Trigeminal Neuralgia (Tic Douloureux)

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Questions and Answers

In the context of trigeminal neuralgia, which of the following best describes the pathophysiological mechanism underlying the paroxysmal pain?

  • Progressive demyelination of A-delta fibers within the trigeminal nerve, leading to aberrant signal transduction.
  • Chronic inflammation of the trigeminal nerve root caused by herpes simplex virus (HSV) reactivation, resulting in nociceptive sensitization.
  • Thalamocortical dysrhythmia characterized by abnormal oscillations in the trigeminal sensory pathway promoting amplified pain perception.
  • Ectopic action potential generation in the trigeminal ganglion due to increased expression of voltage-gated sodium channels, coupled with impaired inhibitory interneuron function. (correct)

A patient presents with classic trigeminal neuralgia. Which neuroimaging protocol would provide the most definitive evidence to differentiate between primary and secondary causes of the condition?

  • High-resolution T1-weighted MRI with gadolinium enhancement focused on the cerebellopontine angle. (correct)
  • Magnetic resonance angiography (MRA) to rule out vascular malformations compressing the trigeminal nerve.
  • Diffusion tensor imaging (DTI) to assess microstructural changes in the trigeminal nerve root entry zone.
  • Positron emission tomography (PET) scan with fluorodeoxyglucose (FDG) to evaluate metabolic activity in the trigeminal ganglion.

A patient with trigeminal neuralgia experiences breakthrough pain despite being on a stable dose of carbamazepine. Which augmentation strategy would be the MOST appropriate next step?

  • Initiate a trial of intravenous lidocaine infusions to desensitize peripheral nociceptors.
  • Recommend acupuncture or other complementary therapies to manage the pain symptoms.
  • Prescribe a short course of oral corticosteroids to reduce inflammation around the trigeminal nerve.
  • Add lamotrigine to the existing carbamazepine regimen, titrating slowly to minimize adverse effects. (correct)

Following microvascular decompression (MVD) surgery for trigeminal neuralgia, a patient develops new-onset diplopia and ataxia. What is the MOST likely cause of these post-operative complications?

<p>Cerebellar edema secondary to surgical retraction during the procedure. (B)</p> Signup and view all the answers

Which surgical intervention for trigeminal neuralgia is LEAST likely to provide long-term pain relief while preserving facial sensation?

<p>Retrogasserian glycerol rhizotomy. (B)</p> Signup and view all the answers

A 70-year-old female presents with trigeminal neuralgia refractory to medical management. Her MRI reveals no clear vascular compression, but shows mild age-related brain atrophy. Which surgical approach is MOST suitable?

<p>Stereotactic radiosurgery targeting the trigeminal nerve root entry zone. (C)</p> Signup and view all the answers

Which of the following best explains the rationale behind using Tegretol (carbamazepine) as a first-line treatment for trigeminal neuralgia?

<p>It inhibits voltage-gated sodium channels, reducing the ability of trigeminal nerve fibers to fire rapidly and repetitively. (C)</p> Signup and view all the answers

A patient undergoing percutaneous balloon compression (PBC) for trigeminal neuralgia reports immediate post-operative facial numbness. What is the MOST appropriate initial management strategy?

<p>Reassure the patient that numbness is a common and expected side effect of the procedure. (B)</p> Signup and view all the answers

In the context of trigeminal neuralgia secondary to multiple sclerosis (MS), what is the most likely mechanism contributing to trigeminal nerve dysfunction?

<p>Demyelination within the trigeminal nerve itself, disrupting axonal conduction and causing ectopic firing. (D)</p> Signup and view all the answers

A patient with trigeminal neuralgia reports that even gentle touch to their cheek triggers excruciating pain. This phenomenon is best described as:

<p>Allodynia, indicating pain perception from normally non-painful stimuli. (C)</p> Signup and view all the answers

Which of the diagnostic imaging modalities has the highest sensitivity for detecting subtle vascular compression of the trigeminal nerve?

<p>High-resolution 3 Tesla MRI with specialized sequences (B)</p> Signup and view all the answers

What is the primary mechanism of action of baclofen in the management of trigeminal neuralgia?

<p>GABA-B receptor agonism, leading to decreased neuronal excitability (A)</p> Signup and view all the answers

Post-operative nursing care following microvascular decompression (MVD) for trigeminal neuralgia should prioritize:

<p>Frequent neurological assessments to monitor for cranial nerve deficits (C)</p> Signup and view all the answers

Which of the following is a key consideration when educating a patient newly diagnosed with trigeminal neuralgia?

<p>The chronic nature of the condition and the need for ongoing management (B)</p> Signup and view all the answers

A patient with trigeminal neuralgia is considering Gamma Knife radiosurgery. What aspect of this treatment should be emphasized during pre-operative counseling?

