The osteopathic management of Trigeminal neuralgia trigeminal neuralgia
EDNA M. LAY, D.O., IAAO Kirksville, Missouri
nose to the angle of the mouth, which is supplied by the second division of the fifth cranial nerve, is the most common trigger The cause of the painful syndrome of zone, . . . but as the disease progresses, secondary trigger zones trigeminal neuralgia, in which the area of occasionally develop. The stimulus may be talking, chewing, the face supplied by one or more branches washing the face, blowing the nose, or sometimes the lightest, almost imperceptible touch or even a draft of cool air on the face. of the fifth cranial nerve is affected, has The pain is often triggered by hot or cold food or drink. The long been obscure. Sutherland s single, momentary episode of pain may eventually progress to a observation of the disturbed physiology of series of multiple single bursts, which follow one on the other for an hour or longer. After a prolonged attack of this nature, some the dural membrane enveloping the patients complain of a mild, dull, aching pain, which may persist gasserian ganglion as a result of articular between attacks in the same distribution as the original short, strain between the petrous portion of the severe pain. temporal bone and the sphenoid bone has The severe form of trigeminal neuralgia usually been supported by observation of a occurs in patients past the age of 50 and is twice as structural imbalance between the right and frequent in women as in men. It is almost always left temporal bones where the nerve passes unilateral and most often occurs on the right side. over the petrous apex. Release of dural The attacks rarely awaken the patient from sleep stresses due to strains on the cranial unless the trigger zone is stimulated inadvertently. articulations and elsewhere in the body is When attacks are triggered by chewing or swallow- helpful, particularly after early diagnosis. ing, the patient s condition may deteriorate to an advanced state of emaciation and dehydration. In some cases the pain and suffering become intracta- ble and, if relief is not offered, may lead to suicide. Jannetta2 stated: The pain is described as unbearable and the most severe pain that the patient has ever experienced . . . The pain is limited to the face in the distribution of the trigeminal nerve. It is most common in the lower part of the face (third division of the trigeminal Trigeminal neuralgia is pain in the structures sup- nerve), slightly less common in the middle part of the face (second plied by one or more of the three branches of the division of the trigeminal nerve), and least common in the upper (first) division pain . . . Attacks may occur less than once a day, or trigeminal (fifth cranial) nerves. The pain may vary well over 100 times a day. in intensity from mild to extreme, and for this paper trigeminal neuralgia will be considered as any pain, from minor to moderate to severe, in the structures Anatomic considerations supplied by this largest pair of cranial nerves. In its In order to bring the osteopathic approach to the severely painful manifestation, trigeminal neuralgia problem of trigeminal neuralgia into focus, a review is called tic douloureux, which Finneson said . . . of the anatomic and physiologic relation of this pair . . . is characterized by recurrent, eposodic attacks of extremely of nerves to the total body structure is in order. severe pain over the distribution of one or more branches of the The trigeminal nerves are the largest of the cra- fifth cranial nerve . . . The pain occurs suddenly and without nial nerves. Each of them possesses three peripheral warning, usually lasts 10 to 30 seconds, and stops as abruptly as it began. Patients describe the pain as an electric shock or a shooting divisions, but each is attached to the brain system by or jabbing sensation. The pain can occur spontaneously or may be two bundles of nerve fibers, a large sensory and a brought on by stimulating a "trigger zone," which may exist in any much smaller motor root. The sensory fibers pass part of the face. The trigger area most frequently indicates the branch of the nerve involved; otherwise it might be difficult to through a large ganglion in which the somatic affer- localize the pain precisely. The area from the lateral border of the ent cell bodies are situated. The peripheral divisions
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of the nerve are the ophthalmic (first), the maxillary Another point of practical importance is that a topographical localization of function exists in the spinal nucleus, in the sense (second), and the mandibular (third). By way of that fibres of the ophthalmic division of the trigeminal nerve end these three divisions, the peripheral branches of the in its lower third, those of the mandibular division in its upper axons of the somatic afferent cells are distributed as third, and those of the maxillary division in the intermediate part. In other words, the sensory areas of the face are represented in nerves of common sensation to the face, the front of the nucleus in an inverted order. Thus it is possible fora localized the scalp, the eyeball and conjunctiva, the nose and lesion involving a limited portion of the spinal nucleus to be nasal cavity, and parts of the interior of the mouth accompanied by a loss of pain and temperature sensation over one part only of the face .. . (including the palate, the teeth, and the front por- The mesencephalic nucleus consists of unipolar cells similar in tion of the tongue) and the external ear. All the appearance to those found in posterior root ganglia . . . The motor fibers join the mandibular division and are fibres of the mesencephalic tract actually are processes of the cells distributed through it, chiefly to the masticatory of the nucleus. In other words, they have their cells of origin within the brain stem and not in the trigeminal ganglion like the muscles. This term is ordinarily used to include the other sensory fibres. The functional significance of the mesence- temporalis, masseter, and lateral and medial phalic nucleus ... is concerned with the reception of impulses pterygoid muscles. from stretch receptors in the masticatory muscles and pressure receptors related to the teeth and hard palate. It appears that The trigeminal nerve has a small and discrete these impulses, in constituting the afferent side of masticatory motor nucleus (branchiomotor) and an extensive reflex arcs, play a part in the coordination and control of chewing sensory nucleus (general somatic afferent). The lat- movements. Peripherally, the mesencephalic fibres are distri- buted with the mandibular division of the fifth nerve, and with ter extends throughout the whole length of the the palatine and superior dental branches of the maxillary divi- brainstem as far as the upper end of the midbrain, sion.. . The motor and sensory roots of each trigeminal nerve have and below it reaches down into the second cervical their superficial origin from the corresponding side of the pons segment of the spinal cord. The motor nucleus lies . . . From here the two roots pass forwards and laterally, beneath in the floor of the upper part of the fourth ventricle. the anterior part of the tentorium, and