth opening, to assess the function of the active eye and brain nerve, to assess the response to medication, and, if necessary, to diagnose together with a dental, oral surgery or neurology specialist, as well as radiological diagnostic examinations (mainly cranial CT or MRI) to exclude brainstem lesions in the posterior cranial fossa or The diagnosis of trigeminal neuralgia should be based on the diagnosis of brainstem lesions in the posterior cranial fossa or skull base tumors.
5.What is the differential diagnosis of trigeminal neuralgia?
In clinical practice, trigeminal neuralgia needs to be diagnosed differently from facial pain symptoms such as teeth, gum disease, zoster, temporomandibular joint disease, eye disease, temporal arteritis and intracranial tumor, because the treatment methods for different diseases are different.
6.What is the treatment of trigeminal neuralgia?
The treatment methods include medication and surgical treatment.
7.What is the drug diagnosis and treatment method of trigeminal neuralgia?
At present, the cause of trigeminal neuralgia is considered to be a result of epileptic seizure, not a general inflammatory pain, so the drug treatment is mainly anti-seizure drugs, and general pain relief and anti-inflammatory drugs are not effective. In short, if the patient’s facial pain can be relieved by general anti-inflammatory drugs, it is not trigeminal neuralgia.
8.What is the drug treatment for trigeminal neuralgia?
The drug of choice for diagnostic treatment is carbamazepine (Tegretol), usually in the form of 100 mg per pill, with the starting dose starting from one, and the frequency of treatment is two to three times a day (100 mg, bid-tid), that is, the minimum dose to achieve pain control effect, most clinical cases start with good efficacy, but with the disease and the progress of symptom control is often getting worse. However, with the progress of the disease and often worse symptom control, even if the drug dose is increased, it is not satisfactory, and the side effects of the drug are also larger.
9.What are the advantages, disadvantages and side effects of drug treatment for trigeminal neuralgia?
However, the disadvantage is that patients need to take drugs for a long time, and they can only suppress the pain symptoms, not treat the disease, and drug resistance will occur 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 same efficacy, but at the same time, there will be mild and severe side effects, the most important side effects are dizziness, unstable walking, drowsiness, skin lesions, allergies, whitening, etc. The most important side effects are dizziness, unstable walking, drowsiness, skin lesions, allergy, white blood cell reduction, liver function impairment, gastrointestinal discomfort, etc.
10.What are the indications for surgical treatment of trigeminal neuralgia?
The indications for surgical treatment are patients who are unable to sustain treatment because of the ineffectiveness of medication, too high dose (total daily dose of carbamazepine > 800 mg), ineffective medication, or too many side effects of medication (dizziness, unstable walking, skin allergy, reduced white blood cells, liver function damage); or patients who are mentally or physically disturbed by the disease, which affects their life or work. The patients with trigeminal neuralgia are those who have been affected by the disease in their life or work.
11.What are the surgical methods for trigeminal neuralgia? What are their advantages, disadvantages and side effects?
(1) Open cranial microvascular decompression surgery
Craniotomy is the only internationally recognized surgical treatment for the cause of trigeminal neuralgia, with the main advantages of long-term control, low recurrence rate, and almost no loss of sensation (facial numbness) after surgery; however, the disadvantages are: this treatment requires opening the posterior cranial fossa of the patient, which is a craniotomy, and the operation time and anesthesia time are long. A few patients have other complications of varying severity, such as facial nerve palsy, tinnitus, hearing loss, cerebrospinal fluid leakage, incisional infection or unsatisfactory surgical results, etc. Postoperative recovery takes some time, and it is especially worth mentioning that there are still serious complications related to this surgery at home and abroad, especially death cases are still reported sporadically.
(2) Transdermal trigeminal nerve balloon compression avulsion surgery
The main advantages of this procedure are: the operation technique is simple, the patient tolerates it well, the whole procedure is performed under general anesthesia, there is almost no pain and discomfort during the procedure, the operation time is short (half an hour on average), the immediate postoperative pain relief rate can reach more than 95%, the patient can get out of bed on the same day after the operation, if the patient is not satisfied with the pain relief, he can receive the same operation again on the next day, the pain caused by the ophthalmic branch can be treated The postoperative sensory loss is mild, the chance of complications is low (<1%), the number of hospitalization days is low (5 days on average), no craniotomy is required, no intensive care unit is needed, the postoperative wound is small (about 2mm), the whole treatment process is painless, there is no wound pain, and the patient's comfort is high; the main disadvantages are mild to moderate hemifacial numbness and loss of masticatory muscle strength, but the symptoms will improve over time. The main disadvantages are mild to moderate hemifacial numbness and masticatory muscle weakness, but the symptoms will improve over time.
The procedure is simply performed by puncturing the affected side of the orofacial angle, introducing a microballoon into the trigeminal nerve’s hemimelia in Meckle’s cavity through a sheath tube under X-ray fluoroscopic surveillance, then slowly injecting contrast filling the balloon, decompressing the nerve fibers causing trigeminal neuralgia and destroying them by compression of the expanded microballoon, and finally withdrawing the balloon and wound Finally, the balloon is withdrawn and the wound is compressed to stop bleeding.
(3) Transdermal trigeminal ganglion thermal coagulation radiofrequency
The advantages of this procedure are that it also has a high rate of immediate pain relief, a low rate of pain recurrence, and a clearer intraoperative localization by square wave measurement; however, the disadvantage of this procedure is that it mainly targets the treatment of trigeminal neuralgia caused by the lower jaw branch (V3) and the upper jaw branch (V2). The patient is often unable to cooperate with the treatment because of the great pain and discomfort caused by the needles and stimulation of localization.
