In this episode we host Dr. Mazda K. Turel. Dr Mazda is a practicing Neurosurgeon at the prestigious Wockhardt Hospital, South Mumbai, India. He is also an Honorary Assistant Professor of Neurosurgery at the Grant Medical College and Sir J.J. Groups of Hospitals. He specializes in the treatment of diseases of the brain and spine and advocates an approach to neurosurgery that is both balanced and proactive.

Key Topics covered are:
1. What is Trigeminal Neuralgia?
2. Symptoms and signs of Trigeminal Neuralgia.
3. Causes and Diagnosis of Trigeminal Neuralgia.
4. Treatment approaches to Trigeminal Neuralgia – Medicine based treatment, Radiosurgery and Neurosurgery.

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Trigeminal Neuralgia: Symptoms, Diagnosis and Treatment

A Talk with Dr. Mazda K.Turel.

Speaker: Mr. Vivek

Hello, welcome to Dr. Talks. This is your host Vivek. Here we talk with the best doctors about diseases and conditions they treat. Our guest today is Dr. Mazda K.Turel. Dr. Mazda is a practicing neurosurgeon at the prestigious Wockhardt hospital, South Mumbai, India. He is also an honorary Assistant Professor of Neurosurgery at the Grant Medical College and Sir J.J Groups of hospitals. He specializes in the treatment of diseases of the brain, spine and advocates an approach to neurosurgery that is both balanced and proactive. Welcome Dr. Mazda.

Speaker: Dr. Mazda

Hi Vivek. It’s a pleasure to speak to you once again on Dr. Talks.

Speaker: Mr. Vivek

I’m eager to hear the condition you would discuss with us today. Our last discussion about brain tumor was a great learning experience for myself and our audience.

Speaker: Dr. Mazda

So I’m glad we had a great chat last time and this time, we’re going to talk about commonly misdiagnosed and often confused condition. A condition we call Trigeminal Neuralgia or facial pain. This is a condition that is often misdiagnosed because a lot of the times patients present with pain in the jaw or tooth pain. And the first person they go to is a dentist. And it’s possible that they might have a cavity that may be contributing to it and that’s treated but the pain doesn’t go away. Sometimes they might require a root canal done. That’s done but the pain doesn’t go away. Sometimes you do multiple root canal and still the pain doesn’t go away. So it’s extremely important to discuss what the clinical physiology of this condition is. And what are the typical symptoms that can be attributed to Trigeminal Neuralgia. The term Trigeminal refers to the fifth cranial nerve which arises from the brain and supplies the area of the face and is responsible for sensation so it basically has three divisions. The first division supplies the forehead, and the eye. The second division supplies the cheek, the upper lip and the roof of the mouth and the third division supplies the jaw and the lower lip. So that’s three divisions, trigeminal is the name of the nerve and neuralgia refers to a neurologic pain. It’s a severe kind of pain that comes from, you know, any kind of damage or excessive injury to the nerve. And this kind of pain is typically a shock like pain, it’s a lancinating pain, it’s a sharp pain. If you know, it comes and goes like a current in this particular distribution of the nerve either or the forehead, either over the cheek or the jaw. And it’s such a typical kind of pain, you know, patients spin in pain, and sometimes it may reach a point where they find it difficult to talk, chew or swallow. And you might even have some kind of triggers like brushing your teeth. They’ll have severe pain exactly at one point and that can last either for a few seconds or a few minutes. And usually it initially starts off with just being once in a while, but it can be really life altering. If it happens multiple times a day, I’ve had patients who experience this pain just sitting under a fan. And you know, just the breeze of the fan or the other direct blast of the air condition coming over the cheek can trigger off this pain and sometimes the pain can be so excessive that it is almost suicidal. We had one patient in a government hospital where we work whose operation was delayed for some reason and the pain was so severe he jumped off from the sixth floor of the building and committed suicide. So it’s an extremely debilitating pain, some women say, it is even worse than the pain of natural delivery without having an epidural injection. So it’s very important to make people aware that this kind of pain may not be related to tooth pain or jaw pain. When I’ve spoken about this in various forums, a lot of people have come back to me and said, Oh, this is what I have. And nowadays, even dentists are very mindful and aware of this particular condition. And they know what symptoms that this particular condition presents within when they do a preliminary check of the teeth and they find that okay, they are very prompt to refer these patients to a neurologist or a neurosurgeon. And that really makes a big difference.

Speaker: Mr. Vivek

Why is it also called Tic douloureux?