enter a recess of the dura It represents the upper end of the column of cells mater in the middle fossa of the skull by passing over the upper edge of the petrous part of the temporal bone and under the from which the branchial musculature is innervated, superior petrosal sinus. The dural recess (cave of Meckel) con- for its fibers supply the musculature derived from tains the flattened and crescentic trigeminal, or semilunar, gangl- the first branchial arch. Since this musculature is ion, into the concave posterior border of which the sensory root passes. mainly concerned with movements of the mandible, the motor root of the fifth nerve is sometimes called The semilunar (gasserian) ganglion occupies a the masticator nerve. Boyd and associates3stated: cavity in the dura mater covering the trigeminal The sensory fibres of the trigeminal nerve innervate the face, the impression near the apex of the petrous part of the anterior part of the scalp, the mouth, the teeth and the nasal temporal bone. It is somewhat crescentic, with its cavity. They terminate in three nuclei, the main sensory nucleus, the descending or spinal nucleus, and the mesencephalic nucleus. The convexity directed forward: . medially, it is lateral to main sensory nucleus is situated in the pontine region of the the internal carotid artery and the posterior part of hind-brain, immediately lateral to the motor nucleus. The spinal the cavernous sinus. nucleus appears to be continuous at its upper end with the main sensory nucleus; it extends down through the hind-brain as a The ganglion receives, on its medial side, fila- long, slender and rather well defined column of grey matter ments from the carotid plexus of the sympathetic which eventually reaches as far as the level of the second cervical nerves. It gives off minute branches to the tentorium segment of the spinal cord .. The main sensory nucleus and the spinal nucleus have impor- cerebelli and to the dura mater in the middle fossa of tant functional differences. In the main sensory nucleus termi- the cranium From its convex border, which is di- 1 nate the relatively coarse sensory fibres of the trigeminal nerve rected forward and laterally, three large nerves pro- which convey tactile impulses . . . The spinal nucleus, which con- sists of very small cells, receives mostly fibres of fine calibre which ceed, the ophthalmic, maxillary, and mandibular. convey impulses related to pain and temperature sensation .. . Associated with the three divisions of the trigemi-
374/56 nal nerve are four small ganglia. The ciliary gan- sinuses, upper teeth and gums, the skin on the side glion is connected with the ophthalmic nerve, the of the nose, cheek, and upper lip, the skin and con- sphenopalatine ganglion with the maxillary nerve, junctiva of the lower eyelid, and the periosteum of and the otic and submaxillary ganglia with the man- the orbit4 (Fig. 1). dibular nerve. All four receive sensory filaments The mandibular nerve is the largest division of the from the trigeminal nerve and motor and au- fifth nerve and is made up of two roots: a large tonomic filaments from various sources; these fila- sensory root proceeding from the inferior angle of ments are called the roots of the ganglia. the semilunar ganglion and a small motor root that The ophthalmic nerve, a sensory nerve, supplies passes beneath the ganglion and unites with the branches to the cornea, ciliary body, and iris; to the sensory root just after its exit through the foramen lacrimal gland and conjunctiva; to part of the mu- ovale. A small branch is given off just outside the cous membrane of the nasal cavity; and to the skin of cranium (nervus spinosus) and reenters the cranium the eyelids, eyebrows, forehead, and nose. It arises through the foramen spinosum and supplies the from the upper part of the semilunar ganglion, pass- dura mater and the mastoid air cells. The mandibu- es forward along the lateral wall of the cavernous lar nerve supplies the muscles of mastication, the sinus, and, just before entering the orbit through the superior orbital fissure, divides into the lacrimal, frontal, and nasociliary nerves. The ophthalmic nerve is joined by filaments from the cavernous plexus of the sympathetic nerves and communicates with the oculomotor, trochlear, and abducent nerves, giving off a recurrent filament which passes between the layers of the tentorium cerebelli. The maxillary nerve, the second division of the trigeminal nerve, also is a sensory nerve. It begins at the middle of the semilunar ganglion. Passing hori- zontally forward, it leaves the skull through the foramen rotundum. It then crosses the pterygopalatine fossa, inclines laterally on the back of the maxilla, and enters the orbit through the inferior orbital fissure. It traverses the infraorbital groove and canal in the floor of the orbit and ap- pears in the face at the infraorbital foramen. Within the cranium a small meningeal branch supplies the dura mater of the middle cranial fossa. In the pterygopalatine fossa some of its branches pass through the sphenopalatine ganglion. Branches of the maxillary nerve supply the mucous membrane of the roof of the pharynx, posterior ethmoidal and sphenoidal sinuses, and the roof, septum, and con- chae of the nose, soft and hard palate, maxillary Fig. 1. Distribution of trigeminal nerve.
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tensor tympani, tensor veli palatini, and mylo- terior end is attached to the crista galli; its upper hyoidus muscles, the anterior belly of the digastric border is attached to the cranial vault along the muscle, the temporalis muscle, and the temporo- median line from the crista galli to the internal occi- mandibular joint. The mucous membrane of the pital protuberance. The anterior two-thirds of its cheek, gum, lower lip, mouth, and anterior two- lower border is free, and the posterior third of this thirds of the tongue, the lower teeth and jaw, the border is attached to the tentorium cerebelli. skin and fascia of the cheek, the upper half of the The tentorium cerebelli is a large crescentic parti- ear, the external auditory meatus, the tympanic tion (shaped like a double sickle), which forms a membrane, the skin of the temple and scalp, the skin membranous, tentlike roof for the posterior cranial over the jaw, chin, and lower lip, and the parotid, fossa and thus separates the cerebral hemispheres sublingual, and mandibular glands are supplied by and the cerebellum. Its highest point is in front at the mandibular nerve.5 the median line where it is attached to the falx cere- With this extensive sensory nerve supply to most bri. It slopes downward and backward to its pos- of the dura mater in the cranium and all of the terior border, which is attached to the internal oc- anterior portion of the head and the face, it is under- cipital protuberance and along the transverse ridges, standable that painful conditions of this nerve or its across the mastoid angles of the parietal bones, and branches cause much suffering. all along the petrous ridges of the temporal bones. The attachments of the dura mater and its redu- The anterior termination of these borders on either plications on the inside of the base of the cranium side is called the petrosphenoid ligament and at- and