MRIMS Journal of Health Sciences

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 9  |  Issue : 2  |  Page : 56--60

Clinical profile, management, and postoperative complications among patients with trigeminal neuralgia at a tertiary care hospital


Rajesh R Raykar1, Sibhi Ganapathy2,  
1 Department of Neurosurgery, St. John Medical College and Hospital, Bengaluru, Karnataka, India
2 Department of Neurosurgery, St. John's Medical College, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Rajesh R Raykar
Department of Neurosurgery, St. John Medical College and Hospital, Bengaluru, Karnataka
India

Abstract

Background: There is no clarity in diagnostic criteria of trigeminal neuralgia, and hence, the diagnosis is difficult and often delayed. Therefore, the patient has to visit many clinics before the final and correct diagnosis is established. Trigeminal neuralgia is not harmful, but it definitely affects the quality of life. It may become nonresponsive to treatment. Objective: To study clinical profile, management, and postoperative complications among patients with trigeminal neuralgia. Methods: The present study was designed as a retrospective study for which the case records of patients as having trigeminal neuralgia kept with Medical Records Department, of a tertiary care hospital were studied and the patients were called for follow-up during the study period of July 2012 to December 2015 in the present study. Sixty-five patients who responded to follow-up call during the study period were included in the present study. Results: Majority belonged to 41–50 years (36.9%). Males (75.4%) were more than females (24.6%). Male-to-female ratio was 3.1:1. Both sides were equally affected. Pain distribution was commonly seen (38.5%) in V2+V3. Most common precipitating factor was cold (33.8%). 13.8% had hyperesthesia and 12.3% had hypoesthesia. Majority (83.1%) were directly operated for microvascular decompression. Trigeminal neuralgia was due to vascular compression (83.1%). The most common microvascular relationship was with superior cerebellar artery (50.8%). Only five patients had postoperative complications. Conclusion: Males were affected more than females. V2+V3 was common site of pain distribution. Cold was found to precipitate trigeminal neuralgia. The most common microvascular relationship was with superior cerebellar artery. Thus, trigeminal neuralgia has varied presentation, and hence, care needs to be taken in the diagnosis and management.



How to cite this article:
Raykar RR, Ganapathy S. Clinical profile, management, and postoperative complications among patients with trigeminal neuralgia at a tertiary care hospital.MRIMS J Health Sci 2021;9:56-60


How to cite this URL:
Raykar RR, Ganapathy S. Clinical profile, management, and postoperative complications among patients with trigeminal neuralgia at a tertiary care hospital. MRIMS J Health Sci [serial online] 2021 [cited 2021 Oct 21 ];9:56-60
Available from: http://www.mrimsjournal.com/text.asp?2021/9/2/56/318156


Full Text



 Introduction



Trigeminal neuralgia is a chronic condition. It causes severe facial pain. The facial pain occurs in the area of the face which is supplied by the 5th cranial nerve. The pain presents like shocks of electricity, it is sudden in onset and sporadic. It can last from the seconds to minutes. Causes can be primary where exact cause is difficult to find out or it can be secondary to multiple sclerosis, tumor, or infarction. Secondary cause is not common. Trigeminal neuralgia secondary to multiple sclerosis is rare. There is no clarity in the diagnostic criteria for the diagnosis of the trigeminal neuralgia, and hence, the diagnosis is difficult and often delayed. Therefore, it is a common finding that the patient has visited many clinics before the final and correct diagnosis is established. Trigeminal neuralgia is not harmful, but it definitely affects the quality of life of patients. It may become nonresponsive to the treatment.[1],[2],[3]

The pain which is seen in the pathways of the nerves is called neuralgia. Pain occurring in the maxillofacial region attracts the clinical visit of the patients to not only medical practitioners but also dental practitioners and exhibits burden not only psychologically for the patient but also puts a burden on the society.[4] Trigeminal neuralgia affects quality of life of the patients and is confused with maxillofacial pain disorder.[5]

It has been estimated that the yearly occurrence of trigeminal neuralgia is around 12.6/1 lakh persons per year.[6] The incidence of trigeminal neuralgia has been reported to increase with age. Most commonly affected age group is 50–70 years; however, it has been reported from pediatric age group also. Gender wise, females are affected more than males but recent statistics indicate that trigeminal neuralgia affects around 60% of women.[7] When the incidence of trigeminal neuralgia is compared between sexes, it has been reported that it is 5.9 versus 3.4/1 lakh per year in females and males respectively.[8]

The characteristic feature that distinguishes between trigeminal neuralgia and glossopharyngeal neuralgia is the difference in the pain. In trigeminal neuralgia, it is like electric shock and difficult to control with triggering factors, while in glossopharyngeal neuralgia, it occurs in the oropharyngeal area and is found to be associated with deglutition.[9]

