Trigeminal neuralgia (TN) is defined by The International Association for The Study of Pain (IASP), as “sudden usually unilateral severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve”.
One sufferer described the pain as “ I was having Supper with friends. suddenly started having sharpshooting electrical sensations running down my upper and lower jaw. The guests started staring, concerned, and appalled. I cannot speak to explain why the tears stream down my face. I cannot even swallow, my own saliva dribbling onto my plate. All I can do is try not to scream.”
Only the patient’s arresting report gives us insight into the personal experience of TN pain, illustrating the suffering and fear accompanying the first attack, which many patients remember because of its dramatic onset.
TN has an emormous psychological impact, but few scholarly papers highght the way it can affect the quality of life. TN is a neuropathic consition with a unique clinical manifestation;it is also one of the chronic pain conditions in which sufferers can be rendered 100% pain-free either with medications or interventions like gasserian ganglion radiofrequency ablation or percutaneous balloon compresion or surgery. for this reason correct diagnosis is crucial so thet patients can then follow a generally acknowledged care pathway as soon as possible.
Although the main diagnostic symptoms of TN, as defined by IASP and the International Classification of Headache Disorders (ICHD), appear to be clear, there is considerable overlap between these symptoms and those of other trigeminal autonomic cephalalgias, as well as unilateral persistent idiopathic facial pain, temporomandibular disorders, and dental pain. Dr. Deepesh an Interventional pain specialist in tertiary care hospital highlight the diagnostic problems, suggesting that “the majority of patients attend- ing their tertiary facial pain clinic had previously been misdiagnosed and had undergone irreversible dental treatment, even when they had presented with classical features of TN”. Dental disorders, such as peri-apical abscesses, can produce pain identical to that of TN. Dentists and patients are both correct to consider these extremely common disorders initially. However, dentists should not carry out irreversible procedures if a patient’s clinical history, examination, and investigations are equivocal or inconsistent. On the other hand, primary medical practitioners have learned very little about the causes of facial pain and may tend to overdiagnose TN because it may be the only diagnosis with which they are familiar.
When symptoms caused by non-nociceptive triggers sharp, shooting pain lasting only a few seconds, and the inability of opioids to adequately reduce pain provides an 81% probability that a case is TN rather than pulpal or temporomandibular pain.
The following testimonies recount typical stories:
“I went for my appointment to a dental consultant. He examined me and did a full mouth x-ray. He seemed really confident that I definitely did NOT have TN, and that it is all dental.”
When patients come to realize they have received an incorrect diagnosis, they begin the long process of consulting ear-nose-throat and maxillofacial specialists—each of whom may also be unfamiliar with this rare condition—before finally reaching a neurologist or pain specialist experienced in managing TN.
One patient encountered a neurologist who recognized the condition but not its severity or the urgent need for treatment: “My neurologist gave me a thorough examination and advised that he definitely thought it was TN, and the next step would be an MRI scan…. I have to wait another six months for a scan. The thought of being in pain every day before I even get to the next step of treatment is really getting me down…. I got my scan results and, no surprise, they haven’t found anything. The neurologist wrote to say he didn’t need to see me again.”
Diagnosing TN Correctly
The principal way a health-care professional can make a proper diagnosis is to receive a careful history. This requires allowing patients adequate time to complete their opening statement. It is important to allow patients to tell their story in their own words, and “This takes time—face time, time looking into their faces instead of a clock or computer.” As William Osler said to his students a century ago: “Listen to the patient: he is telling you the diagnosis.”
Because no objective diagnostic tests exist for idiopathic TN, listening remains the only reliable tool. In contrast, examinations and x-rays improve the diagnosis of dental pain. As part of the diagnostic work-up, patients should have a magnetic resonance imaging (MRI) scan or, at the least, a computed tomography scan to rule out TN secondary to tumors or other compressive causes and to reveal plaques indicative of multiple sclerosis. In classical TN, high-resolution MRIs will indicate the presence of neurovascular compression of the trigeminal nerve in the posterior fossa.
Managing the Pain
Once a correct diagnosis has been reached, it becomes possible to start to control the pain. Patients may value the risks, benefits, and side effects of the various options very differently from the physician. The first approach is with drugs. Carbamazepine has long been the gold standard, but a wide variety of drugs are available; All these drugs have side effects, which in some cases preclude their use, and they tend to become less effective for pain control as the disorder progresses. It is important for patients not only to learn how to use their medications to maximum effect but to be allowed to control the dosage themselves.
The Percutaneous Pain Management Interventions and Surgery Option
When drugs no longer provide relief, a variety of surgical options are available. It is important to gauge patients’ reactions to each option and take their preferences into account. Options include percutaneous procedures at the level of the Gasserian ganglion, which are destructive. Balloon compression, glycerol injection, or radiofrequency thermocoagulation and Gamma Knife surgery (at the level of the nerve root) provide pain relief in for as long as five years but may cause facial numbness.
The most successful procedure, providing relief for more than 10 years, is microvascular decompression of the nerve, a nondestructive procedure. This procedure involves major neurosurgery and is therefore not suitable for all patients; it carries a mortality rate of 0.5% and a 2% risk of hearing loss. However, satisfaction is high after this operation.
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Also read: https://www.painx.in/blog/epidural-steroid-injection-epidural-neuroplasty-for-sciatica/
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