spinal column are pertinent to understanding taches firmly to the posterior clinoid process of the the osteopathic management of trigeminal neural- sphenoid bone. This portion of the dura mater is gia. placed under marked strain in dental traumatic le- The dura mater is the outermost envelope of the sions between the petrous portion of the temporal central nervous system, a tough membrane of two bone and the sphenoid bone. The roots of the layers in the cranium. The external layer serves as trigeminal nerve pass beneath this dural band and the internal periosteum for the cranial bones and is over the petrous ridge before it enters the semilunar continuous through the sutures with the periosteum ganglion on the anterior surface of the petrous por- on the external surface of the skull. The internal tion of the temporal bone. layer has four reduplications or folds: the falx cere- The anterior, or free, border of the tentorium is bri; the tentorium cerebelli; the falx cerebelli; and concave, and within it lies the midbrain. The free the diaphragma sellae. There are spaces between edges run forward, cross over the converging petro- the folded layers that contain several important sphenoid ligaments, and insert firmly into the an- structures, listed as follows by Magoun:6 terior clinoid processes of the sphenoid bone. (I) Meckel s cave for the semilunar ganglion; Around the foramen magnum and on the floor of (2) the endolymphatic sac; the cranial cavity the dura mater is firmly adherent (3) the venous sinuses, into which most of the to the bone. This is particularly marked in the pro- blood from the brain drains; jecting parts of the cranial floor, such as the petrosae (4) the meningeal vessels; and and clinoid processes. The firm dural adherence in (5) the nerve supply to the dura from the trigem- these regions is strengthened by sheaths of the fi- inal and vagus nerves. brous dura mater that accompany the nerves as they The falx cerebri is a sickle-shaped partition which leave the cranium through the various foramina. descends between the cerebral hemispheres. Its an- Outside the cranium the prolongations of the mem-
376/58 brane blend with the fibrous sheaths of the nerves. thus giving rise to nerve impulses that affect the branches of the Thus articular strains between the sphenoid, oc- fifth nerve, resulting in tic douloureux. ciput, and temporal bones may put a pull or drag or Utilizing their general osteopathic knowledge and tension on the second and third divisions of the the premise that there is cranial articular mobility, trigeminal nerve by way of the nerve sheath, as an Wilson and Muir in 1946 described several os- overly tight sleeve does on an arm. teopathic manipulative techniques and reported on The internal layer of cranial dura mater is at- results in 26 cases of tic douloureux, in 16 of which tached firmly to the cranium at the foramen mag- all symptoms were relieved. num, is then continuous into the spinal cord as the Magoun,9 in 1962, pointed out the effect of tough covering of the spinal cord (spinal dura), and trauma caused by dental extraction techniques and extends to the second sacral segment, where it is described how trauma induces articular strains attached firmly to the bone on the anterior surface through the mandible into the temporal and of the sacral canal. The spinal dura is attached firmly sphenoid articulations and through the maxilla to to the second and third cervical vertebrae and at- the relations between the palatine process and tached loosely within the spinal canal to allow for sphenoid bones. He stated: spinal motion. In the sacral canal the filum ter- The mechanics of cranial lesions produced by dental extraction minale, which pierces the dura and drags off a can be summarized as follows: The lesion includes a membranous sheath from it, extends downward to blend with the articular strain in relation to the temporal, the sphenoid, the periosteum on the back of the coccyx. The inferior maxilla, and the mandible. On the lesioned side, the temporal bone is found to be crowded inward, with its petrous portion in end of the tube is thus securely anchored and held in internal rotation. The position of the pterygoid process of the places sphenoid is upward and lateral, whereas that of the maxilla is Thus, it is evident that a disturbance in position or downward. The mandible is malaligned at the temporomandibu- lar articulation. physiologic motion of the sacrum (pelvis) can di- rectly affect the base of the skull and the tension of He went on to describe the forces from the head- the cranial dura and its reduplications. Similarly, a rest of the dental chair and the twisting and lateral structural strain involving the first, second, and force of the dental forceps, which combine to pro- third cervical vertebrae and the occiput places the duce marked strains in the cranial articulations and spinal dura under tension that may extend into the lead to trigeminal neuralgia, particularly of the sec- entire base of the cranium. Conversely, a dental ond and third divisions. He stated: traumatic strain between the sphenoid and temporal Such abnormal physiology does not stop at the occiput. The bones may affect the occiput and the same cervical tem poromandibular joint is supplied by the masseteric and au- vertebrae. riculotem poral branches of the fifth cranial nerve. The three occipital and upper three cervical nerves on either side can be the Etiologic considerations site of excitation for a reflex manifested in a site of reference over the distribution of the first division of the fifth cranial nerve on In 1939 Sutherland published a treatise on cranial the forehead. articular mobility in which he stated: The muscular spasm of trismus, induced by irritation of the motor branches of the trigeminal nerve, is essentially no different I contend that articular fixations of the sphenoid and temporal from the muscular spasm of lumbago. Nor is the etiology of bones cause malalignments of the glenoid fossae; with conse- herpes in the scalp and face, as explained by affectations of the quent abnormal movement of the mandible or the inferior maxil- nerve root ganglion, at variance with the explanation offered for lary, like that of a wobbling wheel of a car due to malalignment of the same condition in the thoracic area. The gasserian ganglion is an axle. The phenomenon of overbiting is cited as an example. just as vulnerable to anabolic influences as any other. The fixations occurring in the articulations of the sphenoid and The nerve root leaves the pons and passes in a groove over the temporal bones, as I find frequently in cranial practice, cause a petrous ridge of the temporal to reach the ganglion lying in a stretching of the membrane embedding the gasserian ganglion; hollow on the anterior surface. Rotation of the petrous temporal
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can be a definite factor in irritative stretching of the nerve fibers. The reduplication of the dura, called Meckel s cave, in which the ganglion lies, can also be influenced by sphenopetrous and sphenosquamous lesions, thus producing metabolic disturbance. There are many further possibilities along the distribution of the three divisions, as they relate to the various facial bones.
