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Trigeminal neuralgia is a facial pain complaint one side attacks are repeated. Trigeminal neuralgia is called, because this facial pain occurs on one or more of the three branches of the nerve Trigeminal nerve. This large nerve located in the brain and carry sensations from the face to the brain. The pain caused by a disturbance of nerve function in accordance with the regional distribution Trigeminal innervation one Trigeminal nerve branches caused by various causes.

Trigeminal neuralgia attacks may take place within a few seconds to a minute. Some people experience mild illness, sometimes feels like being stabbed. While others feel the pain quite often, heavy, such as pain during the taxable electric stun.

Disease prevalence is estimated at 107.5 in men and 200.2 women per million population. The disease is more common on the right side of the face compared with the left side (ratio 3:2), and is a disease in adult age groups (six to seven decades). Only 10% of cases occur before age forty years.

Another source said, the disease is more common in those aged over 50 years, although there are also young people and children.

Trigeminal neuralgia is a relatively rare disease, but very disturbing comfort in living patients, but the actual administration of drugs to cope with Trigeminal neuralgia is usually quite effective. This drug will block the pain signals sent to the brain, so pain is reduced, it's just that many people do not know and Trigeminal Neuralgia misinterpreted as pain caused by abnormalities in the teeth, so the treatment is performed is not exhaustive.


ANATOMY trigeminal nerve
Trigeminal nerve is the largest cranial nerve and serve the first Branchialis arcus. These nerve fibers contain branchiomotorik and general somatic afferent (consisting of components and component ekteroseptif proprioceptive), with nuclei as follows:

a. Nucleus Nervi Motorius Trigemini

From this Nucleus branchiomotorik out the fibers that run directly into the ventrolateral fibers intersect pedunculus cerebellaris medius (fibrae pontocerebellares) and will eventually serve m. Nervi motori Masticatores through rami mandibularis and m. Tensor Veli Palatini and m. Mylohyoideus.

b. Pontius Nucleus, Nucleus spinalis Nervi Nervi Trigemini and Trigemini

Second Nucleus receives impulses from the region eksteroseptif face and calvaria region ventral to the vertices.
In between there is a nucleus on the functionally important difference: in the nucleus ends Pontius aferan nerve fibers V is relatively coarse, which deliver impulses felt sense, while the nucleus spinalis N. V consists of small cells and neurons receive nerve fibers Which deliver a smooth V impulses eksteroseptif pain and temperature.

Trigeminal nerve PHYSIOLOGY

Trigeminal nerve function can be assessed by examining the sense of temperature, pain and touch the nerve innervation area V (the ventral face and calvaria), corneal reflex examination, and inspection functions of the muscles of mastication. The function of muscles of mastication can be checked, for example by asking the patient to close his jaw in a meeting, so that the teeth on the lower jaw teeth pressing on the upper jaw, while the m. Masseter and m. Temporalis can be palpated easily.
In the unilateral destruction of motor neurons, mm. Masticatores mngelami not function disorder, because the nucleus motorius N. Fibrae corticonucleares V received from both cortex cerebri.
In addition to the cutaneous functions, maxillaris and mandibularis branches is important in dentistry. Maxillaris nerve provides sensory innervation to the teeth maxillaris, palate, and gingiva. Mandibularis branches provide sensory innervation to the mandibularis teeth, tongue, and gingiva. Variation of nerve that provides innervation to the tooth to the alveolar forwarded, to the socket where the tooth comes into the superior alveolar nerve from the tooth maxillaris maxillaris branch of trigeminal nerve. Inferior alveolar nerve to tooth mandibularis mandibularis branch originating from trigeminal nerve.

DEFINITION trigeminal neuralgia

Literally, Trigeminal Neuralgia means pain in the trigeminal nerve, which delivers the pain to the face.
Trigeminal neuralgia is a condition that affects nerve V, the largest cranial nerve. Characterized by a sudden pain, severe, such as electric shock, or stabbing pain, usually on one side of the jaw or cheek. In some patients, the eyes, ears or palate can also be attacked. In most patients, pain is reduced at night, or when the patient was lying.

