Trigeminal nerve

• Also known as the fifth cranial nerve, cranial nerve V, or simply CN V
• It is a cranial nerve responsible for sensation in the face and motor functions such as biting and chewing
• It is the most complex of the cranial nerves
• It have three major branches: Ophthalmic nerve (V₁), Maxillary nerve (V₂), Mandibular nerve (V₃).
  • Ophthalmic and maxillary nerves are purely sensory
  • Mandibular nerve supplies motor and sensory functions
  • It has also autonomic nerve fibers as well as special sensory fibers for taste.

Structure[edit]

Origin[edit]

From the trigeminal ganglion, a single, large sensory root (radix sensoria s. portio major) enters the brainstem at the level of the pons. Immediately adjacent to the sensory root, a smaller motor root (radix motoria s. portio minor) emerges from the pons slightly rostrally and medially to the sensory root.

Motor fibers pass through the trigeminal ganglion without synapsing on their way to peripheral muscles, their cell bodies being located in the nucleus of the fifth nerve, deep within the pons.

Trigeminal ganglion[edit]

The three major branches of the trigeminal nerve—the ophthalmic nerve (V₁), the maxillary nerve (V₂) and the mandibular nerve (V₃)—converge on the trigeminal ganglion (also called the semilunar ganglion or gasserian ganglion), located within Meckel's cave and containing the cell bodies of incoming sensory-nerve fibers. The trigeminal ganglion is analogous to the dorsal root ganglia of the spinal cord, which contain the cell bodies of incoming sensory fibers from the rest of the body.

Sensory branches[edit]

The ophthalmic, maxillary and mandibular branches leave the skull through three separate foramina: the superior orbital fissure, the foramen rotundum and the foramen ovale, respectively. The ophthalmic nerve (V₁) carries sensory information from the scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses and parts of the meninges (the dura and blood vessels). The maxillary nerve (V₂) carries sensory information from the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses and parts of the meninges. The mandibular nerve (V₃) carries sensory information from the lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw, which is supplied by C2-C3), parts of the external ear and parts of the meninges. The mandibular nerve carries touch-position and pain-temperature sensations from the mouth. Although it does not carry taste sensation (the chorda tympani is responsible for taste), one of its branches—the lingual nerve—carries sensation from the tongue.

The peripheral processes of mesencephalic nucleus of V neurons run in the motor root of the trigeminal nerve and terminate in the muscle spindles in the muscles of mastication. They are proprioceptive fibers, conveying information regarding the location of the masticatory muscles. The central processes of mesencephalic V neurons synapse in the motor nucleus V.

Dermatomes

• V1/V2 distribution – Referring to the ophthalmic and maxillary branches
• V2/V3 distribution – Referring to the maxillary and mandibular branches
• V1-V3 distribution – Referring to all three branches

Nerves on the left side of the jaw slightly outnumber the nerves on the right side of the jaw.

Function

• Sensory function: Tactile, proprioceptive and nociceptive afference to the face and mouth.
• Motor function: Mastication muscles, Tensor tympani, Tensor veli palatini, Mylohyoid and the anterior belly of the digastric.
• Somatic afferent fibers, which innervate the skin of the face via ophthalmic (V1), maxillary (V2) and mandibular (V3) divisions.
• Special visceral efferent axons, which innervate the muscles of mastication via the mandibular (V3) division.

Muscles[edit]

The motor component of the mandibular division (V3) of the trigeminal nerve controls the movement of eight muscles, including the four muscles of mastication: the masseter, the temporal muscle, and the medial and lateral pterygoids. The other four muscles are the tensor veli palatini, the mylohyoid, the anterior belly of the digastric and the tensor tympani.

With the exception of the tensor tympani, all these muscles are involved in biting, chewing and swallowing and all have bilateral cortical representation. A unilateral central lesion (for example, a stroke), no matter how large, is unlikely to produce an observable deficit. Injury to a peripheral nerve can cause paralysis of muscles on one side of the jaw, with the jaw deviating towards the paralyzed side when it opens. This direction of the mandible is due to the action of the functioning pterygoids on the opposite side.