(4) Transdermal trigeminal ganglion glycerol block surgery
This method is relatively economical and belongs to one of the transcutaneous trigeminal ganglion block procedures, similar to the transcutaneous trigeminal ganglion thermal coagulation radiofrequency surgery, its advantages are also high immediate pain relief rate, low pain recurrence rate, but its disadvantages are similar to thermal coagulation, for the eye branch (V1) caused by the pain is relatively contraindicated, for the lower jaw branch (V3), the upper jaw branch (V2) positioning requires very Patients may experience greater pain and discomfort during surgery due to needle lancing and stimulation during positioning, and postoperative facial sensory deficits are also more common.
(5) Trigeminal nerve peripheral branch block
It can suppress the pain, but the effect is short-lived about three months to six months, local anesthesia, treatment will cause patients pain and discomfort, the overall recurrence rate is high, and recurrence will become more frequent.
(6) Gamma knife or photon knife trigeminal ganglion block
Local anesthesia is required to set the trigeminal ganglion position by MRI, which may cause distortion and displacement, and the effect is unstable.
12. What is transdermal trigeminal ganglion balloon compression?
Transdermal trigeminal ganglion balloon compression was first proposed by Mullan and Lichtor in 1983. This procedure is safer and more effective than traditional open microvascular decompression surgery. The recurrence rate is about 15-20% after 5 years and 20-30% after 10 years; even if the patient has a recurrence of pain, he can be treated again by this procedure and the effect is still very good.
13.Who is the target of transdermal trigeminal ganglion balloon compression?
Patients who need surgical treatment for trigeminal neuralgia, especially those who are elderly, whose general condition does not allow or do not want to undergo open microvascular decompression, or whose MRI examination excludes vascular compression in the REZ area of the trigeminal nerve, including patients with persistent trigeminal neuralgia who have failed after other surgeries or whose symptoms recur.
14.What is our surgical experience and results of transdermal trigeminal ganglion balloon compression?
Most of the patients had spontaneous pain with no specific cause, probably due to vascular compression of the trigeminal nerve originating from the brainstem, 6 patients had tumors in the posterior cranial fossa or skull base, and 1 patient had arteriovenous malformation near the brainstem in the posterior cranial fossa; 115 patients had previous surgical treatment, 6 patients had open microvascular decompression surgery, and 1 patient had a second open microvascular decompression surgery. Six patients had undergone cranial microvascular decompression, one patient had undergone secondary cranial microvascular decompression, 102 patients had undergone peripheral branch trigeminal nerve block, 27 patients had undergone trigeminal ganglion thermal coagulation radiofrequency, and 12 patients had undergone gamma knife surgery.
The average operation time was about half an hour, the average hospitalization was 5-6 days, and no serious complications occurred in any of the patients. 190 patients had immediate pain relief after the first operation, and the rate of immediate pain relief after the operation was up to 96% or more (no need to take drugs such as carbamazepine). After successful surgery, the pain was immediately relieved and replaced by persistent mild to moderate hemifacial numbness and masticatory weakness, which was tolerated by most of the patients. To date, there has been no recurrence of pain in the outpatient follow-up of patients with successful surgery.
The average cost of treatment is about $9,000.
15.What should I do if I need to undergo transdermal trigeminal ganglion balloon compression?
Please bring along any tests you have received, especially MRI and CT films (very important), as well as any medications you have been taking, for detailed diagnosis and treatment by the physician. 16.What is the treatment procedure if the patient receives transdermal trigeminal ganglion balloon compression?
The current treatment process is: the patient must be hospitalized for five to six days. On the first day, the patient is hospitalized for basic tests (including blood sampling, X-ray, ECG, etc.), and on the second or third day, the patient is operated on lying down, under general anesthesia with tracheal intubation. After the operation, the pain is relieved and the half of the face is numb, and the patient can be observed for 2-3 days after the operation.
17.What are the risks if a patient undergoes transdermal trigeminal ganglion balloon compression?
The risks can be divided into two types: the risks of anesthesia and the risks of surgery.
(1) Risk of anesthesia
Most of the patients are older, often combined with hypertension, diabetes and other high-risk patients, so we recommend that patients be hospitalized, and do some necessary tests, and postoperative observation for 2-3 days, in order to reduce the risk of anesthesia; for surgery, general anesthesia is the safest anesthesia, the patient does not have any pain state can significantly reduce the risk of cardiovascular and cerebrovascular accidents, especially the time of our surgery is relatively short. It is short and will not have any effect on the patient.
(2) Risk of surgery
Any surgical procedure can be risky, especially this is a highly precise stereotactic functional surgery, which requires high precision, accuracy and rich surgical experience, so it needs to be performed by a very experienced surgeon in order to reduce the risk of surgery.
18.What are the possible complications if a patient undergoes transdermal trigeminal ganglion balloon compression?
Two patients had temporary paralysis of the sixth cranial nerve (adductor nerve) and diplopia after surgery, which returned to normal within three months. Most of the patients had immediate relief of pain and no more medication to control the symptoms. Instead, there was persistent mild to moderate hemifacial numbness and masticatory muscle weakness, which was tolerated by most of the patients. Other than the above, there are no other complications of the procedure.
19.What should I know if a patient undergoes transdermal trigeminal ganglion balloon compression?
Patients may have a simple rash on the corners of the mouth, lips, or oral cavity from the third day after surgery.
Persistent mild to moderate hemifacial numbness and masticatory muscle weakness, which is tolerated by most patients, is difficult to tolerate in the first week after surgery. This numbness and masticatory muscle weakness can be improved in most patients after three months, and the patient will return to the clinic half a month after discharge and every 2-3 months thereafter until the hemifacial numbness disappears and the masticatory muscle strength is normal.