Lack of diagnostic criteria which is uniform and approved affects the patient care and research.[10] The complex nerves network is one of the important factors that offers difficulties in the diagnosis and treatment of facial pain. Thus, it makes it very frustrating.[11] Hence, a cautious diagnostic approach is required. Other conditions which present like trigeminal neuralgia features are dental pain; psychiatric diseases; diseases of ear, nose and throat; tumors, etc., in addition to referred pain.[12],[13] The signs and symptoms of the different types of neuralgia are similar. Hence, proper examination of such patients with appropriate laboratory tests is required to arrive at the proper diagnosis and management of trigeminal neuralgia.[14]

Most of the times, the diagnosis of trigeminal neuralgia is delayed as it is often confused with the other causes of pain like dental problems. Hence, studies are required to focus more light on trigeminal neuralgia. With this background, the present study was carried to study the clinical profile, management, and postoperative complications among patients with trigeminal neuralgia.

 Methods



Settings

The present study was carried out at the department of neurosurgery of a tertiary care hospital.

Study design

The study was designed as a retrospective study.

Study period

July 2012 to December 2015.

Ethical considerations

The patient data was kept confidential with regard to their identity. The Institutional Ethics Committee permission was obtained. Informed consent was taken from the study participants.

Methodology

For the present study, case records of patients as having trigeminal neuralgia kept with Medical Records Department, of a tertiary care hospital were studied and the patients were called for follow-up during the study period of July 2012 to December 2015 in the present study. Sixty-five patients who responded to follow-up call during the study period were included in the present study.

From the case records of each patient, details were noted and entered into the study questionnaire. After follow-up, the details were noted, and all clinical data were transferred to a master chart. Variables such as age, sex, side affected, distribution of pain, precipitating factors, operative findings, microvascular relationships, and postoperative complications were recorded in the predesigned, pretested, semi-structured study questionnaire. The patients were asked to come for follow-up at every 3 months till 6 months. The data were expressed as proportions.

Microvascular decompression

Trigeminal neuralgia patient's refractory to medical management is treated by operative procedure called microvascular decompression. Before surgery, computed tomography was done to assess if ecstatic arteries are present or not; to rule out extra axial cerebello pontine angle tumors and arteriovenous malformations. Plain skull roentgenograms were also done. During surgery, anesthetist did the anesthetic management of the patients. Supracerebellar retromastoid approach was used. Using the operative microscope, the involved adherent vessels (usually vascular loops arising from the superior cerebellar artery) was carefully dissected from the 5th nerve and a small piece of permanent sponge or any other alloplastic material is placed between the nerve and the vessels to maintain separation.

 Results



[Table 1] shows the distribution of study participants as per age, sex, and side affected. Majority of the study subjects belonged to the age group of 41–50 years (36.9%) followed by 51–60 years (29.2%). Males (75.4%) were seen more affected with trigeminal neuralgia than females (24.6%). The male-to-female ratio was found to be 3.1:1. In terms of side affected, both sides were found to be equally affected.{Table 1}

[Table 2] shows distribution of study subjects as per pain distribution, precipitating factors, and neurological status. Pain distribution was commonly seen (38.5% of the cases) in V2+V3 followed by V1V2V3 area (27.7% of the cases). Most common precipitating factor was cold in 33.8% of the cases followed by eating food in 23% of the cases. No patient was found to have any motor deficit or hearing loss or facial palsy. 73.8% of the cases had normal sensations. 13.8% had hyperesthesia and 12.3% had hypoesthesia.{Table 2}

[Table 3] shows the distribution of study subjects as per procedure used for microvascular decompression. Majority, i.e., 83.1% of the cases were directly operated for microvascular decompression, while in 16.9% of the cases, it was done as a secondary procedure.{Table 3}

[Table 4] shows the distribution of study subjects as per operative findings. In 83.1% of the cases, trigeminal neuralgia was found to be due to vascular compression, while in 16.9% of the cases, it was as the result of vascular anomaly.{Table 4}

[Table 5] shows the distribution of study subjects as per microvascular relationship. The most common microvascular relationship was with superior cerebellar artery in 50.8% of the cases which was seen in just more than half of the cases. Eleven cases were not found to have any kind of microvascular relationship.{Table 5}

[Table 6] shows the postoperative complications. Only five patients had postoperative complications. Among them, three had decreased corneal reflex while one had motor weakness and one had cerebellar contusion.{Table 6}