The ophthalmic division may be disturbed by a nar- rowing or distortion of the superior orbital fissure through trauma to the frontal bone imposed on one or both of the lesser wings of the sphenoid bone. The nasociliary branches may be compressed by ar- ticular strains of the ethmoid and frontal bones. Fig. 2. Model of temporal bones viewed from back of head, showing Since all three divisions pass through apertures in the right temporal bone in external rotation (with the mastoid process the sphenoid bone to reach the facial structures, all caudad, the petrous apex high, and the squama temporalis deviated abnormal strain patterns (torsion, side-bending ro- laterally) and the left temporal bone in internal rotation. tation, and vertical and lateral strains) of the sphenoid bone in relation to the occiput must be considered possible etiologic factors in any or all the series of cases in which the roentgenographic studies peripheral branches. It follows that all articulations supported the findings of Sutherland. 7 He stated: between the sphenoid and the facial bones (ethmoid, This . . . suggested to Taarnh4j that pressure on the sensory root vomer, frontal, palatine, and zygoma) are possible might explain all cases of trigeminal neuralgia. From a study of areas of somatic dysfunction that may affect the the normal anatomy, he postulated that the logical place for such branches of the fifth cranial nerve. The maxillae do pressure to occur was at the narrow dural foramen where the nerve root crosses the apex of the petrous bone . not articulate directly with the sphenoid; the Taarnhqs theory and the success of this operation stimulated palatine bones lie between the pterygoid processes us to do a roentgenographic study of the . petrous ridges of 130 and the maxilla. The force used in extracting upper patients with trigeminal neuralgia. On the posterior-anterior views the relative height of the two petrous bones was compared molar teeth may grossly disturb the relation among and on the lateral views the height of the dens in relationship to maxilla, palatine bones, and pterygoid processes McGregor s line was measured. This line is drawn from the pos- and cause pain in the maxillary or mandibular divi- terior end of the hard palate to the lowest portion of the occipital bone for the purpose of determining the degree of basilar impre- sion or both. Trauma to or through the mandible ssion. In our series there were 84 women and 46 men with an may turn the sphenoid bone on its anteroposterior average age of 60.5 years. There were 13 patients (10 women and axis by the pull through the sphenomandibular lig- three men) with bilateral pain and seven patients with multiple sclerosis. This relatively high incidence reflects the fact that bilat- aments or may force the temporal bones out of bal- eral cases or patients with neurological findings were more cer- ance through the temporomandibular ligaments tain to be studied roentgenographically. This, therefore, was not and bony contact in the mandibular fossae. Thus, a wholly unselected series. Of the unilateral cases, the neuralgia was on the right side in 60 per cent and on the left in 40 per cent; the articulations between the sphenoid and tem- 62 per cent were women and 38 per cent men. Similar measure- poral bones are of prime importance, as stated by ments were made on the roentgenograms of 200 adults who did Sutherland. 7 If one temporal bone is forced into in- not have trigeminal neuralgia. This control series consisted of 104 women and 96 men with an average age of 45.7 years . ternal rotation and the other into external rotation, For ease of comparison in the data that follow, measurements the medial end or tip of the petrous portion proba- and percentages in the controls are indicated in parentheses. In bly will be higher on the side in external rotation the patients the apex of the right petrous bone was higher than that of the left in 46 per cent (controls, 47.5 per cent) The left (Fig. 2). was higher than the right in 34 per cent (controls, 29 per cent) ... Gardner," a neurosurgeon, reported in 1967 on a They were of equal height, i.e., less than 1 mm. difference, in 20
378/60 per cent (controls, 23.5 per cent). These figures show that the suggest that in trigeminal neuralgia there is a mechanical lesion apex of the right petrous bone is likely to project farther into the that produces a derangement of axons in the posterior root at a cranial cavity than that of the left, regardless of the presence of point of angulation or compression. The point of derangement trigeminal neuralgia. This finding may be related to the fact that may be at the petrous pyramid where increasing elevation of the more persons are right-handed and therefore inclined to use the pyramid with age alters the angle of the dural band and narrows right hand for lifting. In carrying a suitcase, for instance, the the opening into the cavum. Although this appears to be the cause contraction of the neck and shoulder muscles, particularly the of characteristic pain in the majority of cases, the compression trapezius, exerts a downward pull on the skull so that in effect the might be caused by a cirsoid aneurism of the superior cerebellar suitcase is partially suspended from the skull. This downward artery, or by an angioma or neoplasm such as a cholesteatoma of pull is countered by an upward thrust of the cervical spine which the cerebellopontine angle. tends to push in the base of the skull and with it the apex of the Relief of the neuralgia may be achieved by any method that petrous bone. In the trigeminal neuralgia series the pain was on separates the compressed axons. It may be accomplished by cut- the side of the higher petrous apex in 60 per cent and on the side ting the compressing dural band, decompressing the ganglion, of the lower in 20 per cent. In other words, trigeminal neuralgia cutting the tentorial edge, traumatizing the posterior root, per- occurred 3 times more often . on the side of the higher petrous forming saline stream neurolysis, or pulling on the dural foramen apex than on the side of the lower. In a series of 55 patients with with a blunt hook through a posterior fossa approach. typical trigeminal neuralgia, Bjerrum and Thornval also found that the trigeminal impression at the apex of the petrous bone showed an unmistakable tendency to lie at a higher level on the The foregoing statement was from a symposium affected side . . . [Fig. 3, this paper] on the trigeminal neuralgia, summary and conclu- The average height of the dens above McGregor s line in each sions 12 of which stated: decade in the female patients indicates that there is an upward progression of the dens with aging . . . This progression was not Electron microscopically, trigeminal neuralgia is characterized by obvious in the men with trigeminal neuralgia or in either sex in vacuolated but intact ganglion cells, degenerative hypermyelini- the younger control series, suggesting that postmenopausal os- zation, segmental demyelination with denuding of the axis cylin- teoporosis may cause basilar impression. When the base of the ders, and axonal thickenings and tortuosities. The abnormalities skull is pushed inward, the hind brain assumes a relatively more are much more marked than the degenerative changes seen in caudal position. Because of this, the posterior root becomes more normal ganglia . . . We concluded that the concept that there are angulated and flattened where it crosses the apex of the petrous no pathological changes in the Gasserian ganglion associated with bone. Such angulation cannot be recognized during a middle trigeminal neuralgia is no longer tenable .. . fossa exposure or at the usual autopsy. This is one reason for Consistent pathological changes of unknown etiology have pathologists failure to demonstrate a cause in this idiopathic been demonstrated in the trigeminal ganglia; they are most disease . . marked in patients with trigeminal altered neuralgia. These "de- Two of the 130 patients in our roentgenographic series had generative" changes could be the basis for altered neuronal func- Pager s disease of the skull, whereas this condition was found only tion. Mechanical factors such as petrous ridge compression or once in the survey of 700 consecutive roentgenograms of patients vascular pulsation, which might otherwise be of little significance, without trigeminal neuralgia. In each of these two patients, as the may combine with "degenerative" changes to produce an abnor- result of the softening of the skull, the tip of the dens was 8 mm. mal paroxysm of pain in response to a light sensory stimulus above McGregor s line . applied to the appropriate receptive field (trigger point). Roentgenographic studies support the theory arrived at inde- We can make no definitive statement as to the neurophysiologi- pendently by Lee, Olivecrona, and Taarnh4lj that trigeminal cal mechanism responsible for the paroxysm of pain. neuralgia may be produced by compression of the sensory root at the point where it crosses the apex of the petrous bone. They Thirty-five years after Sutherland s description of show a correlation between basilar impression, age, sex, and trigeminal neuralgia, and suggest that handedness may explain the functional basis for pain in the trigeminal nerve, the greater frequency of trigeminal neuralgia on the right side his palpatory observations were corroborated by and that postmenopausal osteoporosis with resulting basilar im- surgical and electron microscopic findings. The es- pression could account for the rising incidence of trigeminal neuralgia in aging women. sence of the osteopathic view of the problem was succinctly put by Magoun," as follows: In 1967 Malis 1 stated: Thus, it may be said with conviction that trauma producing a sphenopetrous distortion, with the attendant restriction of the We found a constant band of fibers crossing the posterior root at dural investiture, can be a definite etiologic factor. The strain may the petrous apex. These fibers curved outward, downward, and be over the petrous ridge or within Meckel s cave, as well as the backward from the anterior clinoid and were attached to the various foramina. Circulatory stasis and faulty cerebrospinal anterior surface of the petrous ridge lateral to its apex . . . We fluid metabolic function contribute to the irritability.
