NATURAL HISTORY: AN INTRODUCTION TO ANIMATED NATURE
CONTENTS 1 INTRODUCTION DEFINITION OF TRIGEMINAL NEURALGIA AND EVOLUTION OF CONCEPTS ? ? 1 1 1 DEFINITION OF TRIGEMINAL NEURALGIA ? ? 2 1 2 EVOLUTION OF CONCEPTS ? ? 2 2 TERMINOLOGY AND CLASSIFICATION OF TRIGEMINAL NEURALGIAS ? ? 5 2 1 CRITERIA FOR DIAGNOSIS OF TRIGEMINAL NEURALGIA ? ? 6 2 2 CLASSIFICATION ON PRESUMED ETIOLOGY ? ? 7 2 2 1 SECONDARY TRIGEMINAL NEURALGIA ? ? 7 2 2 2 CLASSICAL TRIGEMINAL NEURALGIA ? ? 7 2 2 3 IDIOPATHIC TRIGEMINAL NEURALGIA ? ? 7 3 ANATOMY OF THE TRIGEMINAL NERVE TGN ? ? 9 3 1 DESCRIPTIVE ANATOMY OF THE TGN ? ? 9 3 1 1 THE TRIGEMINAL NERVE IN THE TRIGEMINAL CAVE ? ? 9 3 1 2 THE TRIGEMINAL ROOT IN THE CEREBELLOPONTINE ANGLE ? 11 3 1 3 THE TRIGEMINAL ROOT ENTRY ZONE ? 14 3 2 FUNCTIONAL ANATOMY OF THE TGN ? 16 4 ANATOMY OF THE NEIGHBOURING VESSELS AND STRUCTURES SURROUNDING THE TRIGEMINAL NERVE ? 21 4 1 ARTERIES ? 21 4 2 VEINS ? 24 4 3 SURROUNDING STRUCTURES ? 28 4 3 1 ROLE OF THE SIZE OF THE CEREBELLO PONTINE ANGLE CISTERN ? 29 4 3 2 ROLE OF THE UPPER PETROUS RIDGE ? 29 4 3 3 INFLUENCE OF FOCAL ARACHNOIDITIS ? 31 4 3 4 PRESENCE OF GLOBAL RADICULAR ATROPHY ? 32 5 TRIGEMINAL NEURALGIAS CLINICAL PRESENTATIONS NEUROLOGICAL ASSESSMENT AND SPECIALTY INVESTIGATIONS ? 35 5 1 PROBLEMS OF CHARACTERIZATION ? 35 5 1 1 TRIGEMINAL NEURALGIA MAY RESULT FROM VARIOUS PATHOLOGIES ? 35 5 1 2 THE CLINICAL PRESENTATIONS OF TRIGEMINAL NEURALGIA ? 35 5 1 3 THE ATYPICAL TRIGEMINAL NEURALGIA 36 5 1 4 DISTINCTION BETWEEN CLASSICAL TRIGEMINAL NEURALGIA AND PAINFUL TRIGEMINAL NEUROPATHIES ? 36 5 2 MECHANISMS ? 37 5 2 1 HYPOTHESES ? 37 5 2 2 STRUCTURAL ABNORMALITIES ? 37 5 2 3 ELECTROPHYSIOLOGICAL ABNORMALITIES ? 38 5 2 4 ANOMALIES IN SECONDARY TRIGEMINAL NEURALGIAS ? 38 5 2 5 THE QUESTION OF GENETIC INVOLVEMENT ? 38 5 3 EPIDEMIOLOGY ? 39 5 4 CLINICAL PRESENTATION IN ITS TYPICAL FORM ? 39 5 4 1 PAIN QUALITY ? 39 5 4 2 PAIN TOPOGRAPHY ? 40 5 4 3 CONDITIONS OF TRIGGERING PAINS ? 40 5 4 4 NEGATIVITY OF THE NEUROLOGICAL EXAMINATION ? 40 5 4 5 EVOLUTION ? 40 5 4 6 TRIGEMINAL PRE NEURALGIA ? 41 5 5 OTHER CLINICAL PRESENTATIONS ? 41 5 5 1 ATYPICAL TRIGEMINAL NEURALGIA TRIGEMINAL NEURALGIA WITH CONCOMITANT CONTINUOUS PAIN ? 41 5 5 2 TRIGEMINAL NEURALGIA WITH AUTONOMIC INVOLVEMENT ? 41 5 5 3 TRIGEMINAL NEURALGIA AFTER LONG EVOLUTION ? 42 5 5 4 TRIGEMINAL NEURALGIA AFTER TRIGEMINAL SURGERY ? 42 5 6 CLINICAL ASSESSMENT ? 42 5 6 1 NEUROLOGICAL ASSESSMENT ? 42 5 6 2 OTHER SPECIALTY INVESTIGATIONS ? 43 5 6 3 THE WAY TO ASSESS PAIN INTENSITY IN THERAPEUTIC RESULTS ? 43 6 TRIGEMINAL NEURALGIAS NEURO IMAGING ASSESSMENT ? 45 6 1 STANDARD IMAGING SHOULD RULE OUT SECONDARY NEURALGIAS ? 45 6 2 DETECTION OF THE NEUROVASCULAR CONFLICTS ? 45 6 3 DIFFUSION TENSOR IMAGING DTI MRI ? 47 7 DIFFERENTIAL DIAGNOSES OF TRIGEMINAL NEURALGIAS ? 51 7 1 THE SECONDARY TRIGEMINAL NEURALGIAS ? 51 7 2 THE PAINFUL TRIGEMINAL NEUROPATHIES ? 53 7 3 THE TRIGEMINAL AUTONOMIC CEPHALALGIAS TACS ? 