A method for the treatment of trigeminal neuralgia

 

(57) Abstract:

The invention relates to medicine and can be used in neurology, neurosonology, oral and maxillofacial surgery for the treatment of patients with trigeminal neuralgia. The method comprises oral administration of glycerol in the morning to 0.5 g per 1 kg of patient's weight, then in one syringe trying to enter kenalog 40 mg, vitamin B12 500 mg lidocaine 2% 4,0 ml and injected to the site of demyelination of the second and third branches of the trigeminal nerve in the region of round and oval holes. After intravenous Berlition 300 mg 2 times a day at intervals of 10-12 hours the next day intramuscularly injected milgamma 2.0 ml, alternating in the future through the day with blockades. The treatment 3-5 blockades. The method improves the efficiency of treatment by reducing the neurovascular conflict and enhance the process of remyelination.

The present method relates to medicine and will find wide application in neurology, neurosonology, oral and maxillofacial surgery for the treatment of patients with trigeminal neuralgia.

Trigeminal neuralgia (NTN) is characterized by severe attacks of excruciating pain in the face that arise when talking, eating, shaving, washing, etc. to suicide. The intensity of pain and the lack of effective treatments deprive the patient of the joy of life, disability, closing all of its interests in excruciating pain.

The use of different methods of treatment of trigeminal neuralgia depended on the dominant ideas about the pathogenesis of the disease. Contradictions in the understanding of the pathogenesis of NTN explains the widespread until the present time the use of destructive interventions (alcoholism, neurotomy, nervertheless) and the lack of effectiveness of the treatment methods, culminating in a high percentage (almost 100%) relapses (Savitskaya O. N. Trigeminal nerve: peripheral and Central mechanisms of pathogenesis, questions, clinic and treatment. Dis. Prof. the honey. Sciences. - M., 1976; Gordienko, A. N. The optimization of the treatment of trigeminal neuralgia method of alcoholism // Pain autonomic syndromes and diseases of the face, nose, mouth. Sat. the scientific. works. - M, MMSI, 1987).

In his time great hopes were pinned on drugs dibenzazepines series (Finlepsin, carbamazepine, tegretol) (C. A. Charles, O. N. Savitskaya. Neuralgia of the trigeminal nerve. - M.: Medicine, 1980; Taylor, J. S. et al., Long-term treatment ofTrigeminal neuralgia with carbamasepin. // Postgrad. Med. J., Alt. With each new exacerbation of the disease, the efficacy of these drugs progressively reduced, and the number of adverse events is steadily increasing (Savitskaya O. N. Trigeminal nerve: peripheral and Central mechanisms of pathogenesis, questions, clinic and treatment. Abstract. Diss. on saisc.Uch.step.D. m.N. - M.: 1976; Charles C. A., Savitskaya O. N., Vishnyakova M. A. trigeminal Neuralgia. - M.: Medicine, 1980).

To improve the efficiency of the used anticonvulsants some authors recommend to combine them with blockades branches of the trigeminal nerve on the face with anesthetics, alcohol or steroids (Sabelis, I., Stropus R. A. and others A. S. No. 1114423, bull. No. 35 of 23.09.1984 “a Method for the treatment of trigeminal neuralgia”; Ramirez H., Martinez, S. Oliva J. Montini C. “Pharmacotherapy of Trigeminal Neuralgia.” // Odontol. Chil., 1989, Vol. 37, No. 2, p. 264-269; Stajcic z, R. P. Jumper, Todorovich L. Periphetal streptomycin/lidocain versus lidocaine alone in the treatment of idiopathic Trigeminal neuralgia. // J. Craniomaxillofac. Surg., 1990, vol. 18, No. 6, R. 243-246). Deafferentation complications of alcoholism (loss of sensation on the face, constant burning, baking, nagging feeling in the zone subjected to alcoholism nerve) and the lack of effect with repeated blockades questioned the rationale for their use.

The disadvantages of this method of treatment of trigeminal neuralgia are: execution of blocks away from the site of demyelination, the mismatch of the treatment regimen to the modern understanding of the pathogenesis of the disease and, casino in relatively high doses and after the course of treatment.

