Ineffective medication treatment during 6 monghs – surgery:
microvascular decompression (Fig. 3) - reroute the blood vessel from compressing the trigeminal nerve by padding the vessel with a sponge (without the nerve conduction injury, but invasive technique with craniotomy),
Fig. 3. Microvascular decompression (Jannetta procedure).
percutaneous stereotactic radiofrequency rhizotomy - nerve electrocautery by needle throuwithgh the cheek - the suppression of impulses along the nerve,
percutaneous glycerol rhizotomy – glycerol injection by needle through the cheek- the suppression of impulses along the nerve,
percutaneous balloon compression - a temporary holding balloon (via catheter) to the nerve, this ballon compresses the nerve fibers that are responsible for pain- the suppression of impulses along the nerve,
stereotactic radiosurgery (gamma knife, cyber knife) - nerve destroying by ionizing radiation. These methods are noninvasive and do not cause facial sensory disturbances, as in other operations.
5. Herpetic ganglioneuropathy and postherpetic trigeminal neuralgia.
Shingles (also termed herpes zoster) is a disease caused by reactivation of a previous infection with the herpes zoster virus (also named varicella-zoster virus, VZV, HHV-3 or chickenpox virus). VZV may remain in sleeping state in the body after an individual had chickenpox, usually in the roots of nerves that control sensation (very often – in trigeminal Gasser's ganglion). The virus "wakes up" or reactivates in people who have a decreased ability to fight off infection due to stress or immune deficiency.
Clinic of herpetic ganglioneuropathy. Stages of the disease:
acute onset, headache, fever - 2-3 days
intense pain (like itching, tingling, burning, shooting) in the area of innervation of the trigeminal nerve branches (often - first) - 2-3 days
a rash with blisters (fluid-filled sacs) on top of reddish skin in the same distribution as the pain (there is the threat of herpetic eruptions on the cornea) - 1-2 weeks (Fig. 4),
the rash disappears as the scabs fall off in the next two to three weeks, and scarring may result
neurological examination: hyperesthesia or hypoesthesia relevant parts of the face, hyperpathia, pain at the exit point of the affected I and II branches of the trigeminal nerve.
Fig. 4. Herpetic eruptions.
Herpetic ganglioneuropathy lasts about 3-6 weeks and in most cases ends by recovery. Some patients develop postherpetic neuralgia in which the localized pain of shingles remains even after the rash is gone. Postherpetic neuralgia develops in 16-25 % of cases, often in people over 50 years of age, and can last for a long period of time (years).
Post-herpetic neuralgia is similar to the classic neuralgia but has some differences:
pain occurs spontaneously, lasts for hours, occasionally enhanced, especially at night;
no trigger zones and factors;
pain is localized mainly in the area of innervation of the I branch of the trigeminal nerve.
Besides injury of the trigeminal nerve herpetic lesion of spinal sensitive ganglions can be observed, signs and treatment does not differ from that described above, vesicular rash on the extremities have the form of longitudinal stripes, on the body - a broad band on one side of the body (Fig. 5).
