[Music] trigeminal neurology incidence is about four to twenty in a hundred thousand two type the type one is the best type most of the time type one is associated also with the vascular compression and uh it's really when the patient has a significant amount of pain that means that the patient has at times no pain whatsoever and in the interval of a few seconds to minutes to hours has an excruciating pain that goes so high that is unbearable and then goes back to normal completely normal like nothing happened and then for some time that that time frame could be minutes could be hours could be seconds another excruciating pain coming going 10 10 out of 10 12 out of 10 sometimes some of my patients say 20 out of 10 it's unmeasurable and it's really atrocious and that goes back to normal so this is a type one type one that means that there is period of absolute no pain in between type two the pain is never as excruciating as the type one is however there is a constant pain and there is a component of burning to it now if you can see in the parenthesis i have put 28 percent without neurovascular compression and on the second one i put 18 without neurovascular compression although trigeminal neurology is usually caused by and believed to be caused by vascular compression there are cases and these number numbers are in my opinion a little bit exaggerated i got these numbers from some of my colleagues um publications uh in my personal experience over hundreds of surgery for tragedy i have not had 28 without neurovascular compression i would question the indication for surgery for those patients because i think if the indication and the diagnosis is correct there are very very few situations where you do not find neurovascular compression because basically that's the cause that we are describing so if you've done in 30 you don't find it then you could question this cause what type of etiology is that is not present in 30 30 percent of cases so beside the type 1 and type 2 we have trigonal neurologists that are associated with multiple sclerosis 10 percent of patients with ms after hygiene neuralgia and four percent of patients with trigeminal neuralgia could have ms that's something that has to be considered now that does not necessarily mean that if someone has m s and trigeminal neuralgia then automatically that person does not have a vascular compression you can have a combination of both but you also have to know that multiple sclerosis cause plaque in the brain stem and those plaque can be at the level of the trigeminal nerve and cause trigeminal neurology and treatment for that is different than the treatment that we propose for essential trigeminal neurology we have to be aware also of the atypical facial pain which is the afferentation facial pain this is a pain that is not characteristic of trigeminal neurology trigeminal neuralgia is usually a sharp pain obviously if it's a type one or type two it's a little bit different but what you need to know is that usually it's a sharp pain it's in the branches of the trigeminal nerve v1 v2 or v3 vast majority of the time is unilateral it's exacerbated by a sort of like a zone that if you for instance touch the face that can elicit the pain the cold weather ice chewing sometimes talking eating can uh exacerbate the pain or actually starts the pain and that's why some patients do not eat they can't eat because as soon as they start chewing the pain starts and they become miserable i have pretty operated on some patients mainly because they were becoming cashecta because they couldn't eat anymore and they were within 10 days they were basically they lost 20 kilograms or something like that so uh and a typical facial pain is not like that a typical facial pain usually is a burning pain is it annoying pain is not really a dermatoma dermatozole distribution is not necessarily defined by the branches of the trigeminal nerve can go behind the ear can go on the scalp can pass the midline the frequency is vague it does not respond to neuroleptics necessarily while the trigeminal neuralgia usually respond to neuroleptic that means response to tegritol respond to neurontin etc so that is uh for you to be able to distinguish what is a trigeminal neurology compared to atp facial pain and i i'm you know i have lots of cool surgical videos stuff like that and i will show you that but i think it's important as a medical student that you understand this first before looking at the cool stuff because this is the important part this is the parts that will lead to those beautiful surgeries and videos if you may sort of miss this part and not able to select the right patient for surgery you will not have an identifier cause for trigeminal neuralgia and you will not be able to succeed and the last thing a neurosurgeon or myself as a vascular skull-based surgeon the last thing i want to do is to operate on someone who is suffering dramatically from a trigeminal neuralgia and then i end up after surgery and then come and say hey listen we need the surgery but i don't think it's gonna help you so this is really the last thing i want to have so that's why i'm very selective in finding the right patient for it and that's why i'm going very s um in detail regarding the presentation indication for treatment and so on there are different mri type that you can do after uh identification of the patient with trigeminal neurology and on those mri the in sequences are written here fiesta cis high resolution thin cuts t1 you can look for vascular compression and you can see an area of the proximal part of the nerve that the vessel is sitting on and creating pulsation and that's where the cause is and we're going to get to the treatment of that so one other thing that you have to look for any patient with trigonometry that's a systematic thing that i always look is that when you are planning to treat specifically if you're planning a surgical intervention for a patient with trigeminal neuralgia you want to look at the mri and make sure there is no abnormal t2 signal in the trigeminal nerve in the pons whether they have charge whether they have multiple sclerosis or not because if there is whatever inflammation or disease that has caused t2 signal changes on mri on trigeminal nerve that means that the cause is most likely not a vascular compression even if you see a vascular structure close to the red redlish over steiner zone because it's rare to have a vascular compression and an intrinsic disease inside the trigeminal nerve so look for abnormality in the trigeminal nerve and make sure you rule it out before moving forward with more aggressive treatment [Music] hey everyone ryan rad here from neurosurgery training.org if you like that video subscribe and donate to keep our content available for medical students across the world