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

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)