Inflammation of the trigeminal nerve: causes, symptoms, diagnosis and treatment

Trigeminal neuralgia (trigeminal neuralgia) is a disease during which attacks of pain (intense, shooting, burning) occur in areas of innervation - areas supplying nerve fibers to the temporal, frontal regions, facial skin, masticatory muscles, ocular conjunctiva, and some muscles of the oral cavity ( for example, mylohyoid).

General information

Pain in the facial area is considered the most difficult in medicine, as it is associated with pathologies of the nervous system, ENT organs, dental system or eyes. However, trigeminal neuralgia is often the cause of such pain.

The problem is at the top of the ranking of neurological diseases due to a large number of factors: excruciating paroxysmal pain, social and work maladjustment (it is extremely difficult for a person to work productively, he is under constant stress), long-term treatment. Symptoms can be identified, but only a specialist can prescribe the exact cause of the disease and truly effective treatment. In the 5th city hospital of Minsk, all conditions have been created for high-quality neurological and neurosurgical care: from diagnosis to treatment.

Possible complications

If a person does not pay attention to the symptoms and simply takes analgesics to relieve attacks of pain, the condition may worsen.

Untreated inflammation can cause:

loosening of teeth (molars and wisdom teeth);
atrophy of the muscles with which chewing occurs;
earlier appearance of wrinkles;
inflammation of the mucous membrane of the organs of vision or cornea due to a failure in the production of moisturizing fluid;
deterioration in the appearance of the skin due to lack of normal nutrition;
madarosis, that is, loss of eyelashes and eyebrow hair.

In order not to encounter unpleasant complications, you need to take preventive measures, and if there are initial signs, do not postpone a visit to the doctor.

Pathogenesis

Trigeminal neuralgia develops due to disorders of the central component (blood circulation in the nucleus) or peripheral (peripheral parts of the nerve). For this reason, different approaches are used for treatment.

The pathogenetic mechanisms include vascular, endocrine-metabolic and immunological factors. Because of them, the sensitivity of the nuclei changes and a focus of pathological activity is detected in the central nervous system. After this, trigger (hypersensitive) areas arise in the innervation zones of different branches of the nerve, and when irritated, attacks of pain occur on the face.

The vascular factor is involved in classical neuralgia, when the nerve root is affected by a vertically crossing arterial loop.

Vasculoneural conflict (conflict between a nerve and a vessel) is especially taken into account in people who begin to harden the arteries and nerve fibers. With treginal neuralgia in the elderly, this is the most common case.

Autoimmune processes (in which the body attacks its own cells) cause inflammatory reactions during dental treatment and colds. In this case, it is they that cause trigeminal neuralgia and pain.

Price for treatment of trigeminal neuralgia at SL Clinic

The cost of radiofrequency treatment of trigeminal neuralgia is 120,000 rubles and depends on: - The cost of needles for radiofrequency ablation; — Clinics and class wards. The price includes: — Stay at the clinic before and after surgery; — Operation; - Intravenous anesthesia. — Cost of needles for radiofrequency ablation; — Observation and consultation during the rehabilitation period. All clinic services and costs are listed in the price list.

We invite you to come for a consultation with a neurosurgeon at the SL Clinic. We will help you determine the causes of pain and select the optimal treatment tactics. If necessary, our doctors will be able to carry out effective surgical intervention without unnecessary delay and help get rid of attacks forever. Modern equipment and professionalism of specialists provide an optimistic prognosis for facial neuralgia caused by various factors in patients of any age.

Primary and secondary neuralgia.

The most popular classification is related to etiology (nature of occurrence).

Primary idiopathic . Arises as a response to vascular compression (squeezing) of the trigeminal root. Most often in practice, such compression occurs in the area of the brain stem.
Secondary symptomatic . Consequences of infections, the occurrence of tumors and their growth, bone changes.

In order to recognize the nature of trigeminal neuralgia, tomography (neuroimaging) data of the skull and the nerve itself are used.

With true neuralgia, treatment, first of all, needs to focus on the nature of the disease, and with secondary neuralgia, there is a fight against the symptoms and elimination of the underlying disease.