Trigeminal Neuralgia Clinical

Trigeminal neuralgia attacks may take place within a few seconds to a minute. Some people experience mild illness, sometimes feels like being stabbed. While others feel the pain quite often, heavy, such as pain during the taxable electric stun. Trigeminal neuralgia sufferers who describe the pain like a heavy shot, hit jab punch, or there is a wire along the face. These attacks come and go. Could be a day no pain. However, pain can also attack every day or during Sunday. Then, do not hurt anymore for some time. Trigeminal neuralgia is usually only felt on one side of the face, but can also spread to the broader pattern. Rarely felt on both sides face the same sometime.

CLASSIFICATION

Trigeminal neuralgia (NT) can be differentiated into:
1. Typical NT,
2. NT atypical,
3. NT for Multiple sclerosis,
4. NT Secondary
5. NT Post-Trauma, and
6. Trigeminal Neuralgia Failed.
Other forms of neuralgia must be distinguished from idiopathic facial pain (atypical) as well as other disorders that cause facial pain-kranio.


Aetiology (CAUSE) Trigeminal Neuralgia

Patofisiologis mechanisms underlying NT has not so sure, though have been very much research done. Conclusion Wilkins, all theories about the mechanism must be consistent with:

1. The nature of the paroxysmal pain, with pain-free interval of
long.
2. Generally there is a stimulus 'trigger' which is carried by afferent
large-diameter (not the pain fibers) and often through
divisions outside the division for the fifth nerve pain.
3. The fact that a small lesion or partial ganglion
gasserian and / or nerve roots often eliminate
pain.
4. The occurrence of NT in patients who have abnormalities
central demielinasi (occurring in 1% of patients with multiple sclerosis
multiple)

This fact seems to confirm that the etiology is central than peripheral nerves. Paroksisme pain analogous to the resurrection and the pull is often can be controlled with anti-seizure drugs (carbamazepine and phenytoin).

It seems very likely that the attacks of pain may indicate a spontaneous outburst 'aberrant' of neuronal activity that may begin by entering input through the fifth nerve, originating from throughout the central nerve tracts of five, or at central synapses.

Various pathological conditions indicate possible causes of this disorder. In most patients operated on for NT found in the compression of 'nerve root entry zone' fifth nerve in the brain stem by blood vessels (45-95% of patients). This increases with age due to the elongation of secondary artery with aging and arteriosclerosis and possibly as the cause in most patients.

Autopsies showed many cases with similar circumstances vascular suppression showed no symptoms during life. Nonvaskuler fifth nerve compression occurs in some patients. 1-8% of patients showed benign tumor serebelopontin angle (meningioma, epidermoid cyst, acoustic neuroma, AVM) and compressed by bone (eg secondary to Paget's disease). Unlike most patients with NT, these patients often have symptoms and / or signs of cranial nerve deficits.

Other causes are possible, including peripheral nerve injury fifth (such as dental action) or of multiple sclerosis, and some without obvious pathology.

Pathophysiology

Trigeminal neuralgia can be caused by various conditions involving the ipsilateral trigeminal neural system. In most cases, it appears that the etiology is the presence of arterial compression by one nearby that had lengthening with the passage of age, right at the base where these nerves exit from the brainstem. Five to eight percent of cases caused by benign tumors on the angle-pontin serebelo as meningioma, epidermoid tumors, or acoustic neurinoma. Approximately 2-3% of cases due to multiple sclerosis. There are some cases that do not know why. According to Fromm, Trigeminal neuralgia may have peripheral or central causes.

For example argued that the presence of chronic irritation of this nerve, whatever the cause, can lead to failure on segmental inhibition in the nucleus / core of this nerve that causes the production of ectopic action potentials in the Trigeminal nerve. This situation, namely the excessive neuronal discharge and reduction in inhibition, resulting in a hyperactive sensory channels. If not unstoppable attack will eventually cause pain. Antidromik potential action was felt by the patient as trigerminal that paroxysmal pain attacks. Simple stimulus triggers in the area resulting in a painful attack.

Effective therapeutic effects of drugs that are known to work are central to prove the existence of a central mechanism of neuralgi. About how multiple sclerosis can be accompanied by pain Trigeminal be reminded of the existence of demyelinating plaques at the site of nerve entry, or the main sensory nucleus of trigeminal nerve.

Trigeminal pain post on viral infections, such as post-herpes, it is assumed that the lesion in the nerve will activate nociceptors that cause the pain. About why the pain of post herpes still endure to be said for a long time after recovery and during regeneration remains the bearer of pain substances formed to different time periods. At the young age, this relatively short time. However, in elderly pain can last very long. Giving antiviral quickly and in adequate doses will greatly shorten the duration of this pain.