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to point to the painful area. If he touches his face and head, the condition is probably mild or moder- ate neuralgia, not tic douloureux. With the latter condition the patient will keep his hand a few inches from the face in order not to trigger the pain. He may not be able to speak or will avoid speaking. It may be necessary to get the history from a member of his family or ask him to write the answers to the physician s questions — at that time or before his next office visit. He should be asked where the pain is, how long it lasts, whether it is constant or intermit- tent, and if intermittent whether there is no pain or some pain between attacks, what brings on the pain — talking, chewing, heat, cold, touching certain areas or none of these — how long the pain has been present, how it started, whether there was an erup- tion of the skin in the painful area, whether the onset was associated with dental work or some other trauma to the face, whether the patient has been to a dentist for an examination, and whether x-ray study was done, and what other examinations and/or treatment have been tried by other physicians (in- cluding all procedures and medication tried). Fig. 3. Posteroanterior roentgenogram of the skull, showing the apex Besides a history of the presenting complaint, a of the petrous portion of the right temporal bone higher than the left. history of the patient s general health should be taken. This should include surgical procedures, other modalities, and current medication, any Surgical intervention would involve destruction of the gan- known structural problems, injuries, and trauma, glion, incision of the tentorium to decompress the root, or split- major and minor. He should be asked to think about ting of the dural plica causing the constriction. Destruction is not the various bumps or blows he may have had to his cure. It is far better to secure relief by correcting the structure, where possible. face or head or other parts of his body and to report them at a later visit. (Additional information will be History forthcoming from the patient as treatment Careful history taking is essential. A description of progresses.) the pain must be obtained and the incidents in the patient s past life that set the stage for and initiated Physical examination and aids pain must be uncovered. Nugent" stated: A general physical examination should include This is one condition that is diagnosed by the history alone; chemical evaluations of blood. An examination of therefore, some time should be spent in obtaining a careful anamnesis. the eyes, ears, nose, mouth, throat, and cervical lymph glands is necessary for locating any foci of This will include a description of the pain, its onset, infection, irritation, or abnormality. Dental x-ray character and intensity. The patient should be asked films may be needed for help in evaluating an infec-
380/62 tious process at the roots of teeth. X-ray films of the skull are helpful in viewing the nasal sinuses and the relative positions of the petrous ridges. These do not reveal cranial articular strains but may reveal bony asymmetry or erosion, osteoporosis, malignant change in bone, or Paget s disease. A structural examination of the pelvis, spine, thoracic cage, and cranium should be made, with attention to bony alignment and joint motion, mus- cular, fascial, and ligamentous tensions, and detec- tion by palpation of normal or restricted motion of the spinal and cranial dura mater. Motion is initiated gently by the palpating hand over the bony areas where the dura mater is firmly attached, and the physician observes whether the sacrum has normal Fig. 4. Palpation of sacrum to evaluate its motion on respiratory axis. motion on its respiratory axis and an anteropos- terior rocking motion of the base and apex of the sacrum on a horizontal axis through the second sa- cral segment while the patient is at rest, prone or portion of the temporal bones, and the clinoid proc- supine. Motion of the sacrum on its respiratory axis esses of the sphenoid bone. is involuntary, with a rate of about 12 excursions per Testing motion of the dura mater in the cranium minute. Marked restriction of motion is usual with requires a knowledge of the physiologic motion of trigeminal neuralgia (Fig. 4). each of the cranial bones, a matter too intricate to be With the patient supine, motion at the first, sec- included in this paper. Magoun° has described this. ond, and third cervical vertebrae is tested, and ten- The structural examination of the cranium includes derness, tension, and restriction of motion are testing motion of each of the temporal bones, the noted. The occiput and both temporal bones are sphenoid bone, occiput, and vault and facial bones. observed with both hands cupped under the occiput Restrictions of motion and bony malalignment are and the thumbs lying along the mastoid portions of noted. the temporal bones just behind the ears (Figs. 5A With the patient s mouth closed his temporoman- and B). The physician determines whether the occi- dibular joints are palpated gently for symmetry, put is level or if one side is nearer the shoulders tenderness, and tension of the masseter muscles (more caudad) than the other. The tips of the mas- bilaterally. During light palpation over the tern- toid processes should be observed to determine poromandibular joints, the patient is directed to whether one is lower and more medial (toward the open his mouth slowly (Figs. 6A and B). the excur- transverse process of the atlas) than the other. If the sion of the mandible, deviation of the midline of the palpating hands detect that the temporal bones are chin to one side, and smoothness of glide are noted. not symmetric in relation to the occiput, there is an TravelP 5 stated that the full excursion of the mandi- abnormal stress in the tentorium cerebelli owing to ble can be gauged by the ability of the patient to the attachment of that structure to the inside of the insert the knuckles of three fingers between the squama of the occiput, the mastoid angles of the upper and lower incisors. Excursion of the mandible parietal bones, the superior ridge of the petrous will be restricted to some degree when the mandibu-
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Figs. 5Aand B. Palpation of occiput and temporal bones with both hands cupped under the occiput and the thumbs lying along the mastoid portions of the temporal bones just behind the ears.
Figs. 6A and B. During light palpation over the temporomandibular joints (left and above), the patient is directed to open her mouth slowly.
lar division is painful. Some patients will tolerate almost no motion of the temporomandibular joints. The muscles of mastication of the affected side will be tense, sometimes spastic. As the physician ob-
382/64 serves the excursion, deviation from midline, and possible side-shifting of the heads of the mandible and correlates the findings with the deviation of the temporal bones, he can ascertain the strain pattern in the base of the cranium. With the palpating hands on either side of the vault of the cranium, the physician observes the rate and amplitude of the cranial rhythmic impulse," which is normally about 12 per minute (Fig. 7). If the motion of the dura mater is restricted, the rate and amplitude will be lower than normal. Low rate and amplitude are usual with trigeminal neuralgia. With intractable trigeminal pain, neoplasms of the central nervous system must be suspected and ruled out. A lumbar puncture and examination of the cerebrospinal fluid may reveal abnormalities in Fig. 7. With the palpating hands on the sides of the vault of the cranium, pressure and chemical composition. Electroenceph- the rate and amplitude of the cranial rhythmic impulse are observed. alography and a roentgenographic brain scan may be indicated to reveal neoplasms within the cranium.
