13.1.2.3 Painful post-traumatic trigeminal neuropathy

Identification: 32-year-old male patient, victim of a car accident 6 months ago, with a skull base fracture and traumatic injury to the trigeminal nerve. History of Present Illness: Initial Event: Craniofacial trauma: Fracture of the right temporal bone extending to the foramen ovale Retro-orbital hematoma Coma for 72 hours (GCS 6 on admission) Current Pain: Location: Territory of right V2 (maxillary) and V3 (mandibular) Characteristics: Continuous pain: Deep burning (7/10 on VAS) Paroxysms: Stabbing lancinating pain (9/10), 5-15 episodes/day Neuropathic phenomena: Thermal allodynia (aversion to warm liquids) Hyperpathia to chin percussion Associated symptoms: "Tingling" paresthesias in the lower lip Ipsilateral masticatory weakness Physical/Neurological Examination: Traumatic sequelae: Facial asymmetry due to masseter atrophy Post-temporal craniotomy scar Trigeminal assessment: Sensory: Hypoesthesia to pinprick in V2-V3 Hyperesthesia to light touch on the lip Motor: Paresis of the medial pterygoid muscle (mandibular deviation to the right) Reflexes: Ipsilateral corneal reflex abolished Masseteric reflex diminished Complementary Exams: 3T Magnetic Resonance Imaging (Neurography): Avulsion injury of the mandibular branch at the foramen ovale "Pseudo-meningocele" neuroma of the Gasserian ganglion Electromyography of Upper Limbs: Acute denervation activity in masticatory muscles Trigeminal Evoked Potentials: Absence of ipsilateral N13 potential