Shivam journal.cdr

Indian Journal
of Comprehensive
Dental Care
ABSTRACT:
Trigeminal Neuralgia is the most common form of neuralgia. It is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the lips, nose, scalp, forehead, and jaws. In the past, numerous treatment modalities have been tried to alleviate neuralgic pain and these have ranged from 1. Senior Lecturer, Department of Oral &Maxillofacial Surgery, medicinal therapies to extensive surgical procedures either peripheral or Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar central, with varied patient response. The aim of this prospective study was to 2. Professor, Department of Oral &Maxillofacial Surgery, Sri Guru compare the efficacy of three different treatment modalities in the Ram Das Institute of Dental Sciences and Research, Sri management of trigeminal neuralgia: medicinal management with 3. Resident, Department of Oral &Maxillofacial Surgery, Sri Guru carbamazepine alone or in combination with baclofen or gabapentin; Injection Ram Das Institute of Dental Sciences and Research, Sri of absolute alcohol to the peripheral branches of trigeminal nerve; and Key words: neuralgia, carbamazepine, baclofen, absolute alcohol,
neurectomy
Corresponding Author :
Dr. Sarika Kapila
2-B, Circular Road, Amritsar
M: 08146536193
E-mail : [email protected]
INTRODUCTION
lamotrigine, felbamate, topiramates, vigabatrin, sodium valproate, oxycarbazepine, Mephenesin carbamate, Trigeminal Neuralgia (TN) is a neuropathic disorder of the clonazepam and baclofen. Surgical procedures include trigeminal nerve that causes episodes of intense pain in the peripheral neurectomy, injection of absolute alcohol to the lips, nose, scalp, forehead and jaws. The term “Tic peripheral branches or to the gasserian ganglion, douloureux'' was coined by Nicholaus Andre in 17561. The microvascular decompression, gamma knife surgery, presence of trigger zone is highly suggestive of trigeminal glycerol gangliolysis, radiofrequency thermocoagulation, neuralgia and may be located anywhere with in the percutaneous balloon compression, retrogasserian distribution of the trigeminal nerve. White and Sweet made rhizotomy, medullary tractotomy and cryotherapy. This a significant diagnostic criteria for neuralgia, which includes paper compares the three common treatment modalities of paroxysmal, unilateral pain provoked by light touch to the TN and highlights the merits and demerits of each. face and is confined to the distribution of trigeminal nerve with normal clinical sensory examination2. Several MATERIAL AND METHODS
hypotheses regarding the etiology of TN have been stated 3 The present study was undertaken in 30 patients of primary and large variety of medicinal and surgical treatment and recurrent trigeminal neuralgia reporting to the modalities have been used for the management of this Department of Oral and Maxillofacial Surgery, Sri Guru Ram condition but no single treatment modality has been found Das Institute of Dental Sciences & Research, Amritsar. These to be superior to other options. Medicinal treatment patients were randomly divided into three groups of ten includes the use of various drugs either alone or in patients each, medicinal - Group I, peripheral neurectomy- combination with carbamazepine, gabapentin, phenytoin, Group II and use of absolute alcohol injection- Group III. Indian Journal of Comprehensive Dental Care
Diagnosis of TN was determined by thorough clinical RESULTS:
examination, presence of trigger points and diagnostic In all groups, patients were evaluated periodically for blocks. IOPA x-ray and Panoramic radiographs (OPG) were effectiveness of the treatment and complications with taken for evaluation of dentoalveolar structures in the region regular follow-up period at 7days, 1month, for a minimum of pain attacks and to exclude any local pathology. Magnetic period of 6 months up to the maximum time period available. resonance imaging of brain was done to rule out multiple In Group I, there were 10 patients (100%) of primary TN, 6 sclerosis and for identification of any structural lesion related patients (60%) were treated with single drug and 4 (40%) to the intracranial course of the trigeminal nerve. Routine were treated with combination drug therapy. In Group II, out blood investigations were carried out before initiating any of 10 patients, there were seven patients (70%) of primary TN and 3 patients (30%) of recurrent TN. In Group III, there were MEDICINAL MANAGEMENT
