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Trigeminal Neuralgia Treatment: Radiofrequency Ablation in Kolkata 

What is Trigeminal Neuralgia ? 

Trigeminal Neuralgia is a disease causing intense facial pain It affects the trigeminal nerve, which is responsible for sensation in the face. This disorder causes severe and sudden pain in the face that can be triggered by simple activities such as chewing, talking, or even touching the face. The pain is characterized by sharp electric shock like feeling in one side of the face along the distribution of one or more division of trigeminal nerve.  The pain is often described as sharp, stabbing, or electric shock-like and can last from a few seconds to several minutes. The attacks may be triggered by speaking, chewing, touching the area. In severe cases even blow of air on the affected side of face may be painful.
Trigeminal Neuralgia is a rare disorder that affects approximately 1 in 15,000 people. It is most commonly seen in individuals over the age of 50, and it is more common in women than men. The exact cause of Trigeminal Neuralgia is not yet known, but it is believed to be related to the compression of the trigeminal nerve by blood vessels or tumours.
Living with Trigeminal Neuralgia can be challenging, as the pain can be severe and unpredictable. It can also be emotionally draining, as the fear of pain can cause individuals to avoid social situations and activities they once enjoyed. However, with the right treatment and support, individuals with Trigeminal Neuralgia can manage their symptoms and maintain a good quality of life. 

Trigeminal neuralgia is more common in females. The male-to-female ratio is 2:3. The peak incidence is between 50 and 70 years. If we see the division-wise distribution the most common is the involvement of V2+V3 division (32%), the next common is isolated maxillary(V2) division and involving all 3 divisions (V1+V2+V3) of the trigeminal nerve (17% each). The next common is the involvement of isolated mandibular(V3) division in (15%) of patients. Follows the V1+v2 at 14% of cases. Isolated ophthalmic division involvement is the rarest at 4%

History of Trigeminal Neuralgia

The first Description of a disease like trigeminal neuralgia we get from the writings of Ibn Sina (980-1073) in an Arabic text. The first attempt to treat trigeminal neuralgia was made by John Locke in 1677, who applied sulphuric acid to the face to treat trigeminal neuralgia' Trigeminal neuralgia was successfully treated for the first time by alcohol injection by Pitres in 1902. First RF lesioning for this ganglion was described by Sweet and Vepsic in 1965, First Retro-gasserian glycerol injection was done by Hakanson in 1981. Percutaneous balloon compression was performed by Mullan and Lichtor in 1978 for the first time.

What are the symptoms of trigeminal neuralgia?

The symptoms of trigeminal neuralgia include:

  1. •    Severe shooting pain that may feel like an electric shock.

  2. •    Pain or attacks activated by touching the face, biting, talking, or brushing.

  3. •    Pain areas include the ear, eyes, forehead, jaw, or mouth and face.

  4. •    Over sensitivity, sensitivity to pain, or uncomfortable tingling and burning.

  5. •    Pain affecting one side of the face at a time.

Other symptoms may include facial spasms, pain that lasts from a few seconds to several minutes, pain that is concentrated in one area or spread over a larger area, rarely having pain at night when sleeping, and experiencing pain attacks that get more often and more severe over time

Why does trigeminal neuralgia occur?

The function of the trigeminal nerve is disturbed in trigeminal neuralgia, which is also known as tic douloureux. The cause of the problem is usually a normal blood vessel — either an artery or a vein — touching the trigeminal nerve where it joins the brain. This contact squeezes the nerve and makes it work wrongly.
Trigeminal neuralgia has many possible causes, but one of the most common ones is a blood vessel pressing on the trigeminal nerve. Sometimes, the nerve’s protective layer of myelin can be damaged by multiple sclerosis or a similar condition, which can also lead to trigeminal neuralgia. Another potential cause is a tumour that squeezes the nerve.
A brain lesion or other abnormalities can cause trigeminal neuralgia in some people. Surgical injuries, stroke or facial trauma are also possible causes of trigeminal neuralgia in other cases.