Speaker: Dr. Mazda

Yeah, everybody knows what a tick is. It’s a constant kind of movement that people make and doulour is pain. So sometimes a kind of tick develops in a patient because of the pain that’s uncontrolled facial twitching and this kind of pain actually interferes in the patient’s life in many aspects. And sometimes this may be just a brief second, or sometimes this may go on for a minute or so. And it comes in repeated waves and sometimes if it likes, lasts for an hour, it seems to people like it’s a nervous tick. So in the past, when people really didn’t know about this condition but later on, they really figured out what exactly was in it, what is it due to. It’s primarily due to a blood vessel in the brain in the back of the head that pinches upon the trigeminal nerve that when it pulsates, it tends to irritate the trigeminal nerve and that irritation causes this lancinating kind of pain.

Speaker: Mr. Vivek

What are the symptoms for trigeminal neuralgia ?

Speaker: Dr. Mazda

So like I said, patients describe these attacks as either pins and needles sensations, some kind of irritation, burning, jabbing, an electric shock like pain that lasts from a few seconds to a few minutes. And it’s important to know that even everyday activities can trigger these pains. Patients are sensitive in certain areas of the face, we call these areas, trigger zones. And when touched, even when the air hits, they can have immense pain and these trigger zones can be near the lips, the eyes and like I said, because once it becomes gradually severe and intense, patients even avoid talking, eating, kissing, drinking like activity. Even shaving sometimes can trigger pain. So it’s important to ask patients for these triggers. It’s important to ask patients for the nature of the pain, is it a shock like sharp lancinating pain? It’s usually only on one side of the face, very rarely, on both sides of the face. If you have pain on both sides of the face, then you have to think of a differential diagnosis, you have to think of something different if the pain is not sharp, but it’s a dull pain, so less intense pain, if it’s just, you know, burning or an aching pain, and it’s not sharp then this falls into the category of a typical facial pain that’s, in fact, not only more difficult to treat, but more difficult to diagnose. So, in these conditions, the input of a dentist to make sure that it’s not something local, is also very valuable.

Speaker: Mr. Vivek

What causes Trigeminal Neuralgia?

Speaker: Dr. Mazda

So there are a lot of theories that cause trigeminal neuralgia, but basically, the trigeminal nerve has a covering, every nerve has a protective covering and over time either because of contract or because of disease of the nerve or any of those things, the covering gets damaged or eroded. So, age is a factor that attributes to it. You see this condition commonly in the 50s to 70s that is the predominant age group. Sometimes conditions that affect the nerve, like multiple sclerosis, or demyelination can present with trigeminal neuralgia, tumors in the area of the trigeminal nerve can irritate the nerve and present as trigeminal neuralgia. This is termed as secondary trigeminal neuralgia, but primary trigeminal neuralgia when is caused by a blood vessel, it could either be an artery or a vein or a combination of an artery or vein that physically compresses the trigeminal nerve irritating it and that’s the most common version of trigeminal neuralgia that we know. Present in 85% of cases. But it’s very important to rule out that this kind of pain is not coming from an infected tooth, it’s not coming from a sinus infection. It’s not herpetic neuralgia, or any kind of previous nerve injury. So you have to be very thorough in your analysis, because it’s not a very common condition and affects only about four or five people in every hundred thousand people. Women generally tend to be affected more than men. And so it’s very important to have a background of what kind of demographic you’re dealing with. What is the background disease of the patient? While primary trigeminal neuralgia affects the elderly patients and patients who have Multiple Sclerosis can also develop trigeminal neuralgia. So it’s very important to keep your clinical spectrum in mind before you pinpoint this condition because it mimics a lot of other conditions and a lot of other conditions can mimic it.

Speaker: Mr. Vivek

Doctor, as you mentioned women get affected by it more, any specific reason for that?

Speaker: Dr. Mazda

I’m not particularly sure if there’s any specific reason it’s just the demographics favor, preponderance in women more than men. Sometimes you see certain brain tumors that are more common in women than men, and those are attributed to hormonal issues. But in trigeminal neuralgia, I’m not particularly sure if there’s any scientific evidence to say why women get affected more than men, but it’s a common occurrence, maybe 60:40.

Speaker: Mr. Vivek

So it’s more of a statistical fact which we have observed. How do you go about making a diagnosis for it?