53 7 3 1 CLUSTER HEADACHE ? 53 7 3 2 OTHER TYPES OF TACS ? 54 7 4 NEURALGIAS OUTSIDE THE TRIGEMINAL TERRITORY ? 54 7 4 1 VAGO GLOSSOPHARYNGEAL NEURALGIA ? 54 7 4 2 NEURALGIA OF THE INTERMEDIUS NERVE ? 55 7 4 3 NEURALGIA OF THE SUPERIOR LARYNGEAL NERVE ? 56 7 4 4 OCCIPITAL NEURALGIA ? 56 7 4 5 THE NECK TONGUE SYNDROME ? 56 7 5 ATYPICAL FACIAL PAIN PERSISTENT IDIOPATHIC FACIAL PAIN ? 56 8 PHARMACOLOGICAL TREATMENT OF TRIGEMINAL NEURALGIAS ? 57 8 1 CARBAMAZEPINE TEGRETOL ? 58 8 2 OXCARBAZEPINE TRILEPTAL ? 59 8 3 OTHER ANTIEPILEPTICS ? 60 8 4 NON ANTIEPILEPTIC DRUGS ? 60 9 MICRO VASCULAR DECOMPRESSION MVD AND OTHER OPEN MICROSURGICAL PROCEDURES FOR TRIGEMINAL NEURALGIAS ? 63 9 1 BRIEF ON THE EVOLUTION OF THE SURGICAL TREATMENTS ? 63 9 2 ANATOMICAL PATHOLOGICAL FINDINGS IN PATIENTS WITH NEURO VASCULAR CONFLICTS ? 64 9 2 1 INCIDENCE OF THE NEURO VASCULAR CONFLICTS ? 64 9 2 2 SITUATION OF THE NVC ALONG THE TRIGEMINAL ROOT ? 66 9 2 3 LOCATION OF THE NVCS AROUND THE TRIGEMINAL ROOT ? 66 9 2 4 DEGREES OF COMPRESSION OF THE NVCS ? 67 9 2 5 OTHER ANOMALIES OF OR IN THE POSTERIOR FOSSA ? 67 9 3 MECHANISMS OF PAIN IN THE ROOTS COMPRESSED BY THE NVC ? 73 9 4 MAIN TECHNICAL RISKS OF THE MVD PROCEDURE FOR TRIGEMINAL NEURALGIA ? 73 9 4 1 RISK OF HEARING LOSS ON THE APPROACH HOW TO AVOID ? 73 9 4 2 RISKS FROM VENOUS SACRIFICES HOW TO AVOID VENOUS INFARCTION ? 74 9 4 3 RISKS LINKED TO THE DECOMPRESSION HOW TO AVOID NEO COMPRESSION ? 76 9 5 SURGICAL STEPS ? 77 9 6 SURGICAL TECHNIQUE OF MVD ACCORDING TO VESSELS ? 82 9 6 1 THE SUPERIOR CEREBELLAR ARTERY SCA ? 82 9 6 2 THE ANTERIOR INFERIOR CEREBELLAR ARTERY AICA ? 82 9 6 3 THE VERTEBROBASILAR ARTERY VBA ? 83 9 6 4 MATERIAL FOR DECOMPRESSION ? 84 9 6 5 VENOUS NEURO VASCULAR CONFLICTS NVCS ? 86 9 7 OUTCOME AFTER MVD ? 89 9 7 1 PAIN RELIEF ? 89 9 7 2 THE PUZZLING CASE OF THE VENOUS COMPRESSIONS ? 92 9 7 3 COMPLICATIONS ? 93 9 7 4 CONCLUSIONS AND PERSPECTIVES ? 94 9 8 THE OTHER OPEN MICROSURGICAL PROCEDURES ? 99 9 8 1 THE SUB TEMPORAL TRIGEMINAL RETROGASSERIAN NEUROTOMY ? 99 9 8 2 THE JUXTA PONTINE TRIGEMINAL RHIZOTOMY 100 9 8 3 INTERNAL NEUROLYSIS 101 10 PERCUTANEOUS LESIONING TECHNIQUES FOR TRIGEMINAL NEURALGIAS 103 10 1 BRIEF ON THE EVOLUTION OF THE SURGICAL TREATMENTS 103 10 2 THE PERCUTANEOUS HARTEL ROUTE 105 10 3 RADIOFREQUENCY THERMORHIZOTOMY 109 10 3 1 PROCEDURE 109 10 3 2 OUTCOME 112 10 4 BALLOON COMPRESSION 118 10 4 1 PROCEDURE 118 10 4 2 OUTCOME 118 10 5 GLYCEROL INJECTION 121 10 5 1 PROCEDURE 121 10 5 2 OUTCOME 121 11 STEREOTACTIC RADIOSURGERY FOR TRIGEMINAL NEURALGIAS 125 11 1 BRIEF ON THE EVOLUTION OF THE SURGICAL TREATMENTS 125 11 2 PROCEDURE 128 11 3 OUTCOME 131 11 3 1 MAIN PUBLISHED SERIES 131 11 3 2 COMPARISONS BETWEEN GK LINAC CK 133 11 3 3 RESULTS AFTER SECOND AND THIRD SURGERIES 134 11 3 4 COMPARISONS WITH OTHER TECHNIQUES 134 11 4 CONCLUSIONS 135 12 DECISION MAKING AND CONCLUSIONS 137 EPILOGUE 145 REFERENCES 147 1