Secondary neuralgia can have a central and peripheral form of manifestation. In the central form, pain appears in the area of one or more branches of the ternary nerve. In the peripheral form, the zone of entry of the nerve root into the medullary pons is involved; in most cases, the loop of the cerebellar artery has pathological changes.

Nature of pain and affected area

Another classification is based on the nature of the pain.

Type 1 TN . Neuralgia of this type is characterized by a typically pronounced burning sensation. In this case, the pain is acute, but unstable, episodic. The duration of the episodes may vary.
Type 2 TN . Constant and dull, aching pain.

Type 1 TN ternary neuralgia is more common, while type 2 TN is more rare. At the same time, the disease with this type of manifestation of the disease is most difficult to diagnose, since the picture of the disease is similar to a number of other neurological diseases, and sometimes dental problems, in particular problems with the temporomandibular joint.

The affected area and its scale may also be different, and neighboring zones may be involved. In this regard, the following levels of damage are distinguished:

Damage to one of the peripheral branches of the trigeminal nerve . When the 1st branch is affected, the sensitivity of the skin is impaired (especially in the forehead and anterior scalp, eyelids, dorsum of the nose, mucous membranes of the upper part of the nasal cavity, a number of reflexes are impaired, for example, the superciliary one). When the 2nd branch is affected, the sensitivity of the skin on the cheekbones and cheeks is lost, the sensitivity of the skin near the outer corners of the eyes is lost, and there are problems with the sensitivity of the skin in the area of the upper jaw, lips, and nose. When the 3rd branch is affected, the lower part of the face (chin, lower lip), tongue, and sometimes there is a problem with the masticatory muscles (up to paralysis).
Damage to the trigeminal nerve root at the level of the base of the brain . Most often, it is a lesion of the semilunar ganglion, located on the large root of the trigeminal nerve. Most often it is affected by viral diseases. Advanced neuralgia of the semilunar ganglion is fraught with the rapid development of conjunctivitis and keratitis. As a result, you need not only the help of a neurologist, but also an ophthalmologist
Lesion in the area of the brainstem nuclei . The most painful symptoms are similar to “electric shocks”. Sensation may be lost in areas associated with any branch of the trigeminal nerve.
Dental plexalgia . As the name implies, the localization is associated with the zone of innervation of the dental plexus. The pain is very excruciating. It feels like absolutely everything hurts: the palate, cheekbones, temples, ears, neck (especially the upper third), and the back of the head. The pain especially intensifies when pressing on the problem area.
Damage to the pterygopalatine ganglion . The processes of the maxillary nerve and a number of fibers in the area of the carotid artery, nasal mucosa, and salivary glands are involved.
Damage to the area near the orbit . Persistent unilateral headache in the area of innervation of the trigeminal nerve is combined with lacrimation, difficulty breathing, and redness of the face.

Neuropathy of the buccal nerve.

The causes of the disease can be periostitis, inflammatory diseases of the teeth and gums, traumatic removal of teeth in the lower jaw.

Clinic.

The pain occurs subacutely, is constant, and its intensity gradually increases. First it occurs on the front surface of the gum, transitional fold, and then spreads to the entire front surface of the teeth of the lower jaw and covers the entire area of innervation of the buccal nerve. Numbness is uncharacteristic; an objective examination reveals a decrease in all types of sensitivity in the area of innervation of the mucous membrane of the cheek and vestibular surface of the gums, as well as the skin of the corner of the mouth.

Causes of inflammation of the trigeminal nerve

Damage to the trigeminal nerve can be caused by both trauma (fractures, tissue ruptures, unprofessional conduction anesthesia) and destruction of the myelin sheath of the nerve itself (a typical problem for patients with multiple sclerosis).

But more often we are talking about the inflammatory nature of the pathology.

The most common causes leading to inflammation of the trigeminal nerve:

inflammation of the membranes of the brain or spinal cord (meningitis),
diseases of the paranasal sinuses (sinusitis),
malocclusion,
herpes transmitted to the ganglia (nodes) of the trigeminal nerve,
hypothermia: everyone knows the phrase: “I got a cold on my nerve.” In fact, a person’s tissues become overcooled, and then the nerve becomes inflamed.
bacterial infection of the upper respiratory tract, throat.

