1. Facial Pain: Diagnosis and treatment
Ahmed M. Raslan, MD
Assistant Professor
Department of Neurological Surgery
OHSU, Portland, OR, USA

2. Disclosure
None

3. Diagnosis of Facial Pain
Clinical !
Imaging

5. Classification of Facial Pain
Trigeminal distribution
Other cranial Nerves
Cluster
Migraine
TMJ

6. Classification of Facial Pain
Trigeminal distribution
Other cranial Nerves
TN1
TN2
Symptomatic
Neuropathic
Postherpetic
Deafferentation
Atypical
Rare syndromes

7. Classification of Facial Pain
Trigeminal distribution
Other cranial Nerves
Glossopharyngeal
Nervus Intermedius
Ramsy-Hunt

8. Other Cranial Neuralgia
Glossopharyngeal
Nervus Intermedius
Ramsy-Hunt
Unilateral
Throat pain
Syncope/ Swallow-syncope
Base of tongue-tonsillar fossa-angle of mandible, ear pain

9. Other Cranial Neuralgia
Glossopharyngeal
Nervus Intermedius
Ramsy-Hunt
Unilateral
Sharp episodic pain deep in the EXTERNAL ear

10. Other Cranial Neuralgia
Glossopharyngeal
Nervus Intermedius
Ramsy-Hunt
Sudden onset
Retroauricular and facial pain
Followed 2 days later by facial palsy
Vesicular eruptions ?

11. Trigeminal Neuralgia IASP 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

12. Classification of facial pain
TN1
TN2
Symptomatic
Neuropathic
Post-Herpetic
De-
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-MS
2-Tumour
3-AVM
4-Aneurysm
Etc…..
Un-intentional injury
1- surgical
ENT, Ophth.
Plastic…. 2- traumatic
Herpes Zoster out-break
Severe neuro-pathy
Intentional neuro-surgical injury for treatment of TN
1-Rhizotomy
2-RF
3-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:
Eller J, Raslan A, Burchiel K. Trigeminal Neuralgia: Definition and classification. Neurosurg Focus 18 (5) 2005: E3

13. 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 ..?

14. 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

15. TN2 Type A Type B Progressed from prior TN1
Started de novo a TN2 ; ? Trigeminal ganaglion dysfunction

16. 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:

17. 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 :

18. 5- Post Herpetic TN
Constitutes a severe form of neuropathy to the trigeminal nerve
Easily diagnosed by history of eruptions

19. 6- Deafferentation facial pain Anesthesia 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

20. 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

24. Pre-operative Imaging TOF MRA

26. TOF MRA + 3D SPGR + gad

27. Steady state sequences CISS, FIESTA, BFFE

28. DTI imaging

29. Virtual Endoscopy

31. 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

32. Treatment of facial pain
TN1
TN2
Symptomatic
Neuropathic
Post-Herpetic
De-
afferentation
Atypical
-MVD
-RF
--Radio-surgery
-Radio-surgery
-Surgery
-MCS
-Trigeminal stimulation
-Caudalis DREZ
-Tractotomy
-As neuro-pathic +
-Intra-vent. opioids
-No Surgery

36. Hartel Technique

37. Trigeminal Rhizotomy

38. Meckel’s Cave

39. Motor Cortex Stimulation

40. Motor Cortex Stimulation

41. Trigeminal Tractotomy

42. Thank You