In: Anesthesia7 Nov 2009
The only other effective nonsurgical management of trigeminal neuralgia (*Medication Tegretol is used for controlling certain types of seizures and relieving pain in patients with nerve pain (*Generic Aleve is used for the treatment of mild to moderate pain, inflammation and fever) in the face, jaw, tongue, or throat) is medical treatment. All new patients are initially treated medically as response to treatment is, in part, diagnostic. If the patient responds to medical treatment, the clinician can be fairly confident that the correct diagnosis has been made. A recent metaanalysis has shown that anticonvulsants are effective for the treatment of trigeminal neuralgia. Thirty-seven randomized control trials were systematically reviewed.
Carbamazepine was found to be the drug of choice in the management of trigeminal neuralgia (Tegretol tablets is used for controlling certain types of epileptic seizures). Dosing according to efficacy and side effects is clinically feasible. After dose titration, the patients should preferably be given slow-release formulations so that diurnal variations in serum drug levels do not influence efficacy. When carbamazepine cannot be used, the alternative evidence-based medical treatments are lamotrigine and baclofen. In the case of a lack of effect of a single drug, a combination of 2 or more drugs may be used. Only the lamotrigine-carbamazepine combination is evidence-based treatment. Phenytoin, clonazepam, valproic acid, and gabapentin could also be used, but they do not constitute evidence-based treatments for trigeminal neuralgia. Considering the evidence-based benefits of gabapentin in other neuropathic pain (Canadian Tylenol is a medicine that is used for mild to moderate pain and fever in adults and children) conditions, such as painful diabetic neuropathy and postherpetic neuralgia, this relatively new drug may represent an advance in treatment. A good understanding of the mechanism of action of these drugs will ensure good pain (Generic Motrin is a pain reliever and fever reducer) control with minimal side effects. Severe hematological and biochemical reactions do occur, but are relatively rare.
Surgical management of trigeminal neuralgia is associated with increased morbidity and mortality. Isolated deaths have occurred in patients undergoing surgery at the level of gasserian ganglion, but there is a 1% mortality rate associated with MVD. It has been argued that a 1% mortality risk is too high a price to pay for the relief of pain from a condition that is, itself, not fatal. Hearing loss is common after MVD and partial rhizotomy. Dysesthesia and anesthesia dolorosa can be extremely unpleasant for many patients. The incidence of dysesthesia is especially troubling for all of the surgical procedures, with an incidence as high as 20-70% after percutaneous procedures. MVD and gamma-knife radiosurgery seems to be the surgical technique that produces the lowest incidence of dysesthesia. All of these factors together with the patient’s age and medical status should be considered to decide the choice of surgical procedure or whether to proceed with surgery at all and instead rely on medical therapy.
Currently, there is no strong evidence to support either a surgical or medical approach as the best therapy for trigeminal neuralgia. Both surgical and medical therapies are effective for trigeminal neuralgia. However, factors such as pain relief, recurrence rates, and morbidity and mortality rates should be taken into account when considering which techniques to use. For surgery, peripheral procedures seem to be associated with the highest and earliest recurrence rates. But they can be extremely useful in elderly patients with a limited life span. All procedures performed at the gasserian ganglion level appear to have similar recurrence rates, although it is generally considered highest for glycerol injections. Recurrences do occur after MVD, although from data to date the time interval appears to be much longer. It seems justified from the current evidence to start a patient with trigeminal neuralgia with medical therapy and proceed early with surgical treatment once *pain control is poor or side effects of medications are intolerable. It is usually a composite of many parameters that must be individualized in each patient before deciding which surgical procedure to use.
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