Speaker: Dr. Mazda

So the diagnosis of trigeminal neuralgia in my opinion is primarily a clinical diagnosis, you make a diagnosis based on symptoms. And the symptoms are what we discussed greatly in detail. And the diagnosis can also be supported by a trial of medication. If you start these patients on some kind of anticonvulsants medication, the most commonly used medication is carbamazepine. And patients almost always have an initial response to it. So that just corroborates the diagnosis. In all cases of Trigeminal or suspected trigeminal neuralgia cases they should always do an MRI of the brain, because you don’t know if the trigeminal neuralgia is primary or secondary. So you don’t want to miss out on a brain tumor or something more sinister that could be causing trigeminal neuralgia. And a very special sequence is required to evaluate and examine a blood vessel compressing the nerve. Because these are structures there are just a few millimeters in size. And we need to do something called CISS (Constructive interference in steady state) sequence, which looks at the nerve and very, very fine and minute cuts. And you can very well identify a vessel that’s compressing the nerve. So, however, even though the diagnosis is clinical, every patient with suspected trigeminal neuralgia should always have an MRI of the brain to then decide with the next line of management.

Speaker: Mr. Vivek

What treatments are available for it.?

Speaker: Dr. Mazda

So once you’ve diagnosed it, and it’s not a tumor then it’s probably a vessel compressing the nerve etc. Then you should always start with medication. The main three forms of treatment include medication , needling procedures like injections and Surgery and there are two kinds of surgery. One is radiosurgery, by a sharp dose of radiation. And then there’s conventional open surgery, which we’ll discuss later. So the first line of treatment is always medication and medication is typically in the form of anticonvulsants or muscle relaxants that are prescribed to block the pain signals from the nerve and they almost always show a response in people with trigeminal neuralgia, and about 15 to 20% of patients don’t need anything else apart from medication. A lot of them experience short term pain control and quite a few patients experience long term pain control as well. The medications that we commonly use fall into the category of anticonvulsants. We call it carbamazepine and is commonly known as tegretol or ox carbamazepine then there’s gabapentin, phenytoin, pregabalin also known as Lyrica. And you start off with one medication, and you can gradually increase the dose of that medication to a maximum tolerable limit. And then you can also add if the pain after an initial response comes back, you can try another medication along with it in combination you can try a muscle relaxant, like baclofen. So it’s important to be able to do a trial and error of a couple of medications. Before you say that, okay, medications have ceased to work they initially showed some kind of response, but now we are over the hill as medication is concerned, so medication is always the first line of treatment. The second option, which is less invasive, is probably some kind of needle procedure. So a needle procedure in injection is a minimally invasive technique for reaching the trigeminal nerve through the face. Without a skin incision, you’ve just poked a needle through the cheek and it’s inserted percutaneously into the trigeminal nerve. It’s done obviously under X-ray vision inside the OT but it’s not under general anesthesia but under local anesthesia. And the goal of this kind of a procedure is to inject something in the nerve that numbs the nerve. It prevents the nerve from sending pain signals to the brain. So in effect, it’s a damaging procedure. You’re lesioning the nerve, you’re damaging the nerve, so that it doesn’t send any more pain signals. You can inject glycerol, you can inject alcohol, you can even put a radio frequency probe and pass current within the nerve to be able to damage the nerve. So the only realistic side effect of this is that you will have numbness in that area because you’ve damaged the nerve even the normal sensation supplying the face is affected. But usually this kind of a procedure is reserved for the extremely elderly people or people who are not able to undergo general anesthesia or surgery or as a first line of treatment. If you want to see if this works because this usually provides short term relief in about 60-70% of patients and in long term, this number drops to 30 – 40%. So it’s not the ideal kind of treatment but it is definitely a very strong treatment in the management of trigeminal neuralgia. The other condition if medicines and injection has failed, you can do radiosurgery. Radiosurgery is seemingly non invasive procedure, wherein, again, it’s an outpatient procedure. You give very highly focused radiation to destroy some of the trigeminal nerve fibers that produce pain. So there are various types of radiation frames that are fixed on the head and focused and again it’s a daycare procedure and you will be surprised that there is some amount of instant relief in this procedure but the maximum relief in radiation procedure takes about 3 to 6 months or even a year, because the effective radiation takes that long to manifest. So about one month later you’ll see about 50% of patients will experience some sort of pain relief. And two, three months later that number may increase to 75%. But again, the recurrence rate in about three to five years is quite high. As far as this modality of treatment is concerned, and again, there is the side effect of some kind of facial numbness and even dryness of the eyes that can come from damaging the trigeminal nerve. The last procedure, which is a more invasive procedure, is of course surgery. Surgery it’s done under general anesthesia and in the operation Room. Patients have to be admitted to the hospital. We make a small hole behind the skull, it’s about a two inch hole. And with surgical instruments under the microscope, you go and identify the offending vessel, the vessel that is indenting the nerve and you can see it clearly. You can see how the nerve becomes white from its usual nice shiny yellow self and you can see it indented. And what we do is put a piece of Teflon or fat or muscle between the artery and the nerve to separate it from any kind of contact. Sometimes you can even take a small sling and sling it up and hitch it to an area away from the nerve so that there is absolutely no contact that the artery makes with the nerve and this kind of pain goes away almost instantly. And patients have immense relief and are extremely happy. You know, about 95% of patients have instantaneous pain really. And this remains at about 80 to 90% even after 10 years. So you can taper off all the pain medications and excessive pain medication that causes drowsiness and confusion. The only disadvantage is it’s a invasive procedure and there’s a one to 2% risk of anything major going wrong under general anesthesia or complications related to surgery, which could even be death, paralysis, bleeding inside the brain, hemorrhage, all of those things, but the incidence is less than 1 to 2% .In this procedure, there is no numbness of the nerves. There’s no damage to the nerve, the sensations are intact. So that’s the real advantage. So this is just an overview of the treatment options. Like I said, there are three arms. One is medicine, medicine always almost works in most people. And then when you have tried and escalated, those are medication and don’t work and then you think about an injection. An injection also is very good at giving instant relief, but the relief is primarily short lived, and it can result in some numbness of the face. Usually that numbness may be tolerable. And then you have either radio surgery or open surgery and open surgery. While surgery invasive to some extent, it produces the best immediate and long term results. So that’s an overview of all the treatment modalities that are available. Yes, there are clinical trials happening for newer drugs in your diagnostic procedures and to make treatment less invasive. But that’s in the experimental phase.

