High-Voltage, Long-Duration Pulsed Radiofrequency on Gasserian Ganglion Improves Acute/Subacute Zoster-Related Trigeminal Neuralgia: A Randomized, Double-Blinded, Controlled Trial

BACKGROUND

Trigeminal postherpetic neuralgia is a severe neuropathic pain and often refractory to existing treatment, it develops secondary to herpes zoster-infected Gasserian ganglion. Therefore, it is important to prevent the transition of acute/subacute zoster-related pain to trigeminal postherpetic neuralgia. Despite numerous studies, the optimal intervention that reduces trigeminal postherpetic neuralgia incidence is still unknown.

OBJECTIVES

This study aimed to evaluate the efficacy and safety of high-voltage, long-duration pulsed radiofrequency (PRF) on the Gasserian ganglion in patients with acute/subacute zoster-related trigeminal neuralgia.

STUDY DESIGN

Prospective, randomized, double-blinded study.

SETTING

Department of Pain Medicine, the First Affiliated Hospital of China Medical University.

METHODS

Ninety-six patients with acute/subacute zoster-related trigeminal neuralgia were equally randomly assigned into 2 groups. The electrode needle punctured the Gasserian ganglion guided by computed tomography in every patient. High-voltage, long-duration PRF at 42°C for 900 seconds was applied in the PRF group (n = 48). It was also applied in the sham group (n = 48) without radiofrequency energy output. The therapeutic effects were evaluated using a visual analog scale (VAS) and the 36-Item Short Form Health Survey (SF-36) at different time points. The average dosage of pregabalin (mg/d) administrated within the first month after treatment was also recorded.

RESULTS

The postprocedure VAS scores in the PRF group were significantly lower than those in the sham group at different time points after treatment (P < 0.01). The SF-36 scores, which included physical functioning, physical role, bodily pain, general health perceptions, vitality, social function, emotional role, and the mental health index, were significantly improved at the sixth month after treatment in the PRF group compared with the sham group (P < 0.01). The average dosage of pregabalin administered (mg/d) within the first month after treatment was also significantly reduced in the PRF group compared with the sham group (P < 0.01). There were no bleeding, infection, or other severe side effects in both groups.

LIMITATIONS

Single center study, relatively small number of patients.

CONCLUSIONS

High-voltage, long-duration PRF on the Gasserian ganglion is an effective and safe therapeutic alternative for patients with acute/subacute zoster-related trigeminal neuralgia.

KEY WORDS

Pulsed radiofrequency, zoster-related trigeminal neuralgia, visual analog scale, 36-Item Short Form Health Survey.

Gasserian ganglion injected with Adriamycin successfully relieves intractable trigeminal nerve postherpetic neuralgia for an elderly patient: A case report

RATIONALE

Effective treatments for trigeminal nerve postherpetic neuralgia (PHN) are limited. Adriamycin (doxorubicin) has been applied to the treatment of neuropathic pain. This study reports a new treatment: Adriamycin injected to Gasserian ganglion for an elderly patient with the intractable trigeminal nerve PHN.

PATIENT CONCERNS

A 75-year-old man complained of lancing, burning pain in the right mandibular branch of the trigeminal nerve (V3) for 3 months after rash eruption.

DIAGNOSES

Trigeminal nerve PHN.

INTERVENTIONS

Approximately 0.5 mL of 0.25% Adriamycin and 20 mg methylprednisolone injected to Gasserian ganglion through the foramen ovale with computer tomography guidance.

OUTCOMES

The visual analog scale was 10 of 100 throughout the 1-month follow-up, and oxcarbazepine had also been tapered. The patient remained free of pain at the 12-month follow-up.

LESSONS

The treatment of Adriamycin injection to Gasserian ganglion is effective and safe, and may be considered as an alternative treatment for trigeminal nerve PHN. However, more research is needed to verify the validity.