4 patients (40%) of primary TN and 6 patients (60%) of recurrent TN, in which recurrence of pain occurred after the 10 patients with trigeminal neuralgia were included in this first absolute alcohol block. Out of total 30 patients, there group. Hematological investigations were repeated every 3 were 21 patients of primary TN (70%) and 9 patients of months. Tab Mazetol (Carbamazepine) (Nicholas Piramal recurrent (30%) TN (TABLE -1). There were 22 females India Limited), with a starting dose of 100mg TDS was (73.3%) and 8 males (26.7%), with 15 patients (50%) in the prescribed to all the patients. Patients who did not respond age group of 40-60 years and 15 patients (50%) in the age adequately to single drug therapy were put on combination group 60-80 years. In 22 patients (73.3%) of TN, right side was therapy of Tab Lioresal 10mg TDS (Baclofen 10mg) (Novartis afflicted and in 8 patients (26.7%) of TN, left side was Pharmaceuticals), and Tab Mazetol 200mg TDS involved. The mandibular division was most commonly (Carbamazepine 200mg) (Nicholas Piramal India Limited). affected in 19 patients (63.3%) followed by maxillary division PERIPHERAL NEURECTOMY
Peripheral neurectomy was performed in 10 patients (Table 3) shows the pain scores using VAS (Visual Analogue intraorally under local anesthesia. The involved terminal Scale) in the 3 groups. In Group I, out of 10 patients of branch of the extracranial part of the trigeminal nerve was primary TN, 6 patients were put on single drug therapy (Tab Mazetol 200mg TDS). On 7th day follow up, out of 6 patients, PERIPHERAL ABSOLUTE ALCOHOL INJECTION
4 patients had no pain and 2 patients had mild pain. At 1month follow up, out of 6 patients, 5 had no pain and 1 95 percent absolute alcohol injection was used in 10 patients patient complained of mild pain. At 6months follow up, 4 with primary or recurrent neuralgia to block peripheral patients were pain free, 1 had mild pain and another patient with moderate pain was put on combination drug therapy ASSESSMENT
and later operated (neurectomy) after 1 month. Out of the 5 All patients were evaluated periodically for effectiveness of remaining patients, 4 patients were pain free at the last the treatment with regular follow up at 7days, 15days, follow up (10-17 months). 1 patient had a pain free period of 30days and then continuously every month, for a minimum 12months followed by moderate pain due to which period of 6months, up to the maximum time period combination drug therapy was started which relieved pain till available. A visual analogue scale (VAS) ranging from 0-10 was used for evaluation of pain in all the groups, pre- In Group I, 4 patients were put on combination drug therapy. treatment as well as post-treatment. In all the three groups, On the 7th day follow up, 2 patients had no pain and another patients efficacy of the treatment modality was assessed for 2 patients complained of mild pain. During 1 month follow up period, 3 patients were completely pain free uptil follow up Determination of pain level using VAS scale (0 score- no pain; period (10-22 months) whereas 1 patient at 1 month follow 1 to 3 as 'mild pain'; 4 to 6 as 'moderate pain' and 7 to 10 as up complained of mild pain which worsened to moderate at 6month and thus neurectomy was done. In group II, peripheral neurectomy was done in 10 patients (7 primary and 3 recurrent cases of TN. On 7th day follow up, all the Patient response as excellent (relief of pain over the patients in primary group were pain free at 1month, 6 month entire follow up period), as good (marked relief but had and at maximum follow up (7-12 months) whereas the residual dull ache) or as poor (no response to treatment remaining 3 patients with recurrent neuralgia experienced severe pain at the 7th day follow up and were shifted to Side effects and complications of the procedure Indian Journal of Comprehensive Dental Care
In group lll, 4 patients were of primary whereas 6 were of recurrent TN. On the 7th day follow up, 6 patients were absolutely pain free whereas 1 patient had mild and 2 Treatment Group
No. of Patients
Primary cases
Recurrent cases
(n=30) (%)
patients had moderate pain, 1 patient had severe pain and the absolute alcohol block was repeated following which the patient had pain relief. At 1 month follow up, 6 patients continued to be pain free whereas 3 patients experienced occasional attacks of mild pain. At 6 months follow up, 5 patients were pain free and continued to be so till maximum follow up (6-12 months) whereas, 1 patient had occasional attacks of mild pain and 3 patients experienced moderate pain. Out of these 3 patients, 1 patient was shifted to medicinal group, In the 2nd patient, absolute alcohol block was repeated which relieved pain for 3months and then at 9 months follow up, the patient was given extraoral block for Distribution Of Age, Gender, Side And Division the mandibular division. In the third patient also, peripheral Age (years)
Gender (n=30)
Side (n=30)
Division (n=30)
absolute alcohol block was repeated at 6 months, with pain Treatment
