Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental...
Transcript of Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental...
![Page 1: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/1.jpg)
Trigeminal neuralgia
multidisciplinary approach
Prof Joanna Zakrzewska Eastman Dental Hospital
![Page 2: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/2.jpg)
Aims and Objectives
Trigeminal Neuralgia
Classification
Diagnosis
Art of Listening
Surgical Medical Psychological
![Page 3: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/3.jpg)
Trigeminal Neuralgia –IASP
a sudden, usually
unilateral, severe,
brief, stabbing,
recurrent pain in
the distribution of
one or more
branches of the
fifth cranial nerve.
Misery by Rosa Sepple
![Page 4: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/4.jpg)
Classification of head and face pain
2013
![Page 5: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/5.jpg)
ICHD 2013
![Page 6: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/6.jpg)
13.1.1 Classical trigeminal neuralgia
13.1.1.2 Classical trigeminal neuralgia with
concomitant persistent facial pain
Previously used terms:
Atypical trigeminal neuralgia; trigeminal
neuralgia, type 2.
Chapter 13
![Page 7: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/7.jpg)
Age and gender patterns of TN
pain
DO NOT Resemble :
TMD
Migraine
Tension type headache
Irritable bowel syndrome
DO resemble:
Cancer
Heart disease
Other degenerative disorders
![Page 8: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/8.jpg)
Associations
TN positively associated
hypertension
stroke
Pan et al Cephalalgia 2011; 31(8):937-942
Pan et al Neurology 2011; 77(17):1605-1610.
HCP making diagnosis TN = 5287 ATN = 189 OFP = 857
General medical
practitioner (%) 36 36 18
Neurologist (%) 29 30 17
Dentist (%) 20 15 10
Other specialists (%) 15 19 55
![Page 9: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/9.jpg)
Stories have :
• A teller
• A listener
• A language
• Characters
• A plot
• Time
Marshall & Bleakley Med Hum 2013 : 0: 1-6
![Page 10: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/10.jpg)
Which metaphors used in TN?
1. Rock in my ear and a string pulling it
2. Firework exploding
3. Drums beating
4. Electric needles
5. Plugged into the mains, switched on/off
6. Clamp
7. Heavy brick inside the head
8. Ants crawling
9. Lightening
10.Weight inside the face getting heavier
![Page 11: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/11.jpg)
1 2 3 4
Flickering Jumping Pricking Sharp
Quivering Flashing Boring Cutting
Pulsing Shooting Drilling Lacerating
Throbbing Stabbing
Beating Lancinating
Pounding
5 6 7 8
Pinching Tugging Hot Tingling
Pressing Pulling Burning Itchy
Gnawing Wrenching Scalding Smarting
Cramping Searing Stinging
Crushing
9 10 11 12
Dull Tender Tiring Sickening
Sore Taut Exhausting Suffocating
Hurting Rasping
Aching Splitting
Heavy
13 14 15 16
Fearful Punishing Wretched Annoying
Frightful Gruelling Blinding Troublesome
Terrifying Cruel Miserable
Vicious Intense
Killing Unbearable
17 18 19 20
Spreading Tight Cool Nagging
Radiating Numb Cold Nauseating
Penetrating Drawing Freezing Agonizing
Piercing Squeezing Dreadful
Tearing Torturing
MPQ
Which
words
chosen by
TN?
![Page 12: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/12.jpg)
Table 2. Statistically significant words for discriminating between TN and CIFP (p<0.05).
Use of McGill Pain Questionnaires (MPQ) in discriminating
between trigeminal neuralgia and chronic idiopathic facial pain
Joanna M Zakrzewska§, Mee-Eun Kim§, Teekyu Plangkoon Jorns*
UCL Eastman Dental Institute, 256 Gray’s Inn Road, London WC1X 8LD§
Khon Kaen University, Khon Kaen, Thailand* Email [email protected]
TN n=162 CIFP n= 93
Sensory
flashing, shooting,
stabbing, sharp,
wrenching, hot, searing,
splitting
throbbing, boring,
pressing,
pulling, dull,
aching, tender
Affective exhausting, fearful,
terrifying, vicious tiring
Evaluative intense annoying
Miscellaneous tearing, agonizing,
torturing
radiating,
piercing, tight, squeezing,
nagging, nauseating
![Page 13: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/13.jpg)
Psychological areas of the brain activated
in non evoked trigeminal pain
![Page 14: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/14.jpg)
Tolle et al Pain Practice 2006
![Page 15: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/15.jpg)
Depression and Anxiety
During the last month have you often been
bothered by:
1. Feeling down, or depressed or hopeless?
2. Having little interest or pleasure in doing things ?
Pilling BMJ 2009
NICE guidelines © Green BMJ
![Page 16: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/16.jpg)
© Zakrzewska
Medical management
![Page 17: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/17.jpg)
© Zakrzewska
Which have been evaluated in
Randomised controlled trials - RCTs?
baclofen carbamazepine
valproate lamotrigine epanutin
clonazepam
![Page 18: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/18.jpg)
© Zakrzewska
Which have been evaluated in RCTs?
gabapentin
pregabalin oxcarbazepine
sumatriptan
leviteracetam
Dextromethorphan
Topiramate
Botox
![Page 19: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/19.jpg)
New drug for TN
![Page 20: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/20.jpg)
Systematic reviews surgery
3 studies
2 radiofrequency
thermocoagulation
comparing techniques
1 stereotactic surgery
comparing dosages
Cochrane Database of Systematic Reviews 2011, Issue 9.
Grading
![Page 21: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/21.jpg)
Improving quality
Editorial
![Page 22: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/22.jpg)
AAN/EFNS guidelines
![Page 23: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/23.jpg)
Outcomes
Therapy % pain
relief
Decreased
intensity
frequency
Character of pain
Provoking factors
Side
effects
Beliefs
concerns
Objective
measures
© Zakrzewska
![Page 24: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/24.jpg)
Psychological interventions for
chronic pain: CBT approach
Thoughts/ Cognitions
Physiology Behaviours
Feelings/ Emotions
Miller, 1991; Turk et al., 1983
![Page 25: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/25.jpg)
Support groups US , UK, Australia , Canada
Web sites : http://www.tna-support.org/
http://www.tna.org.uk/
© Zakrzewska
![Page 26: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/26.jpg)
![Page 27: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/27.jpg)
Microvascular
decompression
MS
Drug
therapy
Neurovascular compression
Drug therapy
Tumours etc
Idiopathic TN
MRI
Blood tests Symptomatic TN
Ablative procedures Gasserian
ganglion
Gamma knife
Trigeminal neuralgia Primary care
Carbamazepine
Initial good control but now failing
Refer pain clinic
Neurology headache
Neurosurgery Poor
quality of
life
Carbamazepine
Oxcarbazepine
Lamotrigine
Baclofen
Pregablin
Gabapetin
Joint neurosurgery
clinic Psychology
© Zakrzewska
![Page 28: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/28.jpg)
References – HCP Patients
![Page 29: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/29.jpg)
TN Review BMJ 2014
![Page 30: Trigeminal neuralgia multidisciplinary approach€¦ · Prof Joanna Zakrzewska Eastman Dental Hospital . Aims and Objectives Trigeminal Neuralgia Classification Diagnosis Art of Listening](https://reader034.fdocuments.net/reader034/viewer/2022042315/5f03d9bb7e708231d40b12a8/html5/thumbnails/30.jpg)
Choice, Option, Decision
http://www.advancingqualityalliance.nhs.uk/SDM