Treatment of trigeminal neuralgia with bupivacaine HCL using a temporary epidural catheter and pain pump: preliminary study

Treatment Outcomes in Trigeminal Neuralgia-A Systematic Review of Domains, Dimensions and Measures

BACKGROUND

Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock-like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measures. The aim of this systematic review was to summarize all the outcomes and outcomes measures that have been published to date and highlight variability in their use.

METHODS

We have conducted a literature search using a wide range of databases (1946-2019 for medical and 2008-2019 for surgical treatment), for all intervention studies in TN. Four hundred and sixty-seven studies were selected for data extraction on TN classification, data collection method, intervention, and treatment outcomes mapped to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT guidelines).

RESULTS

Most studies collected data on pain (n = 459) and side effects (n = 386) domains; however, very few collected data on the impact of treatment on physical (n = 46) and emotional functioning (n = 17) and on patient satisfaction (n = 35). There was high variability on outcome measures used for pain relief (n = 10), pain intensity (n = 9), and frequency of pain episodes (n = 3).

CONCLUSIONS

A clear definition of what are the important outcomes for patients with TN is essential. The choice of standardized outcome measures allowing for consistent reporting in TN treatment will allow for comparison of studies and facilitate treatment choice for patients and clinicians thus, improving health outcomes and reducing health care cost.

A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia

BACKGROUND

Trigeminal neuralgia (TN) can have a significant impact on wellbeing and quality of life. Limited data exist for treatments that improve TN pain acutely, within 24 h of administration. This systematic review aims to identify effective treatments that acutely relieve TN exacerbations.

METHODS

We searched Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English language publications. The reference list for all articles was searched for other relevant publications. All studies that satisfied the following PICO criteria were included: (i) Population-adults with acute exacerbation of primary TN symptoms; (ii) Intervention-any medication or intervention with the primary goal of pain relief within 24 h; (iii) Comparator-usual medical care, placebo, sham or active treatment; (iv) Outcome-more than 50% reduction in pain intensity within 24 h of administration.

RESULTS

Of 431 studies, 17 studies were identified that reported immediate results of acute treatment in TN. The evidence suggests that the following interventions may be beneficial: local anaesthetic, mainly lidocaine (ophthalmic, nasal or oral mucosa, trigger point injection, i.v. infusion, nerve block); anticonvulsant, phenytoin or fosphenytoin (i.v. infusion); serotonin agonist, sumatriptan (s.c. injection, nasal). Other referenced interventions with very limited evidence include N-methyl-d-aspartate receptor antagonist (magnesium sulphate infusion) and botulinum toxin (trigger point injection).

CONCLUSIONS

Several treatment options exist that may provide fast and safe relief of TN. Future studies should report on outcomes within 24 h to improve knowledge of the acute analgesic TN treatments.

Greater palatine block for V2 trigeminal neuralgia: Case report

AIMS

This study describes a novel nerve block directed at the maxillary (V2) division of the fifth cranial nerve as treatment for medication-refractory trigeminal neuralgia (TN).

METHODS AND RESULTS

The authors present three cases of TN treated with V2 nerve block using commonly available local anesthetics injected through the greater palatine foramen. Patients' medications were noted before and after the procedure. Following the injection, patients were followed over time and outcome was assessed. Patients experienced rapid and long-lasting pain relief allowing for significant reduction in antineuralgia medications. This was done with the objective of breaking the pain cycle with subsequent discontinuation or reduction of analgesic medications.

CONCLUSION

This technique may be an effective treatment for medication-refractory V2 TN. By interrupting the pain cycle, this renders the condition amenable to long-term control using diminished doses of standard antineuralgia pharmaceuticals. The practical implications of the described procedure are that it is simple, safe, and well-tolerated with few or no adverse effects. This novel technique is a diagnostic feature for the dentist to differentiate between sources of facial pain.