Peter Janetta classify glossopharyngeal neuralgia and hemifacial spasm in a group of "Syndromes of cranial Nerve Hyperactivity." According to him, all the nerves that are classified in this syndrome have one thing in common: they all lie in the pons or medulla oblongata and surrounded by many arteries and veins. At the genesis of the hyperactive syndrome, there are two processes which is actually a reasonable aging process:

1. Longitudinal and circular at the base of the brain arteries.
2. With increasing age, because of atrophy, the brain will shift or fall into the caudal direction in the posterior fossa due to the ever increasing contacts with neurovaskuler which will surely increase the likelihood of an emphasis on the related nerves.

There is the possibility of vascular compression as the basis for a common cause of this syndrome, cranial nerve. Compression of blood vessels pulsing, both from an artery or vein, is the main cause. Location of compression associated with clinical symptoms that arise. For example, compression of nerves in the rostral trigeminal neuralgia will result in the trigeminal nerve branches oftalmicus from, and so on. According to Calvin, approximately 90% of Trigeminal neuralgia causes is the existence of arterial "misplaced" that circles the nerve fibers are at an advanced age. Why the extension and bending of blood vessels, said that perhaps is why lies in the genetic predisposition coupled with some lifestyle factors, namely smoking, dietary patterns, and so forth. Blood vessels do not have large-diameter pressure. Although only small, for example with a diameter of 50-100 um alone, can cause neuralgia, hemifacial spasm, tinnitus, or vertigo. If done correctly microvascular decompression, the complaint will be lost.

DIAGNOSIS

Diagnosis is the key to history. Generally, examination and neurological tests (eg CT scan) was not so clear. The most important factor is the distribution history of pain and the occurrence of 'attacks' of pain with pain-free intervals are relatively long. Pain started in the distribution of two or three nerve divisions of five, eventually often attack them. Some cases begin in the first division.

Typically, the pain attacks occur suddenly, very severe, short duration (less than one minute), and is felt in one part of the Trigeminal nerve, such as the jaw or around the cheek. Pain is often the bait when a specific area is stimulated (trigger areas or trigger zone).

Trigger zones are often found around the nostrils or mouth corners. Unique from the trigger zone is rangsangannya must be a touch or pressure on the skin or hair in the area. Stimuli in other ways, eg by using heat, although the cause of pain in that place, can not provoke the attack neuralgi. Neurologic examination at neuralgi Trigeminal almost always normal. There were no sensory disturbances on Trigeminal neuralgi pure.

Reported the existence of sensory disturbance on Trigeminal neuralgia that accompanies multiple sclerosis. Conversely, approximately 1-2% of patients with MS also suffer from Trigeminal neuralgia, in this case can be bilateral.

A variant called tic Trigeminal neuralgia is marked by convulsive muscle contractions of face sesisih accompanied by severe pain. This situation needs to be distinguished by the face muscle movements that can accompany the common neuralgi, called tic douloureux. Tic convulsive accompanied by severe pain more often found in areas around the eyes and more often found in women.

Systematically, anamnesis and physical examination was performed as follows:

Anamnesis

Localisation · pain, to determine the trigeminal nerve branches
affected.
Determining the time of commencement · Trigeminal neuralgia and
the trigger mechanism.
Determining · pain-free interval.
· Determining long, side effects, dosage, and response to
treatment.
Asking · herpes disease history.

Physical examination

· Assess sensation in all three branches of the bilateral trigeminal nerve
(Including corneal reflex).
Assessing · chewing function (masseter) and function pterygoideus
(Open mouth, chin deviation).
· Assessing EOM.

Diagnostic investigations such as CT or MRI head scan done to find the primary etiology in the posterior region or point-pontin serebelo.



Management of

Treatment is basically divided into three parts:
1. Management of first using drugs.
2. Surgery is considered if the drug did not work satisfactorily.
3. The treatment of psychiatric terms.

Medical therapy (drug)

Need to be reminded that most of the drugs used in this disease has considerable side effects. This disease primarily affects those who are also elderly. Therefore, the selection and use of drugs should be carefully considering the possibility of side effects. Basic use of drugs in the treatment Trigeminal neuralgia and other nerve neuralgi is the ability of drugs to stop the delivery of afferent impulse that causes pain attacks.