Speaker: Mr. Vivek

And doctor once you decide that surgery is the right treatment approach, is it a planned surgery or it has to be done under emergency?

Speaker: Dr. Mazda

No, It’s a completely planned surgery. You do it electively, patients have had pain for months. It’s very rare that you need to do it in an emergency kind of situation . For example a patient has an immense amount of pain and is unbearable, can’t eat, can’t swallow or chew. And if it reaches that extent, yeah, then you can say that you need to do it as soon as possible. And we’ve had that kind of situation in one or two patients. But more often you can take your time and give patients the option of trying out every situation and when they’ve said that okay, now it’s just completely not allowing me to live a decent quality of life you undergo the operation. But emergency operation is done in extremely rare situations.

Speaker: Mr. Vivek

Do you remember any specific case or patient of yours? Or something about the case, which was unique, and you still remember it?

Speaker: Dr. Mazda

Yeah. So I mean, every case of trigeminal neuralgia in some sense is unique, because while the symptoms may be typical they’ve usually tried everything, what you find in surgery is very fascinating. The surgical features of trigeminal neuralgia is different in every patient, configuration of the artery is different, how the artery kicks on the nerve is different, whether it forms a loop in front of the nerve or behind the nerve, or whether it’s only an artery or it’s an artery and a vein. So those are the real interesting features. So, we’ve seen a patient in whom there’s only one artery, we’ve seen a patient in whom there are two arteries. Sometimes we’ve seen a patient with one artery and two veins. We’ve seen a patient in which the only veins that are compressing and there are no arteries. So those kinds of configurations are actually fascinating. And they vary from patient to patient. But like you said, we’ve had a one or two patients who’ve come to us in extreme agony, who you know, they’re actually holding their jaw in their hand and the pain is so severe, in whom we’ve done surgery the very next day, and they’ve had complete relief of pain and just to see the difference in their facial expression before and after surgery is the most rewarding thing.

Speaker: Mr. Vivek

Dr. Mazda your inputs today helped us understand Trigeminal Neuralgia and its treatment better. We got to learn about its symptoms, diagnosis and treatment approaches. Thank you for sharing in depth knowledge about Trigeminal Neuralgia with us.

Speaker: Dr. Mazda

Thanks a lot, Vivek, it was great to talk to you. I’m sure your listeners will really have a nice time understanding this particular topic. And I’d love to chat with you about many other such neurosurgical issues involving the brain and spine so we can spread some knowledge together to enlighten our listeners in being able to take the responsibility of their own health in their own hands, and help them be directed to the right people. In case they need help. So you guys are doing a great job with and I’m really proud to be associated with you. Thank You.

Speaker: Mr. Vivek

Thank you doctor and it would be wonderful for us to talk about more health topics and we would certainly plan about it. Dear listeners, please share and spread awareness about Trigeminal Neuralgia and its treatment by sharing this podcast. Cheers till we meet next time.

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