Trigeminal neuralgia from Latin American experience of Neurologia Segura 2014 (A2014)
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A brief communication over the present on trigeminal neuralgia along one decade experience from the point of view of a high level neurosurgical team from Mexico, directed by Mauro Segura, MD, PhD, neurosurgeon and head manager of neurología segura from Mexico City. Neurología Segura Medical Center www.neurologiasegura.net
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Trigeminal neuralgia from Latin American experience of Neurologia Segura 2014 (A2014)
- 1. Trigeminal Neuralgia Clinical Observation from Latin American Experience Mauro Segura,. M.D., Ph.D. Neurosurgery MEXICO info@neurologiasegura.net
- 3. Functional Anatomy and CE • Clinical examination • Eyes movements • Dermatoma afected • Facial expresion • Audición & equilibrio • Nasopharinge • Cervical and occipital nerve territory • Skin and EAC • Depresion scores • Hamilton´s • GSA – general sensation from head and facial structures • Main sensory nucleus • Descending tract of V to spinal trigeminal nucleus • Functional equivalent of substantia gelatinosa of spinal cord • GSE – muscles of mastication • SVE – branchial arch muscles • Tensor veli palatini • Tensor tympani
- 4. The enemy to beat is at home... and it is not the pain
- 5. Transnational Experience Geography & Demography Arriving by Country usa peru ecua guat colomb venez chile Mexico 63% el salv arg costa nica españa mexico
- 6. TN Natural Course Time living with TN • Pharmacological phase <6y • Non pharmacological response >6y 17% 24% YEARS <3 8% 3 to 6 7 to 10 11 to 14 22% • Recurrence • Sequelae >15 29%
- 7. Analysis male 34% Jul 2010-Jun 2013 Fem 66% Our population distribution by age groups n=257 40 30 35 25 30 20 15 25 10 20 5 15 0 2nd 3rd 4th 5th 6th Decade 10 5 0 20-30 31-40 41-50 51-60 61-70 71-80 81-90 7th 8th 9th
- 8. Utility of Imaging TN1 and TN2 one can identify • Presence and degree of NVC • Mostly MRI does predict the • Nature and number of the NVC symptomatic surgical side • Mostly MRI does demonstrate a higher degree of NVC on the symptomatic • In general, MRI can differentiate arterial and venous compression • Location of NVC along the nerve • Findings can be confirmed during MVD • Small tumor finding
- 9. Non truely functional diagnostic support Case 1
- 10. Trigeminal Vascular Compression (TVS) and MS
- 11. Non truely functional diagnostic support Case 2
- 12. Truely functional diagnostic support
- 14. Our Surgical Procedures n=116 Microvascular decompression (39%) Percutaneous ablative procedures – Radiofrequency gangliolysis (10%) – Glycerol rhizolysis (3%) – Ganglion balloon compression 3% 10% Medical Treatment 2% n=141 Stereotactic radiosurgery (2%) – GK/CK – LINAC-based 45% 39% Peripheral ablative procedures (V1 & V2 pain) – Peripheral branch neurectomy – Alcohol neurolysis Open destructive procedures – Partial sensory rhizotomy – Subtemporal ganglionectomy (Frazier-Spiller procedure) – Trigeminal bulbar nucleus thermoablation (1%) 1%
- 15. Complications of MVD Author Year n= CSF V VII VIII Death Hem Breeze 1982 52 2% 17% 15% 11% Van Loveren 1982 23 Apfelbaum 1983 406 Kolluri 1984 72 Piatt 1984 103 2% Zorman 1984 125 4% Bederson 1989 166 4% Klun 1992 220 0 Sun 1994 61 Barker 1996 1204 Kondo 1997 281 Revuelta 2006 668 nd nd nd nd nd 0,2% Segura * 2013 116 2% 3% 1% 2% 0 1,7% 13% 0 9% 1% 3% 1% 19% 0 1% 8% 1% 2% 3% 0 5% 5% 0 11% 1% 3% 0.5% 0.5% 4.5% 7% 0.2% 3% 6% 0 1% 0.5% 1% 0.2% 7%
- 16. New Surgical Techniques Chronic Stimulation of the Gasserian Ganglion in patients with Trigeminal Neuropathy: A Case Series Jean-Pierre Van Buyten & Caroline Hens Abstract: Between 2009 and 2011 we implanted 8 patients with refractory Trigeminal Neuropathic Pain (TNP) with a custom, tined, percutaneous, tripolar electrode to stimulate the Gasserian Ganglion (TGS). The electrode was positioned with the help of a three dimensional (3D), real-time, tip-tracked, electromagnetic (EM) guidance system. This technique reduced operating time, and augmented electrode targeting and procedural safety. Six of the eight patients had pain relief of at least 30%, all significantly tapered medication-intake (4 stopped opiods completely), two had minor dislocations, and none suffered any major complication. This EM stimulation technique is a valuable, reversible, minimally invasive method to treat refractory TNP.
- 17. Findings can or can not be confirmed during MVD
- 18. Opinions from Latin American Experience • From the last decade experience, by working face to face with TN complicated cases, we resume our current data interpretation from clinical course, imaging and therapeutic options from Latin American population that is not the same than previously publicated. • From a personal point of view, the TN, always must be analyzed as a syndromatic entity but not only as typical neurological state. • The successful treatment of any patient with facial pain in general and TN in particular depends on right diagnosis at the outset. • In our clinical practice, we concentrate a high number of difficult and complex cases but by employing a multimodal therapeutic approach; we are able to reach up to 97% successful treatment free of facial pain for the time of following
- 19. Opinions from Latin American Experience • Our higher and younger incidence rates could be related to Asian or ancestry (Mayan) genetic factors • The age is not a contraindication to achieve a successful MVD, but the comorbidity must be considerated • To be a MS case does not excluded to be a TVC • Of course, there is not a single one better surgical technique but a multimodal surgical and medical approaches • If you offer an earlier personalized surgical procedure, the earliest your patient will live free of facial pain and better QOL • Thank you
- 20. Mauro Segura MD, PhD. Neurosurgery • info@neurologiasegura.net • www.neurologiasegura.net • www.facebook.com/neurologia.segura • http://www.youtube.com/user/neurologiasegura • Mauro Segura (neurologiasegura)