Trigeminal Nerve Injuries

371 Pages·2013·19.667 MB·English

by  John M. Gregg DDS, MS, PhD (auth.), Michael Miloro (eds.)

Michael Miloro
Editor
Trigeminal
Nerve Injuries
123
Trigeminal Nerve Injuries

Michael Miloro
Editor
Trigeminal Nerve
Injuries
Editor
Michael Miloro , DMD, MD, FACS
Department of Oral and
Maxillofacial Surgery
University of Illinois
Chicago , Illinois
USA
ISBN 978-3-642-35538-7 ISBN 978-3-642-35539-4 (eBook)
DOI 10.1007/978-3-642-35539-4
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013938301
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To Beth and Macy, for your endless love and support.
To Joseph Foote, DMD, MD (1949–2010), my teacher and
mentor at the University of Pennsylvania, for inspiring
and supporting my initial interests in the diagnosis and
management of trigeminal nerve injuries.
To Arden K. Hegtvedt, DDS, MS (1958–1993), a man who
I never met at The Ohio State University, but who, in 1993,
was a rising star in our specialty, with a passion for teaching,
whose life was ended far too soon for the magnitude of his
enthusiasm, and all the potential that he had to offer to the fi eld
of microneurosurgery of the trigeminal nerve.

Preface
We live in a society exquisitely dependent on science and
technology, in which hardly anyone knows anything about
science and technology.
Carl Sagan
Microneurosurgery of the trigeminal nerve is still in its infancy, and we
continue to develop more experience and knowledge, as well as technological
advancements, in managing these complex clinical dilemmas. In fact, trigemi-
nal nerve injury management should be considered a subspecialty of oral and
maxillofacial surgery since this area of surgery requires additional training,
knowledge, clinical skills, and experience in order to properly diagnose and
care for the patient who sustains an injury to one of the terminal branches of
the trigeminal nerve. Perhaps some of the earliest publications in the English
literature regarding the lingual and inferior alveolar nerve for reporting data on
information other than local anesthesia were those published in the B ritish
Dental Journal by Cowan in 1946 who described pressure on the lingual nerve
from an impacted third molar and Beauchamp in 1947 who described a case
of severance of the inferior alveolar nerve during a tooth extraction. Simpson
in 1958 published an article on “injuries to the inferior dental and mental
nerves” in the J ournal of Oral Surgery, but the interest in this specialty area
only began to emerge in the 1960s for oral and maxillofacial surgeons, with
sparse publications, including only a few case reports by Ralph Merrill, relat-
ing to decompression for inferior alveolar nerve injury published in the Journal
of Oral Surgery. In the 1970s, microsurgery hands-on training courses were
offered in the USA for those surgeons interested in pursuing advanced spe-
cialty training in the principles, and techniques of microsurgery and courses
were held in various locations throughout the United States, including the
University of Washington. Surgeons such as Chuck Alling, Nick Choukas,
Ralph Merrill, JE Hausamen, Roger Meyer, Lenny Kaban, George Upton, Bob
Campbell, Joe Van Sickels, Peter Mozsary, Larry Wolford, John Gregg, Arden
Hegtvedt, Barry Eppley, Bruce Donoff, John Kiesselbach, Jim Hayward, Lee
Dellon, Sue Mackinnon, Leon Davis, Ray Dionne, Bruce Epker, PP Robinson,
John Zuniga, and John LaBanc were among the fi rst to publish in the area of
trigeminal nerve injuries in the 1970s and 1980s. Throughout the 1990s, there
were many publications on trigeminal nerve injury; however, most of these
were case reports and descriptions of specifi c surgical techniques based upon
individual surgeon experience with little evidence-based data.
Into the new millennium, those surgeons with the most experience in this
area have begun to report the results of their personal experience over many
years with a reasonable number of patients, but a well-controlled multicenter
clinical trial has yet to be performed in this area, although there has been
interest in such a study among those individuals who are routinely evaluating
vii
viii Preface
and treating the nerve-injured patient. Perhaps the only retrospective multi-
center study we have available to date is that reported by LaBanc and Gregg
in the 1992 O ral and Maxillofacial Clinics of North America . This Clinics
of North America publication entitled T rigeminal Nerve Injury : Diagnosis
and Management , edited by John LaBanc and John Zuniga, was the fi rst
attempt to bring the subject of trigeminal nerve injuries to the forefront of
clinical practice for oral and maxillofacial surgeons. This issue was followed
nearly a decade later by a second O ral and Maxillofacial Surgery Clinics of
North America devoted to Clinical Trials in Orofacial Neurotrauma , edited
by John Zuniga and John Gregg. These two clinics were focused efforts to
heighten awareness and increase access to care for patients who sustain
trigeminal nerve injuries. In addition, two Atlases of the Oral and
Maxillofacial Surgery Clinics of North America were published in 2001 and
2011, with illustrated chapters demonstrating speci fi c microneurosurgical
techniques. The paucity of an organized and comprehensive treatise on
trigeminal nerve injury has been the impetus for this textbook on Trigeminal
Nerve Injuries . The Table of Contents of this textbook is organized to include
the requisite information about our current understanding regarding the spe-
cialty of microneurosurgery of the trigeminal nerve, authored by the recog-