Neuropathy of the superior alveolar nerve.

The causes of the disease may be chronic pulpitis and periodontitis, nerve damage in case of complex tooth extraction, sinusitis, and surgical intervention for sinusitis.

It manifests itself as pain and a feeling of numbness in the teeth of the upper jaw. Objectively, there is a decrease or absence of sensitivity in the gum area of the upper jaw, as well as the adjacent area of the buccal mucosa. The electrical excitability of the pulp in the corresponding teeth of the upper jaw is reduced or absent.

If the cause of the disease is stenosis of the infraorbital canal, then patients will complain of pain and numbness of the skin in the area of innervation of the infraorbital nerve (wing of the nose, area above the canine fossa, upper lip).

Symptoms of inflammation of the trigeminal nerve

The following symptoms indicate nerve inflammation:

Facial pain.
Headache, more often migraine.
Burning sensation, as if “being hit with an electric current” in the area of the cheeks, cheekbones, jaw, forehead, eyes. The pain intensifies when moving the facial muscles, chewing, noise, bright light, or touching the skin.
Problems with the blink reflex (decreased amplitude) and, accordingly, increased eye vulnerability.
Involuntary twitching of facial muscles (nervous tic).
Irritability.

Symptoms of the disease

The trigeminal nerve is part of 12 pairs of cranial nerves, is the 5th pair and runs along both sides of the face. It is formed by three bundles:

ophthalmic – responsible for the innervation of the forehead, temporal and superciliary regions, eyes and eyelids;
maxillary - responsible for the transmission of nerve impulses in the area of the upper jaw, facial muscles and nose area;
mandibular - innervates the neck, lower jaw and chin.

Accordingly, the clinical picture of neuralgia will depend on which branch of the trigeminal nerve is affected. This is accompanied by:

sharp short-term burning, powerful one-sided pain strictly along the affected nerve bundle, lasting up to 3 minutes and repeating from 1 to 10 times during the day (at night, lumbago is observed in less than 1% of patients);
pain always occurs in the same area, then flows to a neighboring area, but does not radiate to other parts of the body;
spasms of facial muscles during an attack;
intensive separation of saliva and tear fluid;
dilated pupils;
absolute immobility of a person throughout the entire attack;
the occurrence of pain when touching the skin in the projection of the affected nerve branch, so patients always describe the localization of discomfort without directly touching the face.

In 7% of patients, pain persists for several days. But in the initial stages, patients may only be bothered by short-term, mild shooting pains. Seizures usually occur spontaneously. But they can also be provoked by exposure to specific trigger points (most often located in the area of the nasolabial triangle).

If the reasons for the development of pathology lie in disorders affecting the brain, their manifestations may additionally be present: differences in the size of the pupils, difficulty breathing, drooping eyelids.

Thus, making a diagnosis is not difficult for an experienced doctor, since the symptoms of trigeminal neuralgia are quite specific. Frequent repetition of attacks while brushing teeth, talking or eating only confirms it.

Diagnostics

Based only on a survey, a doctor can distinguish tertiary neuralgia from Sjostad syndrome (with this syndrome, longer attacks), post-herpical pain, and typical migraines. To understand the full picture, it is important to carry out a comprehensive diagnosis:

Tomography. For accurate diagnosis and correct treatment, the most complete data on the state of the brain and the selection of a detailed scheme (the scheme is important for accurate positioning) when performing magnetic resonance imaging of the ternary nerve are extremely important. The most accurate data can be obtained from MRI with contrast.
Tomography (scanning) scan of the trigeminal nerve. Makes it possible to create layer-by-layer images, identify neurovascular conflict, signs of destruction of the myelin sheath of nerves. The scan allows the doctor to get a complete picture of what the nerve being examined looks like and what is happening where it exits the brain stem.
It is extremely important that tomography allows not only to identify that there is a neurovascular conflict, but also to understand its cause. This may be a conflict of the cerebellar arteries, a neuroma (neoplasm) of the nerve. In many cases, the trigeminal nerve scan is performed with a simultaneous scan of the facial nerve.
X-ray of the jaws (if you suspect that the main problem is dental).
Angiography. Important for verification (confirmation) of the vascular origin of compression with an impressive size of the aneurysm and vascular loop or aneurysm.