Diagnosis Treatment The initial diagnosis of neuralgia of one or more The aims of osteopathic management of trigeminal divisions of the trigeminal nerve is suggested by the neuralgia are as follows: patient s history and description of his complaint. (1) to release the membranous strains of the The structural diagnosis of articular strain in the cranium and the ligamentous strains of the tem- cranium is made by the results of palpatory exami- pormandibular joints (Figs. 8A and B); nation. (2) to release the ligamentous strain of the sa- Differential diagnosis from dental infection, crum so that it has normal physiologic motion on its malocclusion, nasal sinus infection, and herpes is respiratory axis and at both sacroiliac joints (Wilson necessary. Roentgenographic studies and other and Muir8 reported a case in which the pain was measures previously mentioned will assist in diag- triggered by touching the right sacroiliac area. With nosis. Tumors and aneurysms must be ruled out persistent treatment to normalize that area, the pain when the condition is intractable. Multiple sclerosis was relieved); rarely causes pain identical with trigeminal neural- (3) to release all strains in spinal articulations gia, but with that degenerative disease there usually (somatic dysfunction), including the upper cervical is other involvement of the nervous system, and the and thoracic and costovertebral articulations (sym- disease usually affects young adults. Nugent" pathetic nerve supply); stated: (4) to provide supportive measures, including administration of supplementary B vitamins, cal- Horton s or cluster headache frequently causes unilateral pain in cium, a food supplement high in nutrients, and vit- the forehead, temple or around the eye, but this usually comes on amins in liquid form if the patient cannot chew food, during the night, lasts longer than the paroxysms of trigeminal neuralgia and causes in addition, redness and tearing of the eye and psychologic support. and stuffiness of the nose on the involved side, An explanation of the nature of the cranial strain
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Figs. 8A and B. Position of hands for release of articular strain between right temporal and sphenoid bones.
and the procedure planned are the best medicine cranial articular strains (somatic dysfunction) and the physician can offer a patient who has been told early and expert manipulative treatment. Educating he must "learn to live with his pain" or submit to a the dental profession in cranial articular mobility radical surgical procedure, which may bring only would be a valuable step in preventive medicine in temporary relief and destroy the sensory function of this area. The patient often seeks help from the half of his face as "the price he has to pay." dentist before he consults his physician. Coopera- These conservative measures should be pursued tion between professional men and women in fully before radical medical treatment (injection of treatment of trigeminal neuralgia promises the best alcohol into the nerve) or surgical procedures are possible patient care. recommended. The value of a conservative ap- proach to releasing the tension on the dural band Report of cases compressing the nerve root by releasing the articu- Case 1 lar strain between the petrous portion of the tem- A woman aged 50 had been treated for several years poral bone and sphenoid bone is suggested by the for a low-back complaint and headache with satisfac- data here presented. If this osteopathic procedure tory results. After about 8 months in which she had can be carried out before there are extensive de- not needed treatment, she presented herself be- generative changes in the ganglion, the prognosis is cause of pain in the left side of her face. It had good. If degenerative changes are extensive, the started about 10 days previously, and was intermit- prognosis is guarded. In my experience the condi- tent and seemed to be in the left upper bicuspid tion in most cases responds to conservative treat- teeth. When asked where the pain was now, she ment, particularly if this is begun early. pointed to her left cheek and upper lip and into the The keys to successful treatment of this painful left temple and stated that her teeth also hurt. She condition are early and accurate diagnosis of the had gone to her dentist, and dental x-ray study had
384/66 revealed nothing abnormal. In response to ques- might be a change in the character or intensity of the tioning about trauma to her face or head, she stated pain, suggesting infectious origin. After 24 hours of that about 3 weeks before, when she was putting a oral medication, the pain and throbbing had de- leash on her large German shepherd dog, he raised creased. These results and the procedures used his head suddenly as she was bent forward, and the were reported to the dentist. He removed a filling top of his head struck her face in the area of the left and did a root canal procedure. When he removed cheek. She recalled that it felt like he "knocked my the nerve a minute droplet of pus that could not be head off." Facial pain had started a few days later. detected by usual dental diagnostic procedures was Palpatory examination revealed normal excur- seen at the end of the root canal. sion of the facial structures on the right and a dis- This case illustrates a combination of traumatic turbed or unphysiologic pull or drag downward on cranial strain and an obscure dental infection. The the left side. Testing of motion of the cranium dental infection came to light after the strain had showed that all the articulations on the left side of been relieved. The minor trigeminal neuralgia was the head — maxilla, zygoma, great wing, parietal relieved completely by the combined efforts of the and temporal bones, and left side of the occiput — dentist and osteopathic physician for about 4 weeks. were much restricted. The left temporal bone was in Without treatment for both the cranial articular internal rotation, and no physiologic motion could strain and the dental infection, the patient might be elicited. The cervical spine was tense and tender have had a much longer and more painful episode. bilaterally along the first four cervical vertebrae, with moderate limitation of motion. The thoracic Case 2 and lumbar portions of the spine showed nothing A woman aged 65 complained of intermittent sharp remarkable. The sacrum was level, with moderate jabbing pain in the right side of her face of about 3 motion on the right and no motion on the left side. weeks duration. Questioning elicited the informa- The patient was treated for release of the multiple tion that the pain was in the area of the right maxil- articular strains of the left side of the cranium, cervi- lary sinus, upper molar teeth, cheekbone, temple, cal spine, and pelvis. The pain decreased after the and right ear. Cold air aggravated the pain. She had first and second treatments. At the third visit the had her right upper second and third molars ex- patient reported that the pain in her cheekbone, tracted 2 months before. The gum and root area had face, and temple had nearly gone, but in the upper remained sore, and she returned to the dental dental area pain remained sharp, "like a toothache." surgeon to see if there was some dental reason for She was treated for the remaining strain in the the pain. He assured her that her gums were healing cranium and pelvis and directed to see her dentist normally. Two weeks before she had consulted an for a recheck of her teeth. Again he could find otorhinolaryngologist over the possibility of a sinus nothing abnormal on examination of her mouth or problem. He gave her an antibiotic, but the pain on x-ray study. persisted and increased in intensity. At the fourth visit the patient said that the pain in Palpation revealed that the entire right side of the her teeth had increased and was throbbing. Palpa- cranium was immobile, and the left side had limited tion showed normal physiologic motion of the cra- motion. The right maxilla was in internal rotation; nial and facial structures, and my impression was the sphenoid wing was a little lower on the right, the that release of the traumatic cranial strain had been right temporal bone was fixed in external rotation, accomplished. Tetracycline, 250 mg. four times a and the occiput was more caudad on the right than day, was prescribed to determine whether there on the left. The right maxilla, palatine bone, and