The pathophysiology of idiopathic trigeminal neuralgia still remains unknown.

One of the proposed mechanisms is the compression of the trigeminal nerve by aberrant blood vessels at the trigeminal root, causing demyelination and ectopic impulse generation. However, it is not found in all cases of idiopathic trigeminal neuralgia.

Secondary Trigeminal neuralgia may be caused by CP Angle tumour, Multiple sclerosis or injury caused by previous surgeries.

How Trigeminal Neuralgia is diagnosed? 

History and Clinical Examination – the following features are suggestive of trigeminal neuralgia. 
•    Type of pain: The pain from trigeminal neuralgia is quick, severe and brief. 
•    Location: Depending on which part of the trigeminal nerve is affected, the pain can occur in different regions of the face. 
•    Triggers: Some activities or sensations can trigger the pain, such as eating, talking, touching the face gently or feeling a cool wind.
•    A neurological examination: helps to exclude other possible causes. 

The diagnosis of trigeminal Neuralgia is mainly based on the history of the patient. The following questions are often asked to the patient. Does the pain occur in attacks? Are most of the attacks are of small duration (seconds to minutes)? Are the attacks unilateral? Do the attacks occur in the region of the face? Are there unilateral autonomic symptoms? Unilateral autonomic features (like lacrimation, nasal stuffiness, conjunctival congestion, and redness on one side of the face ) are not found in trigeminal neuralgia. Other diseases that can mimic trigeminal neuralgia need to be excluded as well. They are Temporo-Mandibular Joint (TMJ) Arthritis, Persistent Idiopathic Facial Pain, Sphenopalatine neuralgia, Migraine, Dental Disorders etc. Neurological Examination of all cranial nerves needs to be done carefully. In idiopathic trigeminal neuralgia, they are normal, in secondary trigeminal neuralgia, the features suggestive of CP Angle tumour or Multiple sclerosis may be found.

Investigation - Magnetic resonance imaging (MRI). The MRI scan helps to rule out multiple sclerosis or a tumour that could cause trigeminal neuralgia. It may also sometimes detect the aberrant vessel compressing on the trigeminal nerve. 

What are the treatments for trigeminal neuralgia without operation? 

Medications are usually the first option for treating trigeminal neuralgia, and some people may not need any other treatment. However, some people may become resistant to medications over time, or they may have unwanted side effects. For those people, other options include injections or surgery to treat trigeminal neuralgia. If the pain is caused by something else, such as multiple sclerosis, the doctor will address the root cause of that condition.

Medicines for trigeminal neuralgia - 

The following medicines are useful for trigeminal Neuralgia 
Anticonvulsants: Carbamazepine is the first-line treatment for trigeminal neuralgia, and it has proven to be effective for this condition. 
Other Anticonvulsant drugs: oxcarbazepine ,  lamotrigine, valproate and phenytoin .Some other drugs, like clonazepam, topiramate, pregabalin and gabapentin may also help.
Anticonvulsants may cause side effects such as dizziness, confusion, drowsiness and nausea. Carbamazepine may also cause a serious drug reaction in some people.
Antispasmodic agents: Patients can use muscle-relaxing agents such as baclofen by themselves or together with carbamazepine. These agents may cause side effects such as confusion, nausea and drowsiness. 
The drugs should be taken under Medical Supervision only. 

Pain Interventions for Trigeminal Neuralgia -  

When patients exhibit intense, paroxysmal unilateral facial pain suggestive of trigeminal neuralgia based on their medical history, a comprehensive clinical examination is advised. To eliminate other potential disorders and identify any aberrant vessels, an MRI scan of the brain is recommended. Initial management typically involves medical intervention with appropriate medications. If medical treatments prove ineffective or if patients experience intolerable adverse effects, interventional or surgical approaches may be considered. In younger patients, Microvascular Decompression (MVD) is often the preferred treatment, while older patients may find Percutaneous Radiofrequency Lesioning around the Gasserian Ganglion to be the treatment of choice.