Also, in most cases, blood and urine tests are prescribed (the role of these studies is especially valuable in pathologies that arise as a result of infectious diseases).

Trigeminovascular system

What do we know about the role of the trigeminal nerve in migraine attacks?

So, trigeminovascular fibers of the trigeminal nerve are involved in the innervation of the vessels of the meninges. Serotonin receptors (5HT-1D type) are located both at the endings of nerve fibers and in the walls of the brain vessels themselves. The release of serotonin leads to hyperactivation of neurons and spasm of cerebral arteries, and a sharp decrease in its level gives a signal to reflex vasodilation.

The dilation of the vessels of the head is accompanied by the release of neuropeptides (calcitonin gene-related peptide, substance P, prostaglandins, etc.), the development of neurogenic inflammation and hypotension of the vascular wall. In the trigeminovascular system, the sensitivity of pain receptors increases, that is, during migraine, the trigeminal nerve more actively transmits pain information, often closing it in a “vicious circle”. This is how an attack of painful and long-lasting headache occurs.

What other migraine symptoms occur with the participation of the trigeminal nerve:

Symptoms of aura at the beginning of an attack due to vasospasm in the areas of influence of the trigeminal nerve: visual and sensory (face, jaw, tongue) disturbances.
Painful sensitivity to irritants: light, sounds, smells, tactile sensations (touching the face, scalp, hair).
Nausea and vomiting, belching, abdominal pain, diarrhea. Activation of the parasympathetic nerve fiber of the trigeminal nerve leads to a disorder of gastrointestinal motility.

Treatment

Treatment is aimed at relieving pain and preventing relapses of the disease.

For milder cases of the disease, drug treatment can help; for advanced stages and large affected areas, surgical treatment is used. It also helps to overcome the nature of the disease itself.

Physiotherapeutic techniques are also used in treatment. But most doctors are inclined: they are effective not as primary ones, but only as auxiliary ones: enhancing the effect of conservative drug treatment, and can also be used after surgery at the rehabilitation stage. For example, drug treatment in the acute stage can be effectively combined with light therapy, especially infrared ray therapy in a small dosage. In the acute period and at the time of rehabilitation, phonophoresis, electrophoresis, and darsonvalization provide the desired effect. In the non-acute phase, it is useful to take medicinal baths (for example, with minerals), massages, acupuncture, and paraffin therapy.

Drug treatment

For conservative therapy, the following medications are prescribed:

Drugs to combat symptoms (pain) . The most common drugs used in drug treatment are carbamazepine, finlepsin, and tegretol. The drug of first choice in most clinics is carbamazepine. It is effective in relieving pain in 70-80% of patients with trigeminal neuralgia.
Antispasmodics and muscle relaxants of central action . One of the common medications in this situation is baclofen.
Alcohol blockades (injections) aimed at “freezing” the affected area of the face. The blockades have an effect, but it is short-lived. Therefore, such injections are often resorted to as a temporary measure, for example, in preparation for surgery.
Metabolic drugs . Their role is important for stabilizing the energy potential of cells and creating an antihypoxic effect.
Anticonvulsants . Helps slow down the transmission of nerve impulses.
B vitamins . They have a neurotropic effect (they improve the metabolism of mediators and certain analgesic activity, therefore enhancing the effect of painkillers).

Surgery

Surgical operations are the most effective for combating trigeminal neuralgia. They make it possible not only to eliminate pain, but also to eliminate the chain of impulses and influence the conflict between the root of the cranial nerve emerging from the brain stem and the vessel that adjoins it.

And, if the cause is just such a conflict, doctors recommend immediately thinking about surgery, and not stalling for time and trying to solve the problem with medication.

In this case, microvascular decompression of the trigeminal nerve root is considered the most effective and safe (the nerve is preserved). The operation involves installing a gasket (protector) between the nerve and the vessel.