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pterygoid process were crowded and compressed on the right side, with no relief of pain. She had had posteriorly, and the tissues in the sphenopalatine her teeth ground repeatedly in an attempt to get fossa were exquisitely tender. The suboccipital mus- normal occlusion. She had been sent to a dental cles were tense and tender, with some limitation of specialist, who made a plastic mouth splint, but this motion at the first three cervical vertebrae. There had put too much pressure on the right tem- was normal motion of the thoracic and lumbar por- poromandibular joint, and she could not wear it. A tions of the spine. The sacrum was level but had roentgenologist had said that she had beginning limited motion on its respiratory axis. The cranial arthritis of the temporomandibular joint. After sev- rhythmic impulse rate was 7 per minute. eral months of continued pain she had been re- Four osteopathic manipulative treatments were ferred to a neurologist, who told her that nothing given at weekly intervals for release of the cranial could be done and that the condition might lead to articular strains and restoration of normal motion of facial paralysis. Needless to say, the patient s psycho- the cranium and sacrum. Progress was steady, with logic state was poor. gradual diminution in intensity and frequency of She said that pain was present all the time, with the pain. periods of increased intensity. Cold air aggravated This case is an example of tic douloureux of the it, and using her right arm for any period, as for maxillary division caused by dental trauma. The ironing, aggravated the pain in the upper part of her principal strain was at the maxillary, palatine, and back, neck, and right side of her head. There was no pterygoid articulations, with lesser strain between palpable motion in the cranial articulations. The the petrous portion of the temporal bone and mandible deviated to the left of the midline when sphenoid. The typical lancinating type of pain did she opened her mouth. Excursion was limited by not start until about 5 or 6 weeks after the extraction. pain and muscular tension. The cranial rhythmic Early diagnosis and treatment aborted what might impulse rate was 6 per minute and of low amplitude. have been severe neuralgia. The pelvis and lumbar, thoracic, and cervical por- tions of the spine showed marked tension, restricted Case 3 motion, and tenderness, with extreme limitation of In a case of dental traumatic strain superimposed on motion of the upper right thoracic portion and ribs. an old structural strain, the patient was a woman Long-term treatment — 35 treatments over 2 aged 31, the mother of four children, and of slight years — was required. The temporal bones were stature. Several years earlier she had had a whip- severely malaligned, maintaining a painful strain in lash-type injury to the upper part of her back and the right temporomandibular joint. The traumatic neck, which had been relieved by osteopathic treat- dental extraction plus surgery on the right maxilla ment. After a considerable interval, she had strained had driven it backward and inward so forcefully that the upper part of her back and right shoulder in try- months of treatment were required to release it ing to move a washing machine and again had been fully. The pelvis was unstable. Structural x-ray treated for structural strain of the pelvis and spine. studies revealed a 3/8-inch difference in length of Two years later she returned with a complaint of the lower extremities. A lift on the left heel relieved pain in the right side of her face along the upper and the persistent pain in the right upper part of her lower jaws and in the temporomandibular joint and back. This in turn helped relieve the strain in the right ear. She had had an impacted right upper right side of the cervical spine and right side of the molar "chiseled out" and additional dental surgery head. Nutritional supplements were advised, and to chisel some bone off the outside of the upper jaw psychologic support was given.
386/68 As the temporal bones were released and the bothered her for 18 years. There was a trigger area malalignment of the base of her skull decreased, the on the right cheek lateral to the right nostril. mandible gradually returned to balance without Her nose had been broken in 1924, and she had midline deviation. Some further grinding of the oc- sustained a minor skull fracture in 1929. Dental clusal surfaces of the teeth was needed to counter- treatment involving removal of nerves in her front balance the grinding that had been done when the teeth was done in 1936, and in 1937 and 1938 caps mandible was in severe strain. The right tem- had been applied to the dead front teeth. In 1939 poromandibular joint became free of pain and com- she had undergone surgery to the nose to facilitate fortable when she ate. Tenderness in the third molar breathing on the right side. In 1944 she had under- area of the right maxilla persisted. The cranial gone childbirth with caudal anesthesia, and in 1946 rhythmic impulse increased to 11 per minute. root canal work had been done on a right front tooth The condition here was not tic douloureux, but to remove an abscess. The pain in the right side of neuralgia involving the second and third division of her face had started in 1950, and two lower right the trigeminal nerve as a result of severe strain of the molars were removed in 1951. In that year the ab- entire base of the cranium, facial bones, and right scess recurred where the root canal work had been temporomandibular joint. done, and the right front teeth were removed. The The condition does not respond in all cases as in right upper three molars were removed in 1954 and those herein reported. If alcohol has been injected 1955; a section of bone was removed from the right in the nerve, progress is slow. As the cranial articular side of the upper jaw in 1956, and the nose was strains are released, the patient has to endure a operated on for deviation of the septum in 1960. All period when the character of pain changes from the procedures done after 1950 were attempts to intermittent stabs to a deep painful soreness of the find the cause of pain in her face. In 1965, alcohol face while the nerve is regenerating and healing was injected into the nerve. This gave only a little from the noxious effect of the destructive irritant. relief. In 1965 an encephalogram showed nothing After surgical incision of the nerve the condition abnormal. does not respond well to manipulative treatment During the 18 years this condition had been pres- of the cranium because the surgical procedure inter- ent, there had been several periods of from 1 to 3 rupts the normal motion of the dural membranes months and one period of 6 months when she had with