The prototype of the proposed method is “a Method for the treatment of trigeminal neuralgia (see sedrenik centuries, Ivanova N. E., Codina C. I. A. S. No. 2202349, BIPM No. 11 of 20.04.2003). The essence of the method is that administered anticonvulsants in small doses and neurovasculature drugs daily, imigran through the day, stadol during the first two days, with once a week to introduce 20 ml of 1% solution of novocaine in star site on the affected side. The disadvantages of this method are the use in the treatment of anticonvulsants, the efficiency with which each recurrent exacerbation decreases, and the number of side effects increases (Charles C. A., Savitskaya O. N., Vishnyakova M. A. trigeminal Neuralgia. - M.: Medicine, 1980), 20 ml of 1% solution of novocaine (anesthetic) is injected (in the neck) away from the trigeminal nerve Innervate the face!) and immediate impact on the affected nerve does not have. The use of such drugs as imigran and stadol, only indicates that the pathogenetic mechanism of trigeminal neuralgia authors took vascular disorders, such as those observed in migraine that is not consistent with the modern understanding of the pathogenesis of trigeminal neuralgia.

The purpose of the invention - the impact of drugs directly to the foci of demyelination, increase the effectiveness of treatment and duration of remission in patients with trigeminal neuralgia if the location of the blockages and the appointment of additional drugs which help to reduce the neurovascular conflict by increasing the distance between the spine and the artery and activation of% the space of the second focus of demyelination of the affected branches of the trigeminal nerve locally injected glucocorticosteroid combined with vitamin B12 and lidocaine and appoint Berlition intravenous, milgamma intramuscularly, alternating every other day with blockades, and glycerin inside, dose antiepileptic drugs are gradually reducing, stopping taking them to the 6-10 day from the start of treatment, i.e. to the time of patient discharge from the hospital.

The feasibility of such techniques is justified by the fact that upon a determination that a cause of trigeminal neuralgia is a neurovascular conflict between the root of the trigeminal nerve and arteries of the cerebellum, nociceptive effect of pulse beats latter leads to demyelination of the fiber stub in place of the conflict, and round and oval holes. The change in the ratio mielinizirovannykh and demyelinizing fibers leads to inhibition of insertion of neurons and makes the uncontrolled flow of pain information to the brain stem and cerebral cortex. When analyzing videotopia operations microvascularity the ascend, the Deco we found that conflict often occurs between predavanja surface of the spine, which is formed from the fibers of the first branch, while the vast majority of patients are affected the second and third branches together or separately. This confirms the fact that the t of the curve at the rear edge of the round and oval holes. Pulse beats artery of the spine are passed through another node on the branch of the trigeminal nerve. When the tension of the spine, followed by the second and third branches, the latter are damaged on the rear edge of the round and oval holes where they are, changing the direction, make the turn down, while the first branch, without changing direction, freely stretched and relaxed, passing through the wide top of the ophthalmic slit. Thus, there are formed two lesions of demyelination in the spine, directly in the field of neurovascular conflict and peripheral branches at the rear edges of the round and oval holes.

With this in mind, changing tactics therapy, namely the introduction of drugs directly to the site of demyelination, which reduces nociceptive effect of pulse beats and stimulates the process of remyelination. Considering the above, the main directions of pathogenetic therapy are: the administration of drugs directly to the site of demyelination, reduced nociceptive effects of pulse beats artery on the spine by increasing the distance between them by reducing the volume of the spine and blood letting is the patient on the first day of admission with the aim of increasing the distance between the root of the trigeminal nerve and compremise his artery prescribe oral glycerol, 0.5 g per 1 kg of body weight as dehydrating drug to help reduce the volume of the spine. Directly to the second focus of demyelination in the area round and oval holes injected complex medicines, as part of kenalog 40 mg, vitamin B12 - 500 mg and 4.0 ml of 2% lidocaine solution. Blockade perform in a day in amounts of from 3 to 5 depending on the onset of remission.

The kenalog-40 (triamcinolone) has anti-inflammatory, membraneactive property, stabilizing cell membranes and organelles by inhibiting the activity of phospholipase A2. Vitamin B12 has a high biological activity as a growth factor, participating in the formation of choline, methionine, nucleic acids, having a positive effect on the function of the nervous system (see M. D. Mashkovsky. Medicinal product. - M.: Medicine, 1993, S. 8 and 18; Reference Vidal, 2001 C. B-370).