Carbamazepine

Drugs that until now considered the first choice is carbamazepine. If effective, the drug is already starting to look the results after 4 to 24 hours of delivery, sometimes even in a quite dramatic. Initial dose is 3 x 100 to 200 mg. When the patient's tolerance to the drug was good, the therapy was continued until a few weeks or months. Dosage should be adjusted by reducing pain responses that can be felt by the patient. Maximum dosage is 1200 mg / day. Because it is known that patients may experience remission, the dose and duration of treatment can be adjusted for this possibility. If the therapy works and monitoring of negative side effects, then these drugs should be continued until at least six months before trying to net. Laboratory monitoring usually includes examining leukocyte count, liver function, and allergic skin reactions.

When the pain settled then it should be examined drug levels in blood. If the content turns out to be sufficient while the pain is still there, then it could be considered for adding other drugs such as baclofen. Starting dose of baclofen 10 mg / day which could gradually be increased up to 60 up to 80 mg / day. The third drug may be added when the combination of two drugs is still not fully control the pain. Available phenytoin, sodium valproate, gabapentin, and so forth. All of these drugs are also known as anti-epileptic drugs.

Neurontin

A new anticonvulsant gabapentin is evidenced by several trials as a drug that can be considered for neuropathic pain. This drug came into use in America in 1994, as anti-epileptic drugs. Ability to reduce neuropathic pain who stubbornly incidental reported from 1995 until 1997 by Mellick, Rosner, and Stacey.

Waldeman suggest that delivery of these drugs when carbamazepin and phenitoin failed to control pain. Initial dose of 300 mg, at night, during the two days. Where no such side effects like dizziness disturbing / dizzy, drowsiness, itching, and confused, the drug increased the dose every 2 days with 300 mg until pain disappeared or until the dose reached 1800 mg / day. The maximum dose allowed by the manufacturer of this drug is 2400 mg / day. Waldeman recommends 1800 mg as the highest dose. Rowbotham et al. found that gabapentin in doses from 900 to 3600 mg a day managed to reduce pain, improve sleep disturbances, and generally improve the quality of life of their patients.

To neuralgi that accompanies a patient with multiple sclerosis was Neurontin in doses between 900 to 2400 mg / day was also effective in six of seven patients.

The workings of gabapentin in pain relief remains unclear right. Which must be noted is that these drugs increase the synthesis of GABA and inhibits GABA degradation. Therefore, the provision of gabapentin increases GABA in the brain. Because the drug is lipophilic so good penetration into the brain.

Non-medical therapy (Surgery)

Non-medical treatment options (surgery) considered whenever more than two-drug combination has not brought the expected results. Dr. Stephen B. Tatter said that surgery reserved for those who can not tolerate the side effects of medical therapy or medical therapy proved ineffective. There are various surgical ways, from the most ancient, which can lead to disability (usually auditory and facial muscle movement) is quite large, up to a more sophisticated manner, with little or almost never seen side effects.

J. Keith Campbell wrote in his article "Are All of the Treatment Options Being Considered? that medical treatment often fails in the relief of pain in a long period. It is often found in elderly patients. For young patients, referring to a surgeon for microvascular decompression should be considered immediately after diagnosis.

Two ancient mode of operation, namely ablatio total resection of the peripheral nerves and sensory parts of the Trigeminal nerve, is now no longer done because there are better methods. However, Waldeman still recommend Trigeminal nerve block using local anesthesia + methylprednisolone. Used was bupivacaine without preservatives are given together with methylprednisolone. Injections were carried out every day until oral drugs that started at the same time, began to be effective.

Radiofrequency rhizotomy (Meglio and Cioni, 1989)

Until now still popular because it is relatively safe and inexpensive. Unfortunately, this approach has the possibility of recurrence by 25%. Other side effects are less comfortable is the occurrence of corneal anesthesia, tingling, and weakness of the jaw which can sometimes be distracting. In fact, there are patients who feel sorry that tingling feeling that this ongoing pain more uncomfortable than the remaining period of his free.