Perioperative pain in patients with trigeminal neuralgia undergoing radiofrequency thermocoagulation of the Gasserian ganglion

Trigeminal neuralgia is the worst pain that human beings have ever experienced. Few researches have illustrated perioperative pain in patients with trigeminal neuralgia undergoing radiofrequency thermocoagulation (RFT) of the gasserian ganglion under local anesthesia. Because there are some undeniable drawbacks of using intravenous short-term anesthesia during the intervention repeatedly, some physicians keep patients awake throughout the puncture procedure, using local anesthesia. The purpose of this investigation was to examine perioperative pain in patients with trigeminal neuralgia undergoing RFT of the gasserian ganglion. Participants were 104 patients with classic trigeminal neuralgia. Worst pain intensity, mean pain intensity, quality of sleep, and analgesia satisfaction were evaluated for 24 hours before admission, 24 hours before operation, and 24 hours after operation. Intraoperative worst pain intensity was determined. Preoperative pain was serious, and preoperative sleep quality significantly and positively correlated with preoperative mean pain (r = 0.52; P = 0.00) and worst pain (r = 0.49; P = 0.00). Few patients (1.9%) responded to preoperative treatment, and the preoperative treatment obtained low analgesia satisfaction scores (3.9 [1.3]). Most patients experienced severe pain during cannulation under local anesthesia. No patients complained of pain during radiofrequency lesioning. The RFT of the gasserian ganglion alleviated pain obviously. Most patients (94.2%) responded to the operation, and the operation got high analgesia satisfaction scores (8.9 [0.7]). The results demonstrate that preoperative pain in patients with trigeminal neuralgia undergoing RFT of the gasserian ganglion is prevalent and undertreated and that intraoperative pain is severe under local anesthesia during cannulation.

Refractory trigeminal neuralgia. Non-surgical treatment options

The guidelines on trigeminal neuralgia management published by the American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS) recommended that patients unresponsive to carbamazepine or oxcarbazepine be offered the surgical option. However, because some patients may not be willing to resort to surgery, we searched the literature for treatment in refractory trigeminal neuralgia. We found other oral treatments, intranasal spray, subcutaneous injections, various kinds of peripheral nerve blocks and injections of botulinum toxin. On the basis of the available evidence we suggest that no oral treatment other than carbamazepine or oxcarbazepine is useful. Among the other options, there is increasingly strong evidence that botulinum toxin injections are efficacious and may be offered before surgery or to those unwilling to undergo surgery.

Pterygopalatine fossa segment neurectomy of maxillary nerve through maxillary sinus route in treating trigeminal neuralgia

PURPOSE

To explore an effective surgical treatment for pain in the distribution area of the maxillary branch of trigeminal nerve (TN).

MATERIALS AND METHODS

Twenty-six patients with pain in the distribution of the maxillary branch of TN were followed up after they had undergone pterygopalatine fossa segment neurectomy of maxillary nerve through maxillary sinus route.

RESULTS

In all cases, the pain initially resolved after operation, with anaesthesia or paraesthesia in the operated side of the maxillary nerve-distributed area. After a mean follow-up period of 24 (range 3-36) months, 19 (73.08%) of the 26 patients had an excellent response, 5 (19.23%) had a good response, 2 (7.69%) had a fair response, and none (0%) had a poor response. One patient had a recurrence with palatal pain 3 months after the operation.

CONCLUSIONS

The maxillary sinus route can provide a clear vision for sectioning of the maxillary nerve. This new surgical technique has proven to be safe and effective. It provides another option for the weak elderly who are intolerant of craniotomy or patients who have contraindications for craniotomy when radiofrequency thermocoagulation (RFT) and percutaneous glycerol neurolysis (PGR) treatment is not possible.

Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and postoperative pain with histological evaluations

PURPOSE

To investigate and compare the influence of surgical difficulty on postoperative pain after treatment of impacted mandibular third molars by rotatory osteotomy or Piezoelectric surgery.

MATERIALS AND METHODS

A prospective, randomized, split-mouth study was performed of 52 patients with bilateral and symmetrically oriented impacted mandibular third molars, who were surgically treated using a burr (Group A) on one random side of the lower jaw and a Piezoelectric device (Group B) on the contralateral side. Surgical difficulty was evaluated using a modified version of the Parant scale to categorize "simple extractions" and "complex extractions". Primary outcome parameters were the comparison of the postoperative pain evaluation rated on the Visual Analogue Scale from day 0 to day 6 postsurgery, and the assessment of differences in surgery time between the groups. Bone biopsies were taken during surgery to assess differences in bone tissue damage levels between the two different techniques.

RESULTS

In "complex extractions" lower pain evaluation and significantly shorter surgery times were recorded when rotatory instruments were used. In "simple extractions", similar surgery times were observed for both techniques, but pain was greatest on the day of surgery when the burr was used. Bone heat osteonecrosis was observed only in the rotatory group and a high level of alkaline phosphatase was noted only in the Piezoelectric group.

CONCLUSION

Pain after extraction of a mandibular third molar increases with increased surgical difficulty and especially in longer interventions. The integrity of the bony structure observed after the ultrasonic technique may favour the bone healing process.