Microvascular decompression of the trigeminal nerve root is a transcranial endoscopic intervention and is performed through a mini-access (in fact, we are talking about a cosmetic incision - no more than 2.5x2 cm, minimal blood loss, no long-term rehabilitation required)

Mechanical destruction of peripheral branches, glycerin rhizotomy, laser thermocoagulation, and radiofrequency destruction can also be used. They allow you to cope with the victory over pain with dignity, but unlike microvascular decompression, alas, such operations do not have the task of preserving the nerve. Therefore, such operations are used more often in cases where microvascular decompression of the trigeminal nerve root is impossible for some reason. For example, glycerin rhizotomy is often the only possible way to combat neuralgia in patients in severe physical condition at an advanced age with a list of other diseases.

Modern surgical techniques, akin to mechanical destruction, make it possible to eliminate additional destructive interventions and at the same time stimulate the necessary deep structures.

Among the complications of surgical intervention using glycerol rhizotomy, radiofrequency destruction, there are sensory disturbances on the face, keratopathy (the occurrence of corneal dystrophy).

Possible complications after microvascular decompression may be ischemic infarction of the brain stem, air embolism, damage to the trochlear nerve, the occurrence of cerebellar hematoma, paresis (reduction) of the facial muscles.

For this reason, it is extremely important to clearly weigh the degree of risk for the patient and choose the right surgical technique. Whether one or the other is suitable in each specific case depends on the individual characteristics of each patient. Careful attention to these details helps minimize the risks of complications.

Where the operation is performed is also important. All the nuances are important: how accurate the preliminary diagnosis is, the qualifications and experience of the neurosurgeon.

Radiofrequency ablation

Minimally invasive surgery

The principle of radiofrequency deinervation is based on the physical method of thermocoagulation and is based on the effect of the release of thermal energy when ultra-high frequency currents pass through biological tissues.

An electrode connected to a current generator is brought to the anatomical area, the site of destruction, through an insulated cannula needle. The intensity of heating of the fabric depends on its resistance. A STRYKER Multigen radio frequency generator is used, which provides voltage to the circuit and is connected by wires between two electrodes. Electric current passes between an active or damaging electrode immersed in body tissue and an indifferent or scattered electrode. Heat production, and as a result, nerve ablation, occurs only around the non-insulated tip of the active electrode.

Procedures

An alternative for patients who are contraindicated for complex operations, but drug and physiotherapeutic treatment does not provide an effect, may be the following procedures during an exacerbation:

Injection of glycerin with a hollow needle through the cheek . The procedure allows you to influence the fibers responsible for pain, but careful monitoring of the procedure is problematic. Only 80% of patients experience real relief.
Balloon compression . It is carried out through the skin using a catheter. A big plus of the procedure is the ability to provide immediate pain relief. Disadvantage: Requires general anesthesia.
Stereotactic rhizotomy under the influence of electrical impulses . The pain relief effect is high, but in addition to eliminating the symptoms of neuralgia, unfortunately, nerve cells also die. Like balloon compression, the procedure requires general anesthesia.
Development of hypochondria, depression.

Prevention

Inflammation of the trigeminal nerve is not only important to treat promptly. It is important to prevent relapses, and here prevention plays a huge role:

Avoid any drafts . It is important and necessary to ventilate the room, but do not get exposed to drafts of air, do not work, do not sleep under the air conditioner.
Avoid hypothermia of the face and head . Don't ignore hats and scarves during the cold season.
Protect your head and face from injury.
Visit your dentist regularly . Avoid periodontitis (inflammation of the tissue around the roots of the teeth). If you treat caries, pulpitis, and periodontitis in a timely manner with modern dentistry, you can avoid it.
Be careful about herpes . This is not just a “cold on the lips”, but a disease that can provoke the occurrence of ternary neuralgia.
Fight psycho-emotional stress . Meditate.
Take up exercise therapy . Focus on exercises that are aimed at working muscles (improving their tone) and increasing heart rate (cardio training).

Remember! Relapses are cyclical. Moreover, exacerbations are more common in the autumn-spring period. Therefore, at this time, pay the most attention to prevention.

Post-traumatic sensory nerve damage. Terminology.

The Association for the Study of Pain has standardized a nomenclature system that defines the most commonly used neurosensory descriptive terms Classification of Chronic Pain, Second Edition: International Association for the Study of Pain Task Force on Taxonomy, ed.: H Merskey and N. Bogduk. IASP Press IASP Council in Kyoto, November 29-30-2007.

