Red,
I like "when you hear hoof beats, look for horses, not zebras." In the case of TN after trauma (25% TN patients experienced trauma in the 6 months prior to symptoms), the medical profession hypothesises TN after whiplash is a result of vascular changes as opposed to cervical dysfunction. Never mind zebras, I suggest they are looking for unicorns.
I think the reason they propose vascular changes is because of the widespread success of MVD in treating type 1 TN. There is a bucket load of evidence to support the vascular theory for type 1 at this point.
I had a physiotherapist try to get me to do neck stretches and align my neck properly. He found that my neck is actually very flexible. The stretching and manipulations did nothing. He tried myofascial release as well, also useless.
Did you have good success with someone trying to fix cervical dysfunction? For me, it felt like he was just employing “if the only tool you have is a hammer, then everything begins to look like a nail.” In the end, he admitted that my pain was probably due to dental injury and no amount of fiddling with my neck was going to fix it.
Toothache,
There is an argument against, "There is a bucket load of evidence to support the vascular theory for type 1 at this point." Just because Microvascular decompression (MVD) relieves the symptoms of TN, both TN1 and TN2, though TN2 to a lesser extent, there are no double blind trials that I am aware of, and so it is the procedure of MVD that offers a certain percentage of patients relief.
TN in the absence of neurovascular compression (NVC) must have a different aetiology, by definition, as stated by Lee et al in 2014. They remarked the absence of NVC in almost 30% of patients with TN1 during microvascular surgery. NVC, therefore doesn't account for all patients with TN1. So in the absence of pathology what area of the trigeminal complex is left to consider?
I am glad you had the foresight to examine other possibilities in consulting a physiotherapist. That said any therapist who concludes I didn't help you by treating your neck, it must be something else, has one huge ego.
There are a couple of members on the forums who claim to have cured their TN by stretching their neck.
Another reference of interest,
Liu SJ et al. Manipulative treatment of 12 cases of cervical spondylosis with trigeminal neuralgia. J Tradit Chin Med. 1982 Jun;2(2):115-8. Still only 12 cases but we are building on five. 17 in total to date. Having referenced this, at this present time, having read it before the abstract I can not finger. So I'll add this,
" Contact between a trigeminal nerve root and an artery in the prepontine cistern is a frequently seen anatomical variant. Therefore, detection of such a variant is not equivalent to finding the cause of a patient's complaints."
Adamczyk M et al. Trigeminal nerve - artery contact in people without trigeminal neuralgia - MR study. Med Sci Monit. 2007 May;13 Suppl 1:38-43.
Hi Aiculsamoth,
I believe it is unethical to perform sham surgeries, which is why there is no double blind placebo controlled trial comparing MVD to sham MVD...there is a risk of death when opening up someone's brain and you would not do so without intending to fix a problem. Maybe in the future, they could develop an animal model of type 1 trigeminal neuralgia and perform more controlled studies that way. The current models use a type of constriction injury to produce neuropathic pain in rats, but this does not exactly match what happens in TN and does not allow surgeons to perform controlled trials. These models are useful for testing medications, however.
You are right in that MVDs do not as reliably relieve the symptoms of TN type 2. I believe the reason is because when TN has progressed to type 2, the patient has a certain degree of inherent nerve dysfunction that is independent of a blood vessel rubbing against the nerve.
You are also right in that some patients do experience relief after "stretching their necks." In this case, there's far less evidence than people getting relief after getting MVDs. TN is also something that spontaneously goes into remission, so we don't know if the people getting relief from neck stretching would have gotten relief by doing nothing at all anyway.