adhesion formation, and obviously the function no pain. One period was during a winter she spent of the severed nerve cannot be restored. Case 4 on the East coat. This led her physician to seek an illustrates this. answer in the field of allergy. She was tested and given a strict diet avoiding foods to which she was Case 4 allergic. She adhered to this. She also had hypo- In a case of long-standing lancinating pain which glycemia and had learned that if she ate about every came in paroxysms, the patient, a woman aged 58, 2 hours, the severity of pain was reduced. She used a was somewhat underweight and had the facial ap- blender to prepare food with added supplements so pearance of anguish and suffering. She was unable that she could drink her meal and avoid chewing. to talk much at her first visit in 1968, and the history The pain involved the right maxillary and man- was obtained by requesting her to write it at home dibular nerves and at times had included the and bring it at the second visit. ophthalmic nerve, but this was not painful at her Her chief complaint was of pain in the right side of first visit. Palpatory examination revealed no her face, which occurred in paroxysms and had physiologic motion in any area of the cranium and
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none at the sacrum. The motion of the lumbar spine Conclusion was limited about 50 percent in all directions; the Neuralgia of the trigeminal (fifth cranial) nerve is a thoracic spine was much restricted, as were the ribs painful syndrome affecting an area of the face sup- on both sides, and the cervical spine was limited plied by one or more branches of the nerve. The about 50 percent in forward and backward bending cause of this painful condition has long been ob- and in right and left rotation. The limitation of scure. Sutherland s observation of a stretching of the motion appeared to be in the periarticular tissues, membrane embedding the gasserian ganglion due which were extremely tense. The patient had held to articular strain between the petrous portion of the herself so tense for 18 years, guarding her head and temporal bone and the sphenoid has been sup- body from any undue motion which tended to trig- ported by other authorities, who have observed a ger the pain, that her musculature was chronically mechanical lesion that produces a derangement of rigid. The cranial rhythmic impulse was low in am- axons in the posterior root near the petrous apex. plitude, with a rate of 6. It was imperceptible to pal- Definite degenerative changes in the nerve cells, pation at the sacrum. axons, and myelin sheaths within the ganglion have The cranium showed compression of the been observed in cases of trigeminal neuralgia. sphenobasilar symphysis. The right temporal bone Roentgenographic studies show that the petrous was in external rotation and the left in internal rota- apex is higher on one side than on the other in 80 tion. The right maxilla was in marked internal rota- percent of patients studied. There appeared to be a tion and compressed or driven posteriorly into the correlation between -age, sex, handedness, and the palatine bone and pterygoid process. The compres- predominance of trigeminal neuralgia occurring on sion and jamming of this area were extreme, with the right side. the right side of the sphenoid and right temporal Trauma to the mandible, face, or cranium creates bones impacted. membranous and ligamentous articular strains This patient was treated at weekly intervals for (somatic dysfunction) of the cranium as well as to about 6 months. During that period there was other articulations of the skeletal system. An articu- gradual improvement in her health and well-being, lar strain between the petrous portion of the tem- but the lancinating pain in her face continued. poral bone and sphenoid can be diagnosed by palpa- There were periods when it seemed to lessen in tion and released by gentle osteopathic manipulative intensity and frequency. She felt better and slept procedures. better; her vitality and spinal mobility improved; she Osteopathic management of this neuralgia is walked and moved more freely, and there was less aimed at early diagnosis and release of the dural anguish in her voice and expression. The tern- stresses of cranial articular strains as well as strains poromandibular joints became less painful and (somatic dysfunction) of the whole body structure. more mobile, and she chewed soft foods without triggering pain, but the pattern of intermittent lan- cinating pain continued. Treatment was discon- tinued when the patient moved to another state. In this case long-standing tic douloureux had 1. Finneson, B.E.: Diagnosis and management of pain syndromes. Ed. 2. W.B. Saunders Co., Philadelphia, 1969 been brought on by repeated trauma to the head 2. Jannetta, P.J.: Trigeminal and glossopharyngeal neuralgia. In Current and face and was complicated by injection of alcohol diagnosis 3, edited by H.F. Conn and R.B. Conn, Jr. W.B. Saunders Co., into the nerve. This trigeminal neuralgia did not Philadelphia, 1971 3. Boyd, J.D., et at: Textbook of human anatomy, edited by W.J. Hamil- improve with treatment. ton. Macmillan Co., New York, 1957
388/70 4. Gray, H.: Anatomy of the human body. Ed. 29. Edited by C.M. Goss. Lea and Febiger, Philadelphia, 1973 5. Romanes, G.J., Ed.: Cunningham s textbook of anatomy. Ed. 11. Ox- ford University Press, London, 1972 6. Magoun, H.L.: Osteopathy in the cranial field, Ed. 2. Journal Printing Co., Kirksville, Mo. 1966 7. Sutherland, W.G.: The cranial bowl. Free Press Co., Mankato, Minn., 1939 8. Wilson, P.T., and Muir, W.P.: Tic douloureux. Yearbook of Academy of Applied Osteopathy, 1946, pp. 47-55 9. Magoun, H.I.: Osteopathic approach to dental enigmas. JAOA 62:110- 8, Oct 62 10. Gardner, W.J.: Trigeminal neuralgia. Clin Neurosurg 15:1-56, 1968 11. Malls, L.I.: Petrous ridge compression and its surgical correction. J Neurosurg 26:163-7, Jan 67 12. Beaver, D.L., et al.: Structural aspects of trigeminal neuralgia. A sum- mary of current findings and concepts, J Neurosurg 26:109-90, Jan 67 13. Magoun, H.I.: Entrapment neuropathy of the central nervous system. Part 111. Cranial nerves V, IX, X, XI. JAOA 67:889-99, Apr 68 14. Nugent, G.R.: Trigeminal and glossopharyngeal neuralgia. In Cur- rent diagnosis, edited by H.F. Conn, R.J. Clohecy, and R.B. Conn, Jr. W.B. Saunders Co., Philadelphia, 1966 15. Travell, J.: Lecture on head pain. Convocation of American Academy of Osteopathy, Colorado Springs, May 25, 1973 16. Frymann, V.M.: A study of the rhythmic motions of the living cra- nium. JAOA 70:928-45, May 71 17. Baker, E.G.: Alteration in width of maxillary arch and its relation to sutural movement of cranial bones. JAOA 70:559-64, Feb 71 Bjerrum, J., and Thornval, G.: Roentgenographic findings in trigeminal neuralgia. Acta Radiol (Stockh) 51:289-96, Apr 59 Lee, F.C.: Trigeminal neuralgia. J Med Assoc Ga 26:431, Aug 37 Olivecrona, H.: La Cirugia del dolor. Arch Soc Cirujanos Hosp 17:366-72, June 47 Taarnh4j, P.: Decompression of the trigeminal root and the posterior part of the ganglion as treatment in trigeminal neuralgia. Preliminary com- munication, J Neurosurg 9:288-90, May 52
Submitted for publication in April 1974. This paper was submitted as partial fulfillment of the require- ments for fellowship in the American Academy of Osteopathy.
Dr. Lay is assistant professor in the Depart- ment of Osteopathic Theory and Practice, Kirksville College of Osteopathic Medicine, Kirksville, Missouri. Dr. Lay, Kirksville College of Osteopathic Medicine, Kirksville, Missouri 63501.
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