Sensation[edit]

Main article: Somatosensory system

The two basic types of sensation are touch-position and pain-temperature. Touch-position input comes to attention immediately, but pain-temperature input reaches the level of consciousness after a delay; when a person steps on a pin, the awareness of stepping on something is immediate but the pain associated with it is delayed.

Touch-position information is generally carried by myelinated (fast-conducting) nerve fibers, and pain-temperature information by unmyelinated (slow-conducting) fibers. The primary sensory receptors for touch-position (Meissner's corpuscles, Merkel's receptors, Pacinian corpuscles, Ruffini's corpuscles, hair receptors, muscle spindle organs and Golgi tendon organs) are structurally more complex than those for pain-temperature, which are nerve endings.

Sensation in this context refers to the conscious perception of touch-position and pain-temperature information, rather than the special senses (smell, sight, taste, hearing and balance) processed by different cranial nerves and sent to the cerebral cortex through different pathways. The perception of magnetic fields, electrical fields, low-frequency vibrations and infrared radiation by some nonhuman vertebrates is processed by their equivalent of the fifth cranial nerve.

Touch in this context refers to the perception of detailed, localized tactile information, such as two-point discrimination (the difference between touching one point and two closely spaced points) or the difference between coarse, medium or fine sandpaper. People without touch-position perception can feel the surface of their bodies and perceive touch in a broad sense, but they lack perceptual detail.

Position, in this context, refers to conscious proprioception. Proprioceptors (muscle spindle and Golgi tendon organs) provide information about joint position and muscle movement. Although much of this information is processed at an unconscious level (primarily by the cerebellum and the vestibular nuclei), some is available at a conscious level.

Touch-position and pain-temperature sensations are processed by different pathways in the central nervous system. This hard-wired distinction is maintained up to the cerebral cortex. Within the cerebral cortex, sensations are linked with other cortical areas.

Sensory pathways

• Sensory pathways from the periphery to the cortex are separate for touch-position and pain-temperature sensations.
• All sensory information is sent to specific nuclei in the thalamus.
• Thalamic nuclei, in turn, send information to specific areas in the cerebral cortex. Each pathway consists of three bundles of nerve fibers connected in series:

The secondary neurons in each pathway decussate (cross the spinal cord or brainstem), because the spinal cord develops in segments. Decussated fibers later reach and connect these segments with the higher centers. The optic chiasm is the primary cause of decussation; nasal fibers of the optic nerve cross (so each cerebral hemisphere receives contralateral—opposite—vision) to keep the interneuronal connections responsible for processing information short. All sensory and motor pathways converge and diverge to the contralateral hemisphere.

Although sensory pathways are often depicted as chains of individual neurons connected in series, this is an oversimplification. Sensory information is processed and modified at each level in the chain by interneurons and input from other areas of the nervous system. For example, cells in the main trigeminal nucleus (Main V in the diagram below) receive input from the reticular formation and cerebellar cortex. This information contributes to the final output of the cells in Main V to the thalamus.

Touch-position information from the body is carried to the thalamus by the medial lemniscus, and from the face by the trigeminal lemniscus (both the anterior and posterior trigeminothalamic tracts). Pain-temperature information from the body is carried to the thalamus by the spinothalamic tract, and from the face by the anterior division of the trigeminal lemniscus (also called the anterior trigeminothalamic tract).

Pathways for touch-position and pain-temperature sensations from the face and body merge in the brainstem, and touch-position and pain-temperature sensory maps of the entire body are projected onto the thalamus. From the thalamus, touch-position and pain-temperature information is projected onto the cerebral cortex.

Summary

The complex processing of pain-temperature information in the thalamus and cerebral cortex (as opposed to the relatively simple, straightforward processing of touch-position information) reflects a phylogenetically older, more primitive sensory system. The detailed information received from peripheral touch-position receptors is superimposed on a background of awareness, memory and emotions partially set by peripheral pain-temperature receptors.

Although thresholds for touch-position perception are relatively easy to measure, those for pain-temperature perception are difficult to define and measure. "Touch" is an objective sensation, but "pain" is an individualized sensation which varies among different people and is conditioned by memory and emotion. Anatomical differences between the pathways for touch-position perception and pain-temperature sensation help explain why pain, especially chronic pain, is difficult to manage.

Clinical significance

• Trigeminal neuralgia
• Cluster headache
• Migraine
• Lateral medullary syndrome