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Surgical treatment of trigeminal neuralgia - Home Study Program

AORN Journal, Nov, 2003 by Cassi Brown

The article "Surgical treatment of trigeminal neuralgia" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Nov 30, 2006.

Complete the examination answer sheet and learner evaluation found on pages 761-762 and mail with appropriate fee to

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BEHAVIORAL OBJECTIVES

After reading and studying the article on surgical treatment of trigeminal neuralgia, perioperative nurses will be able to

1. describe how the symptoms of trigeminal neuralgia adversely affect the lives of patients with the condition,

2. identify the pathophysiology of trigeminal neuralgia,

3. explain treatment options available to patients with trigeminal neuralgia,

4. describe perioperative care provided for patients undergoing trigeminal nerve microvascular decompression (MVD), and

5. discuss potential postoperative complications patients recovering from trigeminal nerve MVD may experience.

Trigeminal neuralgia is unilateral electric shock or knifelike pain occurring in one or more branches of the trigeminal nerve, usually the first (ie, mandibular) or second (ie, maxillary) branch. Paroxysms may last seconds or several minutes, and they may be so severe that the patient winces, which is why this condition also is called tic douloureux. Classically, the pain is evoked by stimulation of the face, lips, or gums caused by activities such as shaving, brushing the teeth, or moving trigger zones (ie, chewing, talking, yawning); however, pain may occur spontaneously. The pain is abrupt in onset and termination, with periods of remission and relapse. Paroxysms occur frequently both day and night for several weeks at a time. Patients with this condition have an aversion to being touched, and their speech is guarded. Some patients complain of almost continuous discomfort, itching, and facial sensitivity. This response is regarded as atypical, although it is not infrequent Patients usually have no sensory or motor impairment. (1-4)

HISTORICAL OVERVIEW

In the second century AD, Aretaeus of Cappadocia identified what may have been a condition similar to trigeminal neuralgia, describing it as a facial spasm that distorts a person's countenance. An 11th century Arabic physician, Jujani, wrote about patients experiencing unilateral facial pain that caused spasms and anxiety. He suggested that the pain was caused by the proximity of the artery to the nerve. (1) In 1756, a French physician, Nicholas Andre, named this condition tic douloureux, which means painful wince. Before this time, trigeminal neuralgia was described as pain that gave patients the facial appearance of a dog about to bark. (2)

The relation of vascular compression to trigeminal neuralgia is believed to have been introduced in modern neurosurgery in 1925 by Walter Dandy, MD. In 1959, W. James Gardner, MD, was the first to perform microvascular decompression (MVD) of the fifth cranial nerve. A major shift in neurosurgical practice began to appear in the 1970s after a large case study of MVDs was published. (1)

ETIOLOGY

It generally is accepted that classic trigeminal neuralgia is a consequence of vascular compression and demyelination of the trigeminal nerve as it exits the pons. (2) A blood vessel pressing against time nerve eventually wears off the nerve's insulation, leaving a bare wire that is hypersensitive to sensory stimuli. (2,5)

DIAGNOSIS

Diagnosis of trigeminal neuralgia is made clinically because neither radiological nor physiological studies can confirm or refute vascular compression. A thorough neurological examination with careful evaluation of the fifth cranial nerve, therefore, is of primary importance for diagnosis. A magnetic resonance imaging (MRI) scan should be ordered to exclude mass lesions, vascular abnormalities, or multiple sclerosis in patients with neurological deficits or bilateral or atypical trigeminal neuralgia. (1)

Fewer than 1% of all patients with trigeminal neuralgia have an associated intracranial mass. (2) Bilateral symptoms are more common in patients with multiple sclerosis. (2) Some radiology facilities report that an MRI, performed with 1-mm axial, oblique, and sagittal views through the trigeminal nerve at pontine level, can identify vascular compression from looping of the nearby superior cerebellar artery. Results vary from institution to institution; however, compression can occur from other adjacent smaller arteries, as well as veins. (6) This is a common disorder of middle age and later life and is more common in women than men. (2,4)

ANATOMY

The fifth trigeminal nerve root consists of a larger sensory root and a smaller medially-situated motor root. It arises from the lateral aspect of the pons and courses in a laterally anterior and slightly superior direction through the anterior part of the cerebellopontine angle in the pontocerebellar cistern (Figure 1). The superior cerebellar artery usually passes above the root, and the anterior inferior cerebellar artery passes below. This relationship is not constant because of frequent anatomic variations and loops of vessels. The petrosal vein is lateral and posterior to the trigeminal root. The trigeminal (ie, crescent-shaped) or Gasserian ganglion occupies a shallow bony recess on the anterior aspect of the petrous apex, also known as Meckel's cave. (7)

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Surgical treatment of trigeminal neuralgia - Home Study Program

AORN Journal, Nov, 2003 by Cassi Brown

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