Radiofrequency thermal lessening (Percutaneous Radiofrequency (RF) Rhizolysis)- It is a procedure that aims to destroy the nerve fibres that cause pain. The patient will be given sedation or local anaesthesia. A Radiofrequency needle is inserted by the doctor through the face. The Gasserian Ganglion is reached by the needle.  A mild electric current is sent by the electrode to the tip to find out the exact nerve to be treated. Then RF Lessoning is done.. More lesions are made by the physician if required. This procedure may cause some temporary numbness in face which resolves over time. This is the treatment of choice for trigeminal neuralgia in the aged and can also be done in young individuals. The pain relief period is much longer compared to other techniques. This procedure may be done as a care procedure.

Gasserian Ganglion glycerol injection (Percutaneous Glycerol Rhizolysis)

This is the simplest technique in which 50- 90 % glycerol is injected at the trigeminal ganglion. The average duration of pain relief is 6 months to 1 year. The procedure can be repeated. Foraminal Fibrosis may occur by repeated injection. It aims to stop pain signals from the trigeminal nerve, which is responsible for sensation in the face. The trigeminal nerve has three branches that split from a main root and a ganglion, which is a cluster of nerve cells. The ganglion and the root are surrounded by a small pouch of spinal fluid called the trigeminal cistern. To perform the procedure, insert a needle through the face and into a hole at the base of the skull. Then, the doctor will guide the needle into the trigeminal cistern and inject a small amount of sterile glycerol. The glycerol will damage the trigeminal nerve and prevent it from sending pain signals. This procedure can often reduce pain, but it may not work for everyone. Some people may have pain again later, and some may feel numbness or tingling in their face.

Gasserian Ganglion balloon compression  - It is a procedure that aims to stop pain signals from the trigeminal nerve, which is responsible for sensation in the face. The trigeminal nerve has a main root and a ganglion, which is a cluster of nerve cells. To perform the procedure, a hollow needle is inserted through the face and into the foramen ovale. Then, a thin, flexible tube (catheter) with a balloon on the end is pushed through the needle. The balloon is inflated by the doctor to put enough pressure on the trigeminal nerve and damage it. This prevents it from sending pain signals. In this technique, 4 Fr Fogarty catheter is inserted through 14G, 10 cm needle. The balloon is kept inflated there for 60 seconds to 120 seconds to selectively block A delta and c fibres. Pain relief period is 2- 74 months in different studies,



Other interventional treatment options forf trigeminal neuralgia



Stereotactic Radiation Therapy (Gamma knife) - Stereotactic Radiation Therapy stands out as a non-invasive approach for treating trigeminal neuralgia. Pain relief is not instantaneous, typically manifesting around three months after onset. Complete pain relief is achieved in approximately one-third of patients. While the procedure is deemed safe, there is a scarcity of extensive studies on its efficacy.



Trigeminal Ganglion Cryotherapy - User A comparatively newer mode of neurolysis, Showing good results in trigeminal neuralgia.

An emerging neurolysis method exhibiting promising outcomes in the treatment of trigeminal neuralgia is Gassarian Ganglion Stimulation, currently considered experimental. When conventional modalities prove ineffective, Trigeminal Ganglion Stimulation may be explored as an alternative approach.


Surgical Microvascular Decompression

Microvascular Decompression involves a surgical procedure where the ganglion is isolated from the aberrant vessel using a sponge after performing a craniotomy.

Life Beyond Pain: Exploring Patient Experiences After Trigeminal Neuralgia Radiofrequency Ablation at Samobathi Pain Clinic 

“I would like to share my experience. It has been only six months since I met the doctor. I had a very uncommon illness. I suffered from it for the last four to five years. It was a nerve pain. I visited so many doctors in my life, but no one could treat my pain. But I finally got relief with the medicine he prescribed. He also did my surgery and now I am fully recovered from trigeminal neuralgia. Thank you so much, sir. Dr Debjyoti Dutta is personally a very kind and helpful person.” ( Spelling and Grammar Corrected) 

A patient of trigeminal neuralgia sharing her treatment experience in google review
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