free period for 4months when another block was given to Right (%) Left (%)
relieve the pain. 2 months later i.e. at 12 month follow up, patient was symptomatic and was shifted to medicinal group. Therefore, in a total of 10 patients in absolute alcohol group, 14 absolute alcohol blocks were given. From the VAS (visual analogue scale) it was observed that 70% patients in group l and 70% patients in group ll remained pain free at maximum follow up of 6-22 months and 7-12 months respectively, whereas in alcohol group 50% patients remained pain free at maximum follow up of 6-12 months. Table 4 shows period of pain relief in 30 patients till DETERMINATION OF PAIN LEVEL USING VAS (VISUAL ANALOGUE SCALE) maximum follow up period. In Group I, (medicinal) average No of Patients in various categories of VAS
pain free period was 11.5 months (range 6-17 months) in 6 Follow up Period
patients, who were taking only Tab Mazetol 200mg TDS while ›6 month
Shifted to
in 4 patients of combination drug therapy, the average pain other group
Modality
free period was 14 months, with a range of 6-22 months. In Group II, average pain free period was 6months, with a range (1-3) (4-6) (7-9) 0 (1-3) (4-6) (7-9) 0 (1-3) (4-6) (7-9) 0 (1-3) of 0-12 months in 10 patients. However in 7 patients of primary TN, average pain free period was 9.5 months (range 7-12 months) while 3 patients of recurrent TN had no pain relief. In Group III, 10 patients had an average pain free period of 6 months, (range of 0-12 months). In 4 patients of primary TN, average pain free period was 9 months (range 6- 12 months), while in 6 patients of recurrent TN, average pain free period was 5 months (range 0-10 months). Patient response to the various treatments was evaluated. In group I (medicinal), out of 6 patients (66.6%) had an excellent response with single drug, 1 patient (16.7%) had good response and 1 patient (16.7%) responded poorly. In combination drug therapy, 3 out of 4 patients (75%) had an excellent response and only 1patient (25%) did not respond to combination drug therapy. In group II, 7 patients of 1o TN had complete relief and required no medicine till the maximum follow up period while 3 patients of recurrent TN had no relief after neurectomy and they were shifted to the Indian Journal of Comprehensive Dental Care
PERIOD OF PAIN RELIEF IN VARIOUS TREATMENT MODALITIES dizziness (30% each) and anxiety in (20%) patients. Increase in alkaline phosphatase level was observed in 2 patients Treatment Modalities
Total no of
Range of pain
Average pain
(20%) at 6 months follow up who were taking Tab Mazetol patients (N)
free period
ee period
200mg TDS where as 1 patient (10%) on same drug and dosage reported with impairment of memory at more than 6-17 months 11. 5 months 1 year follow up. However, in Group II, 70% patients had loss of sensation. 30% patients in this group had post operative trismus. Trismus developed following surgery on the inferior alveolar nerve which resolved with the use of muscle relaxants. In Group III, burning sensation was the most common complication (60%) followed by loss of PATIENT RESPONSE TO THE TREATMENT MODALITY sensation and pain at the site of injection (30% Treatment Group
Patients response
respectively). Swelling was observed in 1 patient (10%) following absolute alcohol block of infraorbital nerve which Excellent
took 7 days to subside and in another patient (10%) trismus occurred following inferior alveolar absolute alcohol block DISCUSSION
II (Peripheral
Neurectomy)
A plethora of treatment modalities is currently available for TN . Broadly they can be classified as medical or surgical. Medical treatment consists of drug therapy by antiepileptic drugs whereas surgical treatment can be divided into extracranial and intracranial procedures: extracranial COMPLICATIONS OF VARIOUS TREATMENT MODALITIES options include absolute alcohol block in the peripheral nerve, neurectomy, electrosurgery, cryosurgery and Complications
Post Operative Complications
radiofrequency thermocoagulation whereas intracranial Group-II
Group-III
procedures consists of treatment at the level of gasserian ganglion and higher3,4. Classical TN is primarily treated by antiepileptic drug, adding a second antiepileptic drug may enhance the therapeutic response2. Carbamazepine is the drug of first choice for the treatment of trigeminal neuralgia5. It have antineuralgic and anticonvulsant properties and is associated with side effects such as aplastic anaemia, agranulocytosis, obstructive jaundice and increase alkaline phosphatase level. It can be given upto 800 mg to 1,600 mg/day6. Baclofen is an analog of the putative inhibitory neurotransmitter - , aminobutyric acid. Treatment is initiated with a starting dose of 5 to 10 mg three times a day which can be increased by 10 mg