Billiton injected intravenously 300 mg twice a day. The course of treatment is 5 days of intravenous and 5 days of oral forms in the same dose. The drug has a powerful antioxidant effect and helps to intensify the process of remyelination, improving trophic neurons (see Reference Vidal. - 2001, p. B-77).

Milgamma injected 2.0 ml nutriminc vitamins B1, B6, B12) dictated known for their efficiency in neuralgia of the trigeminal nerve. The drug has analgesic effect, stimulates the regeneration of nerve tissue, is involved in the synthesis of the myelin sheath, and also contributes to the normalization of carbohydrate metabolism (M. D. Mashkovsky. Medicines: - M.: Medicine, 1993, S. 8 and 18; Reference Vidal. - 2001, p. B-370). In addition, thiamine antioxidant activity, regulates the nervous system, affecting the transfer of excitation.

Before admission to the hospital all the patients have long received high doses of carbamazepine (finlepsina), to 1200-3600 mg / day. It is known that the sudden removal of high doses of carbamazepine can cause seizures, so at the time of a treatment regimen, the dose of carbamazepine was gradually reduced within 5-7 days and the drug was completely abolished.

Due to the proposed method in the combination treatment reduced nociceptive effect of pulse beats artery on the root of the trigeminal nerve that activates the process of remyelination. Consequently stops the flow of pathological activity in the cerebral cortex, which in the short term (6 to 10 days) results in the crust is

Example. Patient A. 72 years. Case history No. 238/28.

He entered the clinic of neurosurgery, Russian state medical University with complaints of severe, tearing, sharp, shooting attacks of pain in the right half of the face in the lower jaw caused by talking, eating, toilet mouth, etc. Considers herself a patient of 1988, when, after hypothermia appeared first painful paroxysm lasting 10 s Reception finlepsina 800-1000 mg per day resulted in a decrease in the frequency and intensity of pain attacks. The area of pain is the second and third branches of the right TN. Trigger zone - the inner surface of the cheeks, lower lip, the parotid region. For the period of the last exacerbation (2 months) because of the impossibility of adequate food intake, the patient lost 5 kg of body weight. Neurological examination revealed mild hypesthesia in the area of the second and third branches of the right TN and pain points of these branches to the surface. Quantitative assessment of pain was on a scale 82%. MRI - detected signs of internal and external hydrocephalus due to atrophic process of the brain. Lesions in the posterior fossa is not detected. In the operation the patient was denied due to severe somatic p is cardio-pulmonary insufficiency. Patients received a course of pathogenetic, conservative treatment, which included 3 blockade in the area of round and oval holes of the skull with 1 ml of kenalog 40 mg, vitamin B12 - 500 mg and lidocaine 2% - 4,0 ml Intravenous Berlition 300 mg 2 times a day (10 infusions) followed by oral forms of the drug, milgamma 2.0 ml intramuscularly every other day, alternating with blocks reception of glycerol, 0.5 g per 1 kg of weight 1 time per day during 5 days. Upon completion of the course of treatment the pain was gone, there was no need to use Finlepsin.

The proposed method provides a direct impact on the mechanism of trigeminal neuralgia in the neurovascular conflict through the use of drugs glycerin, milgamma and Berlition, and second foci of demyelination at the rear edges of the round and oval holes by direct summing of drugs (kenalog-40, vitamin B12 and lidocaine) to the site of the lesion. All these advantages compared with the known method give the best of both the near and long-term results. The duration of our ongoing course of conservative therapy does not exceed 6-10 days to reach the counter REM is about entering the clinic of neurosurgery of the Rostov state medical University received medications and various physiotherapeutic methods of treatment for from 1 to 5 months. In addition to the cost of treatment it is necessary to take into account the losses associated with temporary disability for working persons.

A method for the treatment of trigeminal neuralgia by drug therapy, characterized in that morning prescribe oral glycerol, 0.5 g per kg weight of the patient; in one syringe trying to enter kenalog 40 mg, vitamin B12 500 mg lidocaine 2% 4,0 ml and injected to the site of demyelination of the second and third branches of the trigeminal nerve in the region of round and oval holes, then intravenous Berlition 300 mg 2 times a day at intervals of 10-12 hours, the next day intramuscularly injected milgamma 2.0 ml, alternating in the future through the day with blockades; the course of treatment from 3 to 5 blocks.

 

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