Mr K was approaching retirement from his job, where he worked for the last 15 years. He was diligent and hard-working, and his organisation appreciated him. But he was not happy. He had been suffering from this shock-like pain on the left side of his face, which lasted just a few seconds—seconds that seemed like a lifetime! This had started a couple of years ago as a mild pain that was rare but of late was very frequent. He had consulted many doctors, from dentists to physicians and pain specialists; medicines were given, but he did not have any relief. Unable to touch his face, it was difficult to brush his teeth and wash his face; sometimes speaking and eating were very hard. Each moment he lived in fear of when the pain would come! He slowly stopped going out and meeting people, scared that the attacks would come in public when he could not control his pain and the reactions.
He finally met a neurologist, who diagnosed the condition as trigeminal neuralgia – a condition of pain over the face due to irritation of the nerve that takes pain sensations from the face to the brain. He tried medications, but though the pain decreased, he became extremely drowsy – wanting to sleep all the time! That was when he was given the solution of surgery as a cure for the problem.
Trigeminal neuralgia is an electric shock-like episodic pain that occurs on one side of the face. It has been described as sharp, lancinating pain, which is very difficult to tolerate. It can occur spontaneously, i.e., without any apparent stimulus—even an air movement from a fan or the act of opening the mouth to chew food can result in pain.
Trigeminal neuralgia – the pain – happens because of irritation with the trigeminal nerve. The trigeminal nerve is the one that takes sensations from the face to the brain. The nerve – one on each side of the face – has three branches – around the eyes and forehead, the nose and cheek and the lower jaw. The pain can affect any or any combination of the branches of the nerve. When the nerve is in an irritated state, any sensation that it feels is transmitted to the brain as a sharp pain sensation.
Certain symptoms may indicate that the pain is not trigeminal neuralgia, such as giddiness or weakness, hearing difficulty, numbness of the face or limbs, infected teeth or gums, visual problems, pain on both sides of the face, and pain lasting more than a few minutes.
The diagnosis of trigeminal neuralgia is a clinical diagnosis based on the patient’s description of the pain and associated symptoms and signs. Once there is a clinical diagnosis of trigeminal neuralgia, the next step is to get an MRI scan of the brain.
The MRI scan of the brain will allow the doctor to look at the nerve and see if there are any reasons for the irritation. These may include tumours or cysts pressing on or involving the nerve. Occasionally there may be focal swelling (demyelination) along the course of the nerve in the brain. When these secondary causes are ruled out in the MRI scan, special MRI sequences are done (CISS, FIESTA) to see if there is a blood vessel that is compressing the nerve.
In the 1960s it was discovered that where there is no other obvious cause of irritation of the trigeminal nerve, the most likely cause would be a blood vessel that lies across and compresses the nerve. Recent technological advancements, particularly in MRI imaging, have confirmed this theory. The constant contact and pulsation of the blood vessel on the nerve erode the nerve coverings, leading to a short circuit-like situation. This leads to the perception of all nerve-borne sensations as intense, sharp pain in the brain.
As with most conditions, wherever possible, it is best to try medicines first. Other treatment options are considered only when the medicines do not work, the side effects affect the patient, or they cannot be taken regularly. It must be understood here that the medicines cannot be stopped; stopping them will result in a recurrence of the pain, and this episode is usually much more severe than was initially present.
The most effective, and probably the only effective, medication that works for trigeminal neuralgia is carbamazepine. This is a drug that is also given for epilepsy and is reasonably safe. It is generally started off in small doses at regular intervals so that the patient can be pain-free. If the pain is not controlled, an increase in the dosage and frequency is an option. This can be done until the patient develops side effects of the drug or when, after a few increases in dosage, it is evident that the pain is not getting controlled.
Many other drugs, mostly used as anti-epileptic drugs, have been tried for trigeminal neuralgia, especially when carbamazepine cannot be given or as an add-on drug. However, the majority have been found to be ineffective in controlling the pain.
There are multiple interventions or procedures available for the treatment of trigeminal neuralgia. Some of the procedures, e.g., neurectomy (cutting of the nerve), are of historical importance and are not in use currently.
When medicines are not working or the patient is unable to take them properly, the most effective procedure is surgery – microvascular decompression. This provides instant and long-term pain relief without side effects, and the patient can be without medicines.
Most other procedures, like Gamma Knife (SRS), balloon rhizotomy, RF lesioning, and glycerol rhizotomy, work by damaging part of the nerve. They might provide quick pain relief, but the pain often comes back. These procedures are therefore only recommended if the patient cannot undergo the surgical procedure.
This is a safe surgery by experts and is performed from behind the ear, where a small 2.5 cm diameter opening is made in the skull bone. An operating microscope is then used to go to the nerve and identify the vessel that is impinging on it. There are various techniques of separating the vessel from the nerve – but the important step is to make sure that the vessel is completely moved away from the nerve and is kept in the new position. The risk in this surgery is less than 2%, and the complication rate is also very low. When done properly the pain relief is instant without creating numbness in the face. The medicines can be stopped, and the patient can live a normal life without any pain and without medicines.
Mr K approached us for the management of his trigeminal neuralgia. He was in despair, and he was also depressed. Surgery was performed successfully, and what he said made a big difference: “Thank you all for doing this surgery. I am today smiling and have been able to do without pain the small actions of everyday life that we take for granted – like eating, brushing teeth, washing my face, drinking coffee and talking. I feel I have got a second life and can live my life happily.”
Dr. Krish Sridhar Group Mentor, Neurosciences & Director, Institute of Brain & Spine Kauvery Hospital Chennai – Radial Road
What is trigeminal neuralgia?
Trigeminal neuralgia is a chronic pain condition that causes sudden, sharp, electric shock-like pain on one side of the face. It occurs due to irritation or compression of the trigeminal nerve, which carries sensations from the face to the brain.
What are the common symptoms of trigeminal neuralgia?
The most common symptom is sudden, intense facial pain that lasts for a few seconds to minutes. The pain may be triggered by simple activities such as brushing teeth, eating, speaking, touching the face, or even exposure to air.
What causes trigeminal neuralgia?
In many cases, trigeminal neuralgia occurs when a blood vessel compresses the trigeminal nerve. Other possible causes include tumours, cysts, multiple sclerosis, or nerve damage.
How is trigeminal neuralgia diagnosed?
Doctors usually diagnose trigeminal neuralgia based on the patient’s symptoms and medical history. Imaging tests such as MRI scans are often performed to identify nerve compression or other underlying causes.
What treatments are available for trigeminal neuralgia?
Initial treatment usually involves medications such as carbamazepine to control nerve pain. If medicines are not effective or cause side effects, procedures like microvascular decompression surgery or other nerve interventions may be recommended.
What is microvascular decompression surgery?
Microvascular decompression is a surgical procedure that relieves pressure on the trigeminal nerve by moving the blood vessel away from the nerve. It can provide long-term pain relief without causing facial numbness.
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