Occurrence of Herpes Simplex Virus Reactivation Suggests a Mechanism of Trigeminal Neuralgia Surgical Efficacy

Common to the types of surgery that are effective for the treatment of trigeminal neuralgia (TN) is reactivation of herpes simplex virus (HSV). It is likely that such HSV reactivation following surgery indicates altered trigeminal ganglion neuron function, which was caused by the surgery. It is not thought that HSV infection is related to the cause of TN or that HSV reactivation is important for surgical treatment efficacy. Rather, it is thought that HSV reactivation is a marker of altered trigeminal ganglion neuron function resulting from the TN surgery. It is suggested that HSV reactivation is a surrogate marker of ganglion neuron injury. The correlation between effective types of surgery and evidence that they alter ganglion neuron function suggests that altered trigeminal ganglion neuron function may be the basis of the surgical efficacy.

Unusual trigeminal autonomic pain heralding hemichorea due to zoster sine Herpete vasculopathy

BACKGROUND

Varicella zoster virus primary infection is responsible for chickenpox, whereas secondary infection or reactivation can lead to a variety of clinical scenarios. If latent infection is established in trigeminal ganglion, the reactivation can determine viral migration to cerebral arteries, which causes a cerebral vasculopathy and subsequently an ischemic stroke.

PATIENTS

Here we report on a child experiencing recurrent episodes of headache mimicking a trigeminal autonomic cephalalgia, in the absence of any skin rash, which were followed by the occurrence of an ipsilateral hemiparesis associated with a choreic movement disorder a month later.

RESULTS

Magnetic resonance angiography showed evidence of a right-sided infarction of basal ganglia and anterior limb of the internal capsule, corresponding to the vascular territory of the recurrent artery of Heubner, as a consequence of a focal varicella zoster virus arteriopathy.

CONCLUSIONS

We suggest that the recognition of this prodromal manifestation, which can be interpreted as a zoster sine herpete, could provide clinicians an extremely useful time window to start promptly with a prophylactic treatment.

Prevention and management of trigeminal herpes zoster and postherpetic neuralgia

Herpes zoster (HZ, also known as shingles) is caused by the reactivation of a dormant varicella zoster virus and can be a source of significant morbidity. Oral manifestations can include vesicular eruptions of the mucosa, osteonecrosis with tooth loss, and postherpetic neuralgia (PHN). This article discusses treatment for trigeminal nerve involvement with herpes zoster, as well as for the painful syndrome PHN.

SUNCT and trigeminal neuralgia attributed to meningoencephalitis

We describe a 46-year-old female with viral meningoencephalitis (likely varicella-zoster virus) who developed a SUNCT syndrome followed a few days later by trigeminal neuralgia. Both disorders resolved in parallel with the resolution of encephalitis, which suggests a causal link. In conclusion, headache attributed to intracranial infection may have the clinical features of SUNCT or TN.

Evaluation of the sensation in patients with trigeminal post-herpetic neuralgia

BACKGROUND

Post-herpetic neuralgia (PHN) is one complication after herpes zoster infection, which may affect the facial superficial sensitivity.

METHODS

Eighteen patients with PHN were interviewed and evaluated according to a systematized sensitivity approach, including mechanical, thermal and pain.

RESULTS

The pain location was V1 in 15 patients. All trigeminal branches from both facial sides were evaluated; we compared the affected with the opposite side. There was a significant difference at V1 with cold (P=0.038), vonFrey (P=0.008) and pinpricks (P=0.022); at V2, the statistical difference occurred with cold (P=0.034), heat (P=0.019) and pinpricks (P=0.037); at V3, differences occurred with cold (P=0.042) and heat (P=0.036). Only V1 and oral mucosa (V2-3) presented pain threshold differences between both sides (P=0.001, P=0.021).

CONCLUSION

Age, predominance of trigeminal PHN in V1 and continuous burning pain was common and similar to literature. Sensation was hampered with evident deficits of all sensory modalities in the affected trigeminal areas, especially V1.

Herpes zoster of the trigeminal nerve following microvascular decompression

A patient developed herpes zoster of the maxillary division of the trigeminal nerve after microvascular decompression. Varicella zoster virus lies dormant in the Gasserian ganglion until reactivation and can cause herpes zoster ophthalmicus. This can result in serious ocular complications including blindness. Antiviral agents are effective if commenced promptly.