every other day until pain relief is achieved or side effects occur. The usual daily maintenance dose is 50 to 60 mg a day and needs to be given on a 3-4-hour basis. medicinal group. In group III, out of 10 patients,3 patients Surgical access for peripheral neurectomy of the second (30%) of primary and 2 patients (20%) of recurrent TN had and third division is through the oral cavity. The usual period excellent response, 1patient(10%) of primary TN had good of relief produced by peripheral neurectomy ranges from 6 response and 4patients(40%)of recurrent TN had poor months to 2 years, although some longer periods have also response with peripheral alcohol block and therefore they been reported7. The advantages of peripheral neurectomy include easy procedure, well tolerated by elderly, debilitated or congnitively impaired patients and can be performed TABLE 6 shows the complications of various treatment under local anesthesia. There are no major complications of modalities. In Group I, it was observed that drowsiness was these procedures other than some facial swelling in the early the most common (40%) side effect followed by fatigue and Indian Journal of Comprehensive Dental Care
postoperative period and expected loss of sensation in the patients had no pain at the maximum follow up of 6-12 appropriate distribution of the trigeminal nerve8. months. The results are supported by (Mruthyunjaya and Raju 1981)3 who concluded that medicinal therapy as well as The peripheral absolute alcohol injections are reasonably peripheral neurectomy procedures were highly effective. effective in producing short to medium term pain relief in Jackson et al (1999)14 in their study concluded that pain patients. The procedure does carry risks which are temporary relief following carbamazepine or alcohol is temporary and in nature9. Because of its protein precipitant property, most of the patients eventually require surgical intervention. absolute alcohol has been used successfully to destroy nerve tissue. Transient edema, local necrosis, hematoma, trismus, Salama et al (2009)15 compared the outcome response of swelling, transient facial paresis, stinging eyes, burning pain relief following microvascular decompression with that sensation are the few complications, which have been of pharmacotherapy and concluded that 95.2% patients had documented to subside in 1-3 days3. Murali and Rovit immediate pain relief as compared to 53.3% patients, who (1996)8 in their study on evaluation of peripheral showed poor response with pharmacotherapy. neurectomy as a treatment option in TN. Out of 40 patients, The pain free period in our study ranged from 6-17 months 12 patients had primary trigeminal neuralgia and 28 patients (average -11.5 months) in 6 patients on a single drug belonged to recurrent trigeminal neuralgia group who had (carbamazepine). Out of these, 4 patients (66.6%) remained already undergone radiofrequency thermocoagulation. completely pain free till the last follow up (range 10-17 Mruthyunjaya and Raju(1981)3 included 31 cases of primary months).Those on combination drug therapy, remained pain as well as recurrent trigeminal neuralgia in a comparative free for 6-22 months (average 14 months). Out of these, 75% evaluation of the efficacy of medicinal management with patients remained absolutely pain free till the last follow up carbamazepine, injection of absolute alcohol to the of 10-22 months. Stajcic et al (1997)10 have reported peripheral branches of trigeminal nerve, peripheral duration of pain relief as 1-48 months in 16 patients who neurectomy and injection of absolute alcohol to the were given only carbamazepine. Also, Taylor et al (1981)11 gasserian ganglion in the management ofTN. In the present have reported pain relief of 1-4 years in 61.2% patients and of study, patients age ranged from 40-80 years. This is in 5-16 years in 38.7% patients with carbamezepine. In a study concurrence with the studies conducted by Mruthyunjaya conducted by Fromm et al (1984)16, 44.4% patients and Raju (1981)3 and Stajcic et al (1997)10 who found the remained pain free for 1-5 years with combination of maximum number of patients in their study on TN, in the age group of 35-80 years. Taylor et al (1981)11, Gallagher et al In our study, the pain free period in the peripheral (2005)12 and McLeod and Patton (2007)9have reported that neurectomy group ranged from 7-12 months (average 9.5 trigeminal neuralgia may also affect younger age group, the months) in 7 patients of 1O trigeminal neuralgia. Out of these range of age in their study being 22-88 years. 