The indications for gasserian ganglion block for trigeminal neuralgia

Urgent care peripheral nerve blocks for refractory trigeminal neuralgia

OBJECTIVE

After medication failure, patients with refractory trigeminal neuralgia (TGN) often present urgently and seek more potent or invasive therapies such as opioids or surgical options. Peripheral nerve blocks, safe and simple, may offer extended pain relief prior to opioid use or more invasive ganglion level procedures.

METHODS

We report a retrospective case-series (urgent care, at a large urban medical center, over a 2 year period) of nine patients with intractable primary TGN who underwent peripheral trigeminal nerve blocks after failing conservative medical therapy. After antiseptic skin preparation, a 30 g needle was inserted localizing to the supraorbital, infraorbital, and mental foramens. 0.5 mL of 0.25% bupivicaine:1% lidocaine was injected locally at all three foramens. Then, 1 mL of the above was injected in the region of the auriculotemporal nerve (see Video 1). All injections were done on the side with TGN pain.

RESULTS

All nine patients experienced immediate pain relief of >50% with 7 of 9 being completely pain free or just mild paresthesia. Six of nine patients had lasting pain relief (1-8 months); three patients reporting pain now tolerable with adjunct medication and two patients were completely pain free.

CONCLUSIONS

The treatment paradigm for TGN remains unclear when a patient fails conservative medical therapy. In this case series, many patients achieved rapid and sustained TGN pain relief with peripheral trigeminal nerve blocks. This modality should be considered as a potential therapeutic option in the ED or urgent care setting.

Orbital exenteration under trigeminal block: An innovative method of regional anesthesia

Orbital exenteration is a disfiguring operation involving the removal of the entire contents of the orbit, with or without the eyelids. It is widely felt that such extensive surgery can only be performed under general anesthesia. We report our experience with a patient who underwent orbitalexenteration under trigeminal block with intravenous sedation. A 68-year-old male patient was diagnosed to have orbital cellulitis (mucormycosis), uncontrolled diabetes mellitus, ischemic heart disease, dilated cardiomyopathy with severe left ventricular systolic dysfunction with severe pulmonary artery hypertension, and nephropathy. We decided to avoid general anesthesia for such a high-risk patient with many co-morbid illnesses. We gave trigeminal block using a 22-G spinal needle with local anesthetic solution of bupivacaine 0.5% by classic approach. A standard exenteration was performed and the patient tolerated the procedure well with no complications.