<p>The potential for delayed pain relief and the risk of facial numbness (A)</p> Signup and view all the answers

What is the most common cause of trigeminal neuralgia?

<p>Compression of the trigeminal nerve root by a blood vessel. (C)</p> Signup and view all the answers

Which of the following best describes the typical pain associated with trigeminal neuralgia?

<p>Sudden, brief, and severe episodes of stabbing or electric shock-like pain. (A)</p> Signup and view all the answers

Which of the following activities is MOST likely to trigger pain in a patient with trigeminal neuralgia?

<p>Chewing food. (B)</p> Signup and view all the answers

What is the primary goal of surgical interventions for trigeminal neuralgia?

<p>To decompress the trigeminal nerve and relieve pressure. (B)</p> Signup and view all the answers

Which of the following is a common side effect of carbamazepine used in the treatment of trigeminal neuralgia?

<p>Drowsiness. (B)</p> Signup and view all the answers

A patient with trigeminal neuralgia reports that their pain is primarily located in the forehead and around the eye. Which branch of the trigeminal nerve is MOST likely affected?

<p>The ophthalmic branch (V1). (C)</p> Signup and view all the answers

During the acute phase of trigeminal neuralgia, which nursing intervention is MOST appropriate to minimize patient discomfort?

<p>Providing a soft diet and instructing the patient to chew on the unaffected side. (C)</p> Signup and view all the answers

A patient with trigeminal neuralgia is being considered for a percutaneous rhizotomy. Which of the following is the MOST significant risk associated with this procedure that the patient should be informed about?

<p>Corneal anesthesia and potential vision loss. (B)</p> Signup and view all the answers

Compared to younger individuals, what is a distinguishing feature of trigeminal neuralgia presentation in elderly patients?

<p>Higher prevalence of secondary causes, such as tumors. (D)</p> Signup and view all the answers

What is the primary rationale for avoiding hot or cold foods and fluids in patients with trigeminal neuralgia?

<p>To minimize stimulation of temperature-sensitive trigeminal nerve fibers. (A)</p> Signup and view all the answers

A patient with trigeminal neuralgia who is taking carbamazepine develops a skin rash, fever, and sore throat. Which of the following is the MOST appropriate initial action?

<p>Instruct the patient to stop taking carbamazepine immediately and seek medical attention. (A)</p> Signup and view all the answers

A patient reports that wind exposure exacerbates their trigeminal neuralgia pain. Which of the following mechanisms best explains this phenomenon?

<p>Activation of cutaneous mechanoreceptors by air movement, triggering trigeminal nerve firing. (A)</p> Signup and view all the answers

Which of the following statements accurately describes the role of MRI in the diagnosis of trigeminal neuralgia?

<p>MRI can help identify structural lesions that may be causing trigeminal neuralgia. (A)</p> Signup and view all the answers

A key characteristic of trigeminal neuralgia pain is that it is typically:

<p>Unilateral and intractable (A)</p> Signup and view all the answers

Which of the following is a potential long-term complication of repeated alcohol blocks for trigeminal neuralgia?

<p>Development of anesthesia dolorosa (A)</p> Signup and view all the answers

In a patient with trigeminal neuralgia, what is the significance of identifying a venous compression of the trigeminal nerve on MRI?

<p>Venous compression is less likely to be the primary cause of the neuralgia compared to arterial compression (C)</p> Signup and view all the answers

Which of the followiing lifestyle modifications is least likely to benefit someone suffering from trigeminal neuralgia?

<p>Vigorous exercise. (A)</p> Signup and view all the answers

Which of the following is the main disadvantage of percutaneous balloon compression as a surgical treatment for trigeminal neuralgia?

<p>High recurrence rate. (B)</p> Signup and view all the answers

Which of the following is an important point that nurses must make to patients after they undergo surgery for trigeminal neuralgia?

<p>Use artificial tears. (C)</p> Signup and view all the answers

Which of the following best decribes the cause of trigeminal neuralgia?

<p>Occurs most often after 35 years of age. (B)</p> Signup and view all the answers

Which of the following drugs is NOT typically used to treat Trigeminal Neuralgia?

<p>Haloperidol (B)</p> Signup and view all the answers

What is the effect on pain if a patient walks swiftly by a person who is suffering from trigeminal neuralgia?

<p>Air draft can trigger pain. (A)</p> Signup and view all the answers

Which of the following would NOT be used to diagnose Trigeminal Neuralgia?

<p>Biopsy of the brain. (C)</p> Signup and view all the answers

Flashcards

Trigeminal Neuralgia (other names)

Also known as Tic Douloreux, Prosopalgia, Suicide Disease, or Fothergill's Disease.

Trigeminal Neuralgia (definition)

A condition of the 5th cranial nerve marked by paroxysms of pain in the face.

Cause of Trigeminal Neuralgia

Vascular compression and pressure on nerve root entry point.

