Statement of Principles

concerning

TRIGEMINAL NEURALGIA OR TRIGEMINAL NEUROPATHY
(Balance of Probabilities)

(No. 85 of 2024)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 18 October 2024.

Professor Terence Campbell AM

Chairperson

by and on behalf of

The Repatriation Medical Authority

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1.                Name

This is the Statement of Principles concerning trigeminal neuralgia or trigeminal neuropathy (Balance of Probabilities) (No.85 of 2024).

1.                Commencement

              This instrument commences on 19 November 2024.

1.                Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

1.                Repeal

The Statement of Principles concerning trigeminal neuropathy (No. 80 of 2015) (Federal Register of Legislation No. F2015L00912) and trigeminal neuralgia (No 78 of 2015) (Federal Register of Legislation No. F2015L00910) made under subsection 196B(3) of the VEA are repealed.

1.                Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

1.                Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

1.                Kind of injury, disease or death to which this Statement of Principles relates
   1.           This Statement of Principles is about trigeminal neuralgia or trigeminal neuropathy and death from trigeminal neuralgia or trigeminal neuropathy.

Meaning of trigeminal neuralgia or trigeminal neuropathy

1.           For the purposes of this Statement of Principles:

trigeminal neuralgia:

1.           means a clinical facial pain syndrome characterised by recurring paroxysmal attacks of severe, electric shock-like, shooting, stabbing or sharp pain lasting from a fraction of a second to 2 minutes, occurring in the distribution of one or more divisions of the trigeminal nerve, which are precipitated by innocuous stimuli to the affected side of the face; and
2.            includes classical trigeminal neuralgia and secondary trigeminal neuralgia; and
3.            excludes:
   1.             dental or periodontal pain of local origin;
   2.          facial presentations of primary headache disorders;
   3.         glossopharyngeal neuralgia;
   4.         postherpetic neuralgia;
   5.           short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT); and
   6.         trigeminal neuropathy.

Note 1: The trigeminal (or fifth cranial) nerve arises from the lateral surface of the mid-pons and traverses the middle cranial fossa to Meckel’s cave, where the trigeminal ganglion splits into three divisions (ophthalmic, maxillary and mandibular). The trigeminal nerve includes sensory and motor nuclei in the brainstem.

Note 2: The trigeminal nerve provides sensory innervation to the face, teeth, mouth and nasal cavity, and motor innervation to the facial muscles involved in mastication.

Note 3: Trigeminal neuralgia is also known as tic douloureux.

trigeminal neuropathy:

1.           means continuous or near-continuous facial pain, characterised as burning, squeezing, aching or like pins and needles, that occurs in the distribution of one or more branches of the trigeminal nerve, and/or symptoms or signs of impaired motor, sensory or autonomic functioning in the distribution of the trigeminal nerve; and

1.            includes:
   1.             neuropathy confined to the trigeminal nerve;
   2.           neuropathy of the trigeminal nerve occurring simultaneously with other cranial nerve disorders; and
   3.         trigeminal sensory neuropathy; and
2.            excludes:
   1.              persistent idiopathic facial pain; and
   2.           trigeminal neuralgia (classical and secondary).

Note 1: The trigeminal (or fifth cranial) nerve arises from the lateral surface of the mid-pons and traverses the middle cranial fossa to Meckel’s cave, where the trigeminal ganglion splits into three divisions (ophthalmic, maxillary and mandibular). The trigeminal nerve includes sensory and motor nuclei in the brainstem.

Note 2: The trigeminal nerve provides sensory innervation to the face, teeth, mouth and nasal cavity, and motor innervation to the facial muscles involved in mastication.

1.           While trigeminal neuralgia attracts ICD 10 AM code G50.0, in applying this Statement of Principles the meaning of trigeminal neuralgia is that given in subsection (2).
2.           For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from trigeminal neuralgia or trigeminal neuropathy

1.           For the purposes of this Statement of Principles, trigeminal neuralgia or trigeminal neuropathy, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's trigeminal neuralgia or trigeminal neuropathy.

Note: terminal event is defined in the Schedule 1 – Dictionary.

1.                Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that trigeminal neuralgia or trigeminal neuropathy and death from trigeminal neuralgia or trigeminal neuropathy can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

1.                Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, trigeminal neuralgia or trigeminal neuropathy or death from trigeminal neuralgia or trigeminal neuropathy is connected with the circumstances of a person's relevant service:

1.           having maxillary, sphenoid or frontal sinus barotrauma involving the affected trigeminal nerve, within the 3 months before clinical onset or clinical worsening of trigeminal neuropathy;
2.           having one of the following traumatic injuries to the affected trigeminal nerve:
   1.           mechanical injury caused by compression, crush, transection or stretching;
   2.           chemical burn;
   3.           thermal burn;

within the 3 months before clinical onset or clinical worsening of trigeminal neuropathy;