nized experts in the fi eld, including an impressive international group of
surgeons with arguably the most clinical experience and expertise in this
area. While most of these trigeminal nerve injury experts are well beyond
their “textbook chapter writing days,” they were uniformly highly motivated
to participate in this important project. T here was a consensus that a refer-
ence textbook was essential for the practicing clinician, including dentists,
dental specialists, and oral and maxillofacial surgeons, and other medical
and dental professionals, to allow appropriate assessment of patients who
sustain nerve injuries, in order to gain an understanding of the short- and
long-term treatment options and, also importantly, to determine at what
point in time to make the appropriate referral for care, and to whom, either a
microneurosurgeon or neurologist or other medical professional, and to
make the patient referral. In many cases, it is appropriate to obtain a neurol-
ogy consultation to assist with pharmacologic management; however, it may
not be as simple to fi nd an experienced microneurosurgeon of the trigeminal
nerve. The American Association of Oral and Maxillofacial Surgeons pro-
vides assistance to those dentists and surgeons who wish to locate a regional
microneurosurgical expert, but this information should be made readily
available to all practitioners. In fact, regional referral centers should be
established that have the necessary experience to most appropriately manage
the nerve-injured patient. Since the majority of regional experts in the USA
are either full-time or part-time academicians, accredited oral and maxillo-
facial surgery training programs may fulfi ll the need of the clinician for ini-
tial patient referral and triage. As more residents in oral and maxillofacial
surgery are trained in the techniques of assessment and management of
nerve-injured patients, more microneurosurgeons will be available through-
out the country and throughout the world, to improve access to care for the
trigeminal nerve-injured patient.
Preface ix
While we have learned a great deal about nerve injuries and repair and we
have had many reports in the literature over the past few decades and while
much has changed, at the same time, very little has changed in the diagnosis
and management of trigeminal nerve injuries. Certainly, we have learned a
great deal since John C. Warren published his experience in The Boston
Medical and Surgical Journal I: 1; 1, February 19, 1928 entitled “Cases of
neuralgia, or painful affections of nerves.” Dr. Warren describes cases of
trigeminal neuralgia that had failed pharmacologic treatment that he man-
aged with surgical transection of the terminal branches of the nerve, with
immediate recurrence of the painful trigeminal neuralgia symptoms. During
an abstract presentation at the 73rd AAOMS Annual Meeting and Scienti fi c
Sessions in Chicago, Illinois, on September 25, 1991 by Roger Meyer, he
indicated that microneurosurgery delayed for more than 1 year had a
signi fi cantly negative impact on long-term neurosensory recovery, and, in his
2012 publication, he has maintained his opinion based upon a retrospective
review of 167 patients over nearly 20 years. On the other hand, what has
changed in clinical assessment and management of trigeminal nerve injuries
includes the use of cone-beam 3D imaging for IAN injury risk assessment for
third molar surgery, endoscopic-assisted surgery to access dif fi cult sites, the
use of nerve growth factors and other cytokines, suture laser welding of neu-
ral anastomosis sites, the use of allogeneic cadaveric nerve tissue for nerve
grafting, and, certainly, surgeon experience continues to improve. It is inter-
esting to note that according to several publications (including Pogrel and
Robinson, as well as the experience of others), the number of surgical cases
is less than 10 % of all patient consultations for nerve injury. As a result, the
microneurosurgeon and residents in training working with these surgeons are
exposed to a large number of patients that allow the development of diagnos-
tic skills for nerve injury assessment.
At the present time, there is certainly a lack of available data to allow for
evidence-based treatment decisions with regard to patient evaluation, surgical
indications, degree of acceptable paresthesia, proper timing for exploration
and repair, and expected outcomes and following trigeminal nerve repair
surgery. When the patient symptomatology includes unpleasant or painful
sensations, what is the most appropriate pharmacologic regimen to use,
should medications be applied locally and/or systemically, and what is the
role of behavioral therapy, vitamin B therapy, low-level laser therapy, psycho-
therapy, as well as microneurosurgical management of neuropathic pain?
Therefore, and since the majority of existing data is retrospective in nature, a
multicenter trial is essential in order to most appropriately answer these
questions. This should be a well-designed controlled multicenter clinical trial
with experienced microneurosurgeons using standardized data acquisition
(e.g., Sunderland grading system) and examination reporting parameters
(e.g., MRSC grading scale of functional neurosensory recovery). An attempt
at standardization was performed in 1998 by Zuniga et al., which established
the validity of the Sunderland grading system for IAN and LN injuries.
A great deal of credit must be given to those surgeons who have continued to
evaluate their individual experience and publish in this area of the past