Occurrence of Trigeminal Neuralgia

It occurs more often in women, rarely before 35 years of age, and is common in people with MS.

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Clinical Manifestations of TN

Episodes of stabbing or shock-like facial pain on one side of the jaw or cheek; can triggered by vibration or contact.

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Diagnostics for Trigeminal Neuralgia

X-rays of the skull, teeth, and sinuses; MRI.

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First-line Pharmacologic Therapy for TN

Carbamazepine

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Tegretol

A brand of carbamazepine that relieves pain by reducing transmission of impulses; take with meals, and monitor serum levels.

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Other Medical Management for Trigeminal Neuralgia

Muscle relaxants like Gabapentin, Baclofen, Sedatives and Antidepressants.

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Microvascular Decompression

Surgical procedure where artery loop is lifted from the trigeminal nerve using silicon foam.

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Radiofrequency Thermal Coagulation

A surgical management that produces thermal lesion via heat on the trigeminal nerve.

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Percutaneous Balloon Microcompression

Surgical process that disrupts large myelinated fibers in all three branches of the trigeminal nerve.

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Retrogasserian Rhizotomy

A procedure where the sensory root of CNV is surgically severed.

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Alcohol/Phenol Block

Involves injecting alcohol into a CNV branch for transient pain relief.

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Nursing management for TN

Instruct the client to avoid hot or cold foods/fluids, avoid jarring the bed, and to chew on the unaffected side.

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Postoperative Care for TN

Avoid eye rubbing, assess for irritation, use artificial tears, avoid chewing on affected side, and supervise for any difficulty swallowing.

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Study Notes

  • Trigeminal Neuralgia is also knows as Tic Douloreux, Prosopalgia, the Suicide Disease, and/or Fothergill's Disease.
  • This condition affects the 5th cranial nerve and is characterized by paroxysms of pain in the face.
  • John Fothergill lived from 1712-1780.

Cause

  • Vascular compression and pressure due to brain changes with age; a loop of a cerebral artery or vein may compress the nerve root entry point.

Occurrence

  • This occurs most often before 35 years of age.
  • It is more common in women.
  • It is more common in people with MS compared with the general population.

Clinical Manifestations

  • Episodes of sudden, intense, stabbing or shock-like facial pain.
  • The pain is typically felt on one side of the jaw or cheek
  • Intense flashes of pain can be triggered by vibration or contact with the cheek when shaving, washing the face, applying makeup, brushing teeth, eating, drinking, talking, or being exposed to the wind
  • Other signs include a cheek twitch, a tearing eye, or salivation on the same side of the face.
  • The pain is intractable.
  • Pain is unilateral.
  • Air draft can trigger pain.

Diagnostics

  • Skull, teeth, and sinus X-Rays detect any possible abnormality.
  • An MRI can be used to identify any abnormalities.

Medical Management: Pharmacologic Therapy: Antiseizure agents

  • Carbamazepine is most commonly used and is the first line treatment; serum levels should be between 5-12 mcg/mL.
  • Phenytoin is used as a second line treatment (10 to 20 μ/mL)
  • Tegretol is a brand of carbamazepine that relieves pain by reducing the transmission of impulses at certain nerve terminals.
    • It should be taken with meals.
    • Serum levels should be monitored.
    • Monitor for bone marrow depression during long-term therapy.
  • Side effects can include nausea, dizziness, drowsiness and aplastic anemia
  • Muscle relaxants i.e. Gabapentin (Neurontin), Baclofen (Lioresal) used for pain control
  • Other medicines include sedatives and antidepressants.

Surgical Management

  • Microvascular Decompression of the Trigeminal Nerve is necessary if medical interventions fail to work. The artery loop is lifted from the nerve using silicon foam.
  • Radiofrequency Thermal Coagulation is a procedure that produces a thermal lesion on the trigeminal nerve.
  • Percutaneous Balloon Microcompression disrupts large myelinated fibers in all three branches of the trigeminal nerve.
  • A retrogasserian rhizotomy can sever the sensory root of CNV.
  • Radiosurgery with Stereotactic Technique can also severe the CNV using a gamma knife.
  • An alcohol/phenol block injection of alcohol into a CNV branch can lead to pain relief (transient: 1 yr).

Nursing Management

  • Clients should avoid hot or cold food and fluids to prevent pain.
  • Provide room temperature water for rinsing.
  • Avoid jarring of the patient's bed or chair.
  • Instruct the patient to rinse with mouthwash after eating if tooth brushing causes pain.
  • Perform personal hygiene during free-pain intervals.
  • Patients should chew on the unaffected side and ingest soft food.

Providing Postoperative Care

  • Instruct the client not to rub the eye.
  • Assess the eye for irritation or redness.
  • Artificial tears may be prescribed in the affected eye.
  • The patient is cautioned not to chew on the affected side.
  • Observe patient for any difficulty in eating or swallowing foods of different consistencies.

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