Paresthesia is a non-painful altered sensation. May be described by patients as a pins and needles, slight burning or tingling sensation. NEW sensations - stretching, pulling sensations.
Dysesthesia is perverted sensations. Abnormal, sometimes unpleasant sensations experienced by a person with partial damage to sensory nerve fibers when touching the skin. - Unpleasant abnormal sensation, spontaneous or provoked. Note: Dysesthesia is not pain when it hurts or paresthesia. Special cases of dysesthesia are hyperalgesia and allodynia. Dysesthesia should always be unpleasant, and paresthesia should not be unpleasant, although it is recognized that the boundary can create some difficulties when it comes to whether the sensations are pleasant or unpleasant. It should always be stated whether the sensations are spontaneous or provoked.
Neuropathic pain (IASP) is pain caused by damage or disease of the somatosensory nervous system.
Neuropathy (IASP) is a dysfunction or pathological change in a nerve: in one nerve - mononeuropathy; in several nerves - mononeuropathic multiplex; if diffuse and bilateral - polyneuropathy. Note: Neuritis is a special case of neuropathy and is currently a term reserved for inflammatory processes affecting the nerves. - sensitive (touch, heat, pain) - motor (movement).
Allodynia is pain from non-noxious stimuli (pain with light touch/cold/heat). The appearance of pain in response to a stimulus that does not cause pain in healthy people. Thermal allodynia, especially cold allodynia, is a feature of the extraoral dermatome in patients with IANIs. Some patients report decreased taste and heat sensitivity. Perversion of sensitivity is characterized by an increased threshold of sensitivity and increased duration of perception, lack of precise localization of sensations of an unpleasant nature, and a tendency to irradiate. The pain continues when the stimulus is removed.
Hyperalgesia - increased sensitivity to painful stimuli
Anesthesia - numbness
Hyperesthesia and Hypostesthesia are terms that are often used to describe changes in sensitivity that increase or decrease, respectively.

Rice. 5 Anatomy of the II (maxillary) and III (mandibular) branches of the trigeminal nerve. It is important to note that the branches of the superior alveolar nerve retrogradely “merge” into the infraorbital nerve, which explains the symptoms of swelling and pain in the infraorbital region when the superior dental plexus is damaged.

Post-traumatic sensory neuropathy is pain that develops after medical intervention (surgery, treatment, anesthesia), with a minimum duration of 2 months, while other causes of pain are excluded (infection, persistent malignancy, misdiagnosis, etc.), preoperative pain from others must also be excluded reasons.

It is important to add that the neuropathic area does not have to be clearly indicated by the patient, however, about 80% of patients can localize and indicate the neuropathic area.

You can read more about the incidence of “phantom toothache” (atypical odontalgia) after endodontic treatment, which is classified as persistent dentoalveolar pain (PDAP type 2) and occurs in up to 3% of cases.

Consequences and complications

It is important to start treating neuralgia in a timely manner. Untimely treatment is fraught with the following complications:

Continuous pain (both headaches and facial pain).
Paralysis of the facial nerve and, as a result, facial asymmetry.
Weakening of hearing and vision.
Weakening of facial muscles, appearance of wrinkles.
Behavioral disorder. Constant fears. The person constantly thinks that he may have another attack. Therefore, he tries to move minimally when chewing (or chews, moving food behind one cheek), and smile a little.

Features of manifestations of iatrogenic damage to the trigeminal nerve

Painful discomfort, changes in sensations, numbness (anesthesia).
Functional consequences - Patients who experience pain from touch or cold often have difficulty with daily functions: kissing, communicating, speaking, eating and drinking, etc.
Psychological consequences - patients develop various anxiety, fear, anger, post-traumatic stress disorder. Psychological disorders can be aggravated in cases where informed consent for implantation, endodontic treatment, orthognathic surgery, etc., which specifically indicates possible nerve damage, has not been signed before medical intervention.

Rice. 6. Schematic representation of the relationship of the branches of the inferior alveolar nerve with the formed implant bed. Pain during drilling is an important diagnostic criterion for the proximity of the nerve.