1.           having an injury to the affected trigeminal nerve as a result of a dental or surgical procedure or injury to the cornea as a result of surgical or laser treatment, within the 3 months before clinical onset or clinical worsening of trigeminal neuropathy;

1.           undergoing one of the following procedures for the treatment of trigeminal neuralgia, involving the affected trigeminal nerve, within the 2 years before clinical onset or clinical worsening of trigeminal neuropathy:
   1.           fractionated stereotactic radiotherapy;
   2.           Gamma Knife radiosurgery;
   3.           microvascular decompression;
   4.           peripheral alcohol injection;
   5.           percutaneous rhizotomy, including chemical (glycerol) rhizolysis, mechanical balloon compression and radiofrequency thermocoagulation;

1.           undergoing a course of therapeutic radiation, where the affected trigeminal nerve was in the field of radiation, within the 6 months before clinical onset or clinical worsening of trigeminal neuropathy;
2.           having osteoradionecrosis of the mandible at the time of clinical onset or clinical worsening of trigeminal neuropathy;
3.           having bisphosphonate-related osteonecrosis of the jaw at the time of clinical onset or clinical worsening of trigeminal neuropathy;

1.           having vascular compression of the trigeminal nerve close to its point of entry into the brainstem, by one of the following:
   1.           tortuous or aberrant loop of arteries or veins;
   2.           haemangioma;
   3.           aneurysm;
   4.           venous sinus thrombosis;
   5.           arteriovenous malformation;

at the time of clinical onset or clinical worsening of trigeminal neuralgia;

1.           having a mass lesion which compresses, displaces or infiltrates the affected trigeminal nerve, at the time of clinical onset or clinical worsening;

Note: Examples of a mass lesion that can compress, displace or infiltrate the trigeminal nerve include a benign or malignant neoplasm, haematoma, abscess, granuloma, amyloidoma, cyst or benign fibro-osseous lesion.

1.       having cervical disc prolapse or cervical syringomyelia, involving the cervical spine at C4 or above, at the time of clinical onset or clinical worsening of trigeminal neuropathy;

1.       having one of the following inflammatory connective tissue diseases:
   1.           mixed connective tissue disease;
   2.           Sjögren syndrome;
   3.           systemic lupus erythematosus;
   4.           systemic sclerosis (scleroderma);

at the time of clinical onset or clinical worsening;

1.        having sarcoidosis at the time of clinical onset or clinical worsening of trigeminal neuropathy;
2.       having invasive bacterial or fungal paranasal sinusitis or viral meningoencephalitis, at the time of clinical onset or clinical worsening of trigeminal neuralgia;
3.       having one of the following infections involving the affected trigeminal nerve, at the time of clinical onset or clinical worsening of trigeminal neuropathy:
   1.           abscess;
   2.           Lyme disease (Borrelia burgdorferi infection);
   3.           brainstem meningitis or encephalitis;
   4.           herpes simplex virus infection;
   5.           invasive bacterial or fungal sinusitis;
   6.            leprosy (Mycobacterium leprae infection);
   7.           odontogenic infection;
   8.           osteomyelitis;
   9.             suppurative otitis media;
4.       having acute herpes zoster involving the affected trigeminal nerve, within the 6 months before clinical onset or clinical worsening of trigeminal neuropathy;
5.       having multiple sclerosis at the time of clinical onset or clinical worsening;
6.       having Charcot–Marie–Tooth disease at the time of clinical onset or clinical worsening of trigeminal neuralgia;
7.       having a cerebrovascular accident (stroke) involving the brainstem within the 30 days before clinical onset or clinical worsening;
8.       inhaling, ingesting or having cutaneous contact with trichloroethylene on at least 30 occasions, within the 6 months before clinical onset or clinical worsening of trigeminal neuropathy;
9.       having an episode of acute intoxication, from inhaling, ingesting or having cutaneous contact with trichloroethylene, within the 30 days before clinical onset or clinical worsening of trigeminal neuropathy;
10.       inability to obtain appropriate clinical management for trigeminal neuralgia before clinical worsening of trigeminal neuralgia;
11.       inability to obtain appropriate clinical management for trigeminal neuropathy before clinical worsening of trigeminal neuropathy.

1.            Relationship to service
   1.           The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.
   2.           The clinical worsening aspects of factors set out in section 9 apply only to material contribution to, or aggravation of, trigeminal neuralgia or trigeminal neuropathy where the person's trigeminal neuralgia or trigeminal neuropathy was suffered or contracted before or during (but did not arise out of) the person's relevant service.
2.            Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

1.           if a factor referred to in section 9 applies in relation to a person; and
2.           that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                             relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                             terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               trigeminal neuralgia or trigeminal neuropathy—see subsection 7(2).

                             VEA means the Veterans' Entitlements Act 1986.