Percutaneous retrogasserian rhizolisis with glycerol

This is the way advocated by JHO and Lunsforf (1997). That said, the results are very good with minimal disruption on the sensitivity of the face. The hypothesis put forward is that glycerol is neurotoxic and work on nerve fibers which have had demielinisasi, eliminating the compound action potential at the Trigeminal fibers associated with pain. This method is quick and patients can be quickly repatriated. The disadvantage is that still could happen sensory disturbances that may interfere with or recurrent back pain.

Microvascular decompression

The basis of this procedure is the assumption that there is an emphasis vascular cause of all these complaints. Neuralgi is a compressive cranial mononeuropathy. Adherents of these treatments assume that the healing that occurs is the most perfect and permanent. Losses in this way is that somehow this is a kraniotomi and patients need to stay around 40-10 days in the hospital, followed by a period rekonvalesensi that also need 1-2 weeks. Another consideration is that although rare, microvascular dekompression can cause death or other complications such as stroke, facial nerve weakness, and deafness. In the hands of an experienced surgeon, complications are certainly very small. In a successful operation, the reduction or even disappearance of pain can already be felt after 5-7 days after surgery. Dr. Fred Barker and his team report in a scientific meeting about his experience with microvascular dekompression in 1430 patients conducted at the University of Pittsburgh. Most of these patients get complete pain reduction or meaningful. Two years after surgery, the incidence of recurrence of 1% per year. This is generally due to recurrence of new blood vessels that appear on the trigeminal nerve.

Stereotactic Radiosurgery with gamma knife

Is still relatively new developments. The Gamma Knife is a tool that uses stereotactic Radiosurgery. The technique is a way to focus gamma rays that behaves like a surgical procedure, but without opening the cranium. The Gamma Knife was first introduced by Dr. Lars Leksell of Stockholm, Sweden in 1950. This method requires only local anesthesia and the results are supposedly quite good. Approximately 80-90% of patients can expect healing after 3-6 months after therapy.

How it works is through desentisisasi therapy on Trigeminal nerve after radiation directed at this nerve with the help of computers. A neurosurgeon from Seattle Dr. Ronald Young said that with the Gamma Knife is also very satisfactory results with minimal complications.

Meglio and Cioni reported a new way of decompression using a small balloon is inserted through the foramen ovale percutaneous. Balloons filled with approximately 1 ml so that pressing the ganglion for 1 to 10 minutes. It is said in this way brings results in approximately 90% of cases. There has been no report on how many are experiencing recurrent.

Treatment of Psycho Aspects

Another thing that is important to note that in addition to the administration of drugs and surgery are the mental and emotional aspects of patients. In addition to anti-depressant drugs which can give the effect of changes in brain chemistry and affects neurotransmitters in both depression and pain sensation, also can be performed consulting engineering biofeedback (training the brain to change its perception will be pain) and relaxation techniques.

Knot

Trigeminal neuralgia is a facial pain complaint one side attacks are repeated, called Trigeminal neuralgia, facial pain is due to occur in one or more of the three branches of the nerve Trigeminal nerve. The pain caused by a disturbance of nerve function in accordance with the regional distribution Trigeminal innervation one Trigeminal nerve branches caused by various causes. In most cases, it appears that the etiology is the presence of arterial compression by one nearby that had lengthening with the passage of age, right at the base where these nerves exit from the brainstem.

Diagnosis is the key to history. The most important factor is the distribution history of pain and the occurrence of 'attacks' of pain with pain-free intervals are relatively long. Pain started in the distribution of two or three nerve divisions of five, eventually often attack them. Some cases begin in the first division. Typically, the pain attacks occur suddenly, very severe, short duration (less than one minute), and is felt in one part of the Trigeminal nerve, such as the jaw or around the cheek. Pain is often the bait when a specific area is stimulated (trigger areas or trigger zone). Trigger zones are often found around the nostrils or mouth corners.

Drug used to treat Trigeminal neuralgia is usually quite effective. This drug will block the pain signals sent to the brain, so pain is reduced. If there are side effects, other drugs can be used according to doctor's instructions, of course.

Some commonly prescribed drugs such as Carbamazepine (Tegretol, Carbatrol), Baclofen. There are also drugs Phenytoin (Dilantin, Phenytek) or Oxcarbazepine (Trileptal). Your doctor may give Lamotrignine (Lamictal) or gabapentin (Neurontin). Trigeminal neuralgia patients who do not fit with drugs could choose surgery.