The more I read about chronic pain, the less I believe in the structural explanations of pain. They tend to be very wishy washy and lead to inconsistent results in practice. I tend to see type 2 TN, trigeminal neuropathic pain, atypical facial pain, and atypical odontalgia (all have very overlapping symptoms and many have been diagnosed with all of them by different practitioners) as a software dysfunction rather than a hardware dysfunction. There's usually nothing at all wrong with the physical structures that doctors can detect with today's technology, but something is wrong with pain processing.
https://www.painscience.com/articles/structuralism.php
I tend to agree with the author of this article - we put too much emphasis on trying to fix issues that may be non-existent or have virtually nothing to do with our pain. Certain healthcare professionals and alternative medicine practitioners make good money out of this. I myself have spent great chunks of money and time trying to fix these so called problems with my posture, neck alignment, and muscle tension. The thing is, my problems started after a dental extraction - the most likely explanation is that I sustained a peripheral nerve injury that somehow snowballed into constant neuropathic pain. There's actually a huge connection between dentistry and trigeminal nerve pain. This supports the argument for atypical pain being a type of peripheral nerve injury with resultant central sensitization, rather than the cervical spine argument. I was awake during my procedure and I'm pretty sure the oral surgeon didn't do anything to twist my neck.
I hope this helps you understand where I'm coming from.
Toothache,
Mildly agree, agree agree agree and agree.
Whilst I appreciate opening someone's head up with no plan of action is not going to call for many raised hands, you don't have to take it that far, why not anaesthetise a TNr for two to three hours, or in addition cut the soft tissue behind the ear, and analyse results, with no risks of side effects from full MVD. Not exactly double blind but closer to none.
Interestingly I see a software malfunction to be the cause of cervicogenic TN, ie at the spinal trigeminal nucleus.
In reading, I agree dentistry and TN have a huge connection. I also feel dentists are missing something in their defence, the action of dental induced trauma on the cervical spine. If you are not out, constriction of the posterior cervical muscles to combat a dentist pulling on your teeth is huge, rotation of the neck is not needed, why do you assume so? There is also a forum member who states their TN occured after simply dentistry teeth cleaning.
Central sensitisation would form the basis of cervicogenic TN. I believe it offers a better model in explaining the enigmas of the MVD model.
Actually, general anaesthetics are risky medications. That is why you have anaesthesiologists who finish med school and then do years of additional training. They have to be present at every major surgery, and a lot of times, get paid more than the surgeon. Sham surgery trials do get approved. For a procedure like the MVD which has a lot of evidence supporting it, realistically, this trial would not get funded or approved. Also, it would not be adequate blinding because patients are not ignorant. They would know if only their soft tissue got cut and not their skull - no dizziness and balance issues unlike the treatment group.
Typical TN is actually one of the only pain conditions for which surgery works well and consistently. If the main benefits of MVD were placebo induced, you would expect them to have similar results as other pain conditions.
As for the dental extractions…I’m not sure if you’ve experienced one yourself, but for larger teeth, dentists use the surgical extraction technique to prevent excessive force being used. They cut a gum flap and then drill the bone around the teeth to loosen it, then they use a lever method to remove the tooth. There’s no pulling involved and the assistants actually support your neck while this is done. Also, a lot of nerve problems develop post root canal, and that does not involve any tooth removal. I’m just not buying the cervical spine theory based on current evidence. There are too many clues pointing to other more convincing causes.
I think we’ve strayed quite far from the original topic and the intention of the site. It’s here for patients to find support, not debate the cause of our affliction. Have you brought up your concerns with your doctor? He or she would be a much better person to help guide you about something like this. I have seen some really knowledgeable specialists who are willing to “talk science” with me and try some innovative and out of the box treatments. I hope you have someone like that on your treatment team.
Hi Toothache,
I haven't stated that I believe the main benefits of MVD procedure to be palcebo induced.
I have experienced a tooth extraction, and my neck felt painful for some four days. The last time my neck had felt that way was after bumper cars.
If there is no pulling on your neck why do dental assistants support your head as you state?
Dental procedures do cause cervical dysfunction;
http://jnnp.bmj.com/content/37/12/1361.full.pdf
http://www.ncbi.nlm.nih.gov/pubmed/9360224
"The following risk factors are associated with the potential of bony or ligamentous compromise of the upper cervical spine.....recent head/neck/dental surgery" and is referenced in Manual Physical Therapy by Ken Olson page 96.
Cervical Dysfunction can be a cause of TN, dental procedures do cause cervical dysfunction.
This thread was started by that boy who has left the forum. As well as support this site states it is also a source of information, for which I am searching, so thank you for your replies.
I do not have access to a medical team as I don't have TN.