 Discussion



Majority of the study participants belonged to the age group of 41–50 years (36.9%) followed by 51–60 years (29.2%). Males (75.4%) were seen more affected with trigeminal neuralgia than females (24.6%). The male-to-female ratio was found to be 3.1:1. In terms of side affected, both sides were found to be equally affected. Pain distribution was commonly seen (38.5% of the cases) in V2+V3 followed by V1V2V3 area (27.7% of the cases). Most common precipitating factor was cold in 33.8% of the cases followed by eating food in 23% of the cases. No patient was found to have any motor deficit or hearing loss or facial palsy. 73.8% of the cases had normal sensations. 13.8% had hyperesthesia and 12.3% had hypoesthesia. Majority, i. e., 83.1% of the cases were directly operated for microvascular decompression, while in 16.9% of the cases, it was done as a secondary procedure. In 83.1% of the cases, trigeminal neuralgia was found to be due to vascular compression while in 16.9% of the cases, it was as the result of vascular anomaly. The most common microvascular relationship was with superior cerebellar artery in 50.8% of the cases which was seen in just more than half of the cases. Eleven cases were not found to have any kind of microvascular relationship. Only five patients had postoperative complications. Among them, three had decreased corneal reflex while one had motor weakness and one had cerebellar contusion.

Yadav et al.[15] studied 72 cases of trigeminal neuralgia retrospectively. They observed that 54.9 years was the average age for trigeminal neuralgia, and it was more common in females and more frequently seen in people from the rural areas compared to urban areas. Right side was found to be affected in 62.5% of the cases. 60.8% of the cases responded positively to carbamazepine treatment. This form of treatment was found to be better compared to other forms of treatment like addition of gabapentin or neurolytic alcohol bloc. They thus concluded that carbamazepine was effective in cases with trigeminal neuralgia.

Chandan et al.[16] included 20 cases of trigeminal neuralgia to study the efficacy of peripheral neurectomy for the management of the condition. They reported that complications associated with surgery were not significant. Two patients reported pain recurrence in 2 years. They concluded that peripheral neurectomy is a good option to manage trigeminal neuralgia.

Siqueira SRDT et al.[17] investigated 395 cases of trigeminal neuralgia to study the clinical profile. The average age in the first study (n = 290) was 62.5 years with 57.3% of females and 95.5% of whites. Maxillary and/or mandibular branches were found to be affected in 65.5% of the cases. 57.6% of the cases had the right side affected. The average age in the second study (n = 105) was 60.8 years with 57.1% females and 75.2% whites. Maxillary and/or mandibular branches were found to be affected in 79% of the cases. 69.5% of the cases had the right side affected.

Bangash[18] attempted to study the most common side affected in patients with trigeminal neuralgia as well as to study the most common branch of trigeminal nerve affected among 100 cases of trigeminal neuralgia. The average age of the patients in their study was 54 years. Females were twice as affected as males. Sixty-four percent of the cases were found to have right side affected. Bilateral involvement was not seen. Fifty-five percent of the cases had mandibular division affected.

Ayele et al.[19] studied clinical profile of 61 patients with trigeminal neuralgia. The average age of the patients in their study was 50.7 years. Males and females were found to be equally affected. Tooth extraction history was found to be present in 41% of the cases. 68.9% of the cases were found to have right side affected. In 47.5% of the cases, mandibular nerve was involved. In 36% of the cases, it was possible to identify the trigger zone. Most patients presented with pain that was like an electric shock or lancinating or burning in nature. Most commonly used drug was carbamazepine, and there was a good relief with it.

Rehman et al.[20] reported clinical characteristics of 117 patients with trigeminal neuralgia. 58.1% were females. The average age of the patients was 53.9 years. In 53.8% of the cases, right side was found to be affected. Bilateral involvement was seen in 2% of the cases. In 58.1% of the cases, it was found that maxillary division was involved. Infra-orbital site was found to be involved in 58.1% of the cases followed by the mental nerve in 29.9% of the cases. Mild pain was seen in 28.2% of the cases, whereas moderate pain was seen in 46.2% of the cases.

Jainkittivong et al.[21] described clinical profile and treatment of 188 cases with trigeminal neuralgia. It was more common in females (62.8%). Age group 50–69 years showed peak incidence. The right side was found to be more affected than the left side. In 30.3% of the cases, mandibular division was found to be affected.

De Toledo et al.[22] carried out a systematic review to find the prevalence and characteristics of trigeminal neuralgia in the general population. They extracted 728 studies of which only three were eligible for the systematic review. The prevalence of trigeminal neuralgia in women ranged from 0.03% to 0.3%. Most commonly affected nerves were the maxillary and mandibular branches of the trigeminal nerve. Females were found to be three times more affected than males. Those in the age group of 37–67 years were found to be more affected than other age groups.

 Conclusion



Males were affected more than females. V2+V3 was common site of pain distribution. Cold was found to precipitate trigeminal neuralgia. The most common microvascular relationship was with superior cerebellar artery. Thus, trigeminal neuralgia has varied presentation, and hence, care needs to be taken in the diagnosis and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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