Facial Pain: Diagnosis and treatment

Ahmed M. Raslan, MDAssistant Professor

Department of Neurological SurgeryOHSU, Portland, OR, USA

Disclosure

• None

Diagnosis of Facial Pain

• Clinical !

• Imaging

Classification of Facial Pain

• Trigeminal distribution

• Other cranial Nerves

• Cluster

• Migraine

• TMJ

Classification of Facial Pain

• TN1• TN2• Symptomatic• Neuropathic• Postherpetic• Deafferentation• Atypical• Rare syndromes

• Trigeminal distribution

• Other cranial Nerves

• Glossopharyngeal• Nervus Intermedius• Ramsy-Hunt

• Trigeminal distribution

• Other cranial Nerves

Classification of Facial Pain

Other Cranial Neuralgia

• Unilateral• Throat pain• Syncope/ Swallow-

syncope• Base of tongue-tonsillar fossa-

angle of mandible, ear pain

• Glossopharyngeal• Nervus Intermedius• Ramsy-Hunt

• Unilateral• Sharp episodic pain

deep in the EXTERNAL ear

Other Cranial Neuralgia

• Glossopharyngeal• Nervus Intermedius• Ramsy-Hunt

• Sudden onset• Retroauricular and

facial pain• Followed 2 days later by

facial palsy• Vesicular eruptions ?

• Glossopharyngeal• Nervus Intermedius• Ramsy-Hunt

Other Cranial Neuralgia

Trigeminal NeuralgiaIASP IHS

Sudden , usually unilateral, severe brief stabbing recurrent pains in the distribution of one or more branches of the Vth cranial nerve

Painful unilateral affliction, characterized by brief electric shock like pain limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination and may remit for varying periods

Classification of facial painTN1 TN2 Symptomatic Neuropathic Post-

HerpeticDe-afferentation

Atypical

Sharp stabbing episodic pain for more than 50 % of the time.Constitute the typical TN

Sharp stabbing pain < 50 with predominant component of dull aching or burning pain.Advanced from of TN

Due to:1-MS2-Tumour3-AVM4-AneurysmEtc…..

Un-intentional injury1- surgicalENT, Ophth.Plastic….2- traumatic

Herpes Zoster out-break

Severe neuro-pathy

Intentional neuro-surgical injury for treatment of TN

1-Rhizotomy2-RF3-Radio-surgery

Somato-form Pain disorder

Can not be diagnosed By history only

Burchiel K. A new classification of facial pain. Neurosurgery 53 (5) 2003: 1164-1176Eller J, Raslan A, Burchiel K. Trigeminal Neuralgia: Definition and classification. Neurosurg Focus 18 (5) 2005: E3

1- TN1• Represents the classic TN• Severe abrupt stabbing , electric or shock-like pains is

the hallmark • Dull aching or burning pain is absent or present for

less than 50 % of the time the patient experience the pain

• Presence of pain free intervals• Straight forward diagnosis• May progress to TN2 ..?

2- TN2

• Still the patient experience sharp pains, but the hallmark is dull aching, burning pain or back ground pain that constitute more than 50 % of the time

• Constant back ground pain is the most significant attribute with the absence of any structural abnormality

TN2

• Type A– Progressed from prior TN1

• Type B– Started de novo a TN2 ; ? Trigeminal ganaglion

dysfunction

3- Symptomatic TN

• Represents what is usually called secondary TN

• There is another disease or diagnosis that causes demyelination of the trigeminal nerve

• Trigeminal nerve can be still compressed and sometimes can be treated by treatment of the cause

Broggi et al. Operative findings and outcome of microvascular decompression for trigeminal neuralgia in 35 patients affected with multiple sclerosis. Neurosurgery 55(4) 2004: 830-839

4- Neuropathic TN

• Patients complain of pain of constant nature, with areas of numbness as a hallmark

• Due to un-intentional injury to the trigeminal nerve during surgery or trauma, could be spontaneous

*Johnson M, Burchiel K. Peripheral stimulation for treatment of trigeminal post herpetic neuralgia and trigeminal post-traumatic neuropathic pain: A pilot study. Neurosurgery 55(1) 2004 : 135-142

5- Post Herpetic TN

• Constitutes a severe form of neuropathy to the trigeminal nerve

• Easily diagnosed by history of eruptions

6- Deafferentation facial painAnesthesia Dolorosa

• Means “ Painful Anesthesia”

• Doctors’ induced pain syndrome

• Follows destructive procedures for trigeminal neualgia– Surgical rhizotomy– RF procedures, Balloon, rarely Glycerol– Radiosurgery

• Very severe and difficult to treat

7- Atypical Facial Pain• We use this term to describe patients who complain of facial

pain as a part of somatoform pain disorder

• Can be diagnosed by Neuro-psychological evaluation

• Patients usually describe the following symptoms– Bilateral pain, or pain that cross the midline– Pain outside the distribution of trigeminal nerve– Multiple complaints in multiple body parts– Patients often carries diagnoses like “chronic fatigue syndrome”,

“Fibromyalgia” .

• Surgical treatment is contra-indicated

Pre-operative ImagingTOF MRA

TOF MRA + 3D SPGR + gad

Steady state sequencesCISS, FIESTA, BFFE

DTI imaging

Virtual Endoscopy

Surgical Management of Facial Pain

• Non- Ablative– Possibly Curative• MVD

– Modulation of Pain• MCS• Trigeminal Stimulation• DBS• Vent. Opioids

• Ablative– Surgical

• Rhizotomy

• Caudalis DREZ– Percutanous

• RF Rhizotomy• Balloon• Glycerol

• Tractotomy– Radiosurgical

• Gamma Knife• Lin-Ac

Treatment of facial pain

TN1 TN2 Symptomatic Neuropathic Post-Herpetic

De-afferentation

Atypical

-MVD-RF--Radio-surgery

-RF-Radio-surgery-MVD

-RF-Surgery-Radio-surgery-MVD

-MCS-Trigeminal stimulation-Caudalis DREZ-Tractotomy

-As neuro-pathic+-Intra-vent. opioids

-Caudalis DREZ-Tractotomy

-No Surgery

Hartel Technique

Trigeminal Rhizotomy

Meckel’s Cave

Motor Cortex Stimulation

Motor Cortex Stimulation

Trigeminal Tractotomy

Thank You