7 patients, the average period of pain relief following inferior In the study, 26.6% patients were male and 73.3% patients alveolar nerve neurectomy was 7-12 months (average 9.5 were female patients, the ratio being 1:2.7. This is in months) whereas following infraorbital neurectomy it was 7- concurrence with the findings of Gallagher et al (2005)12 and 10 months (average 8.5 months) till the last follow up. Cerovic et al (2009)7.However, Mruthyunjaya and Raju However, the remaining 3 patients in recurrent TN group (1981)3 and Murali and Rovit (1996)8 found a higher were not relieved of pain and were thus shifted to medicinal prevalence of TN in males. It was observed that right side of group. Cerovic et al (2009)7 found average pain relief period the face was afflicted in 73.3% of cases and left side in following first neurectomy in 1O cases as 16.3 months (16.27 26.6%cases.Similar results were found in studies conducted months for infraorbital nerve and 16.5 months for inferior by Mruthyunjaya and Raju (1981)3, Taylor et al (1981)11, alveolar nerve) and concluded that it is not desirable to Murali and Rovit (1996)8, Stajcic et al (1997)10 and Cerovic et perform more than three neurectomies on the same nerve. al (2009)7. Out of 30 patients, the mandibular division was In the absolute alcohol group, 50% patients remained pain affected in 63.3% cases and maxillary division in 36.6% cases free for an average of 9 months (6-12 months) till the last of trigeminal neuralgia accordance with studies by follow up. Pain relief in infraorbital nerve neuralgia ranged Mruthyunjaya and Raju (1981)3 and Freemont and Millac from 6-8 months whereas for inferior alveolar nerve (1981)13.Higher incidence of maxillary division involvement neuralgia, it ranged from 0-12 months. Mruthyunjaya and than mandibular division in TN was observed by Murali and Raju (1981)3 observed that only 50% of the patients who Rovit (1996)8 and Cerovic et al (2009)7. 70% patients each in were given absolute alcohol block remained pain free at the the medicinal group and in the neurectomy group scored had follow up of 8 months. In our study, response of patients to no pain at the maximum follow up of 6 to 22 months and 7-12 the single drug therapy was found excellent in 66.6%, good in months respectively whereas in the alcohol group, only 50% 16.7% and poor in 16.7% patients. 75% of the patients who Indian Journal of Comprehensive Dental Care
were treated with combination of carbamazepine and injection (30%) whereas facial swelling and trismus was seen baclofen had excellent outcome while 25% patients had poor after injection of infraorbital nerve and inferior alveolar response and were operated upon for neurectomy. Fromm et nerve respectively, in only 10% of patients.
al (1984)16 concluded that combination of baclofen and CONCLUSION
carbamazepine resulted in better patient response which The availability of a wide range of effective treatment was explained by the fact that these two drugs have modalities for trigeminal neuralgia has brought satisfactory synergestic effect. In 70% patients of peripheral neurectomy outcomes to many patients. The choice of specific treatment, group, the patient response to the procedure was excellent whether medical or surgical, should be tailored to the needs while in 30% patients it was poor. Murali and Rovit (1996)8 of the individual patient. The most common side effect of found excellent pain relief following peripheral neurectomy medicinal treatment included drowziness followed by in 58.3% cases and good in 41.6% cases of 1o TN. These fatigue, dizziness, anxiety, increased alkaline phosphatase authors proposed that main advantage of peripheral level and impairment of memory. However loss of sensation neurectomy is the direct visualization of the nerve branches and trismus were observed in the peripheral neurectomy as far proximally as possible, thus greatly decreasing the group. In the absolute alcohol group, burning sensation was incidence of recurrence. In Group IIL, patient response in the most common complication followed by loss of 50% patients was excellent, good in 10% patient and poor in sensation, pain at the injection site, trismus and facial 40% patients. Murali and Rovit (1996)8 do not recommend alcohol as a definitive therapeutic option for TN because to produce excellent long lasting anesthesia, absolute alcohol In conclusion, medicinal management and peripheral must be injected directly into the nerve bundle or else it may neurectomy procedures were proved to be highly effective in produce only partial sensory loss, leaving persistent pain as the treatment of TN as the period of pain relief was long well as complications such as soft tissue necrosis. . In the lasting and patient's response was also found to be excellent present study, it was observed that drowziness was the most common side effect of carbamazepine therapy followed by BIBLIOGRAPHY
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