Gamma knife surgery for refractory postherpetic trigeminal neuralgia: targeting in one session both the retrogasserian trigeminal nerve and the centromedian nucleus of the thalamus

OBJECT

The authors tested the hypothesis that two targets are needed to treat postherpetic trigeminal neuralgia (TN): one in the trigeminal nerve for the direct sharp pain and one in the thalamus for the diffuse burning pain.

METHODS

Three patients with refractory postherpetic TN were treated with gamma knife surgery (GKS) through a novel two-target approach. In a single treatment session, both the trigeminal nerve and centromedian nucleus were targeted. First, the trigeminal nerve, ipsilateral to the facial pain, was treated with 60 to 80 Gy. Second, the centromedian nucleus was localized using standard coordinates and by comparing magnetic resonance images with a stereotactic atlas. A single dose of 120 to 140 Gy was delivered to the target point with a single 4-mm isocenter. Patients were followed clinically and with neuroimaging studies. Pain relief was scored as excellent (75-100%), good (50-75%), poor (25-50%); or none (0-25%). Follow up ranged from 6 to 53 months. There were no GKS-related complications. Two patients died of unrelated medical illnesses but had good or excellent pain relief until death. One patient continues to survive with 44 months follow up and no decrease in pain intensity, but with a decreased area of pain.

CONCLUSIONS

Combined GKS of the centromedian nucleus and trigeminal nerve in a single treatment session is feasible and safe, and the effect was promising. A larger study is required to confirm and expand these results.

[Herpes zoster of the trigeminal nerve: a case report and review of the literature]

Herpes zoster (shingles) is caused when the varicella zoster virus that has remained latent since an earlier varicella infection (chicken-pox) is reactivated. Herpes Zoster is a less common and endemic disease than varicella: factors causing reactivation are still not well known, but it occurs in older and/or immunocompromised individuals. Following reactivation, centrifugal migration of herpes zoster virus (HZV) occurs along sensory nerves to produce a characteristic painful cutaneous or mucocutaneous vesicular eruption that is generally limited to the single affected dermatome. Herpes zoster may affect any sensory ganglia and its cutaneous nerve: the most common sites affected are thoracic dermatomes (56%), followed by cranial nerves (13%) and lumbar (13%), cervical (11%) and sacral nerves (4%). Among cranial nerves, the trigeminal and facial nerves are the most affected due to reactivation of HZV latent in gasserian and geniculated ganglia. The 1st division of the trigeminal nerve is commonly affected, whereas the 2nd and the 3rd are rarely involved. During the prodromal stage, the only presenting symptom may be odontalgia, which may prove to be a diagnostic challenge for the dentist, since many diseases can cause orofacial pain, and the diagnosis must be established before final treatment. A literature review of herpes zoster of the trigeminal nerve is presented and the clinical presentation, differential diagnosis and treatment modalities are underlined. A case report is presented.

Are latent, immediate-early genes of herpes simplex virus-1 essential in causing trigeminal neuralgia?

The etiology and pathogenesis of major trigeminal neuralgia remain largely unknown, but are believed to result from an irritative lesion near the semilunar ganglion. We suggest that its primary cause is a single, active DNA sequence in the persistent but non-integrated genome of latent herpes simplex virus type 1 commonly observed in a few infected A-delta nerve fibers of the cheek. Facial pain occurs as a result of herpes virus reactivation and when supplies of neurotrophins controlling normal transport functions of axolemmal ion channels become depleted.

Tooth exfoliation, osteonecrosis and neuralgia following herpes zoster of trigeminal nerve

A case of herpes zoster of the trigeminal nerve with complications of osteonecrosis and neuralgia in the absence of local or systemic predisposing factors is presented. The literature is reviewed and the role of varicella zoster virus in the pathology of tooth exfoliation and osteonecrosis is discussed.

[Clinical course and treatment of herpetic trigeminal ganglionic neuropathy]

45 patients were observed in the periods of both acute herpes zoster and postherpetic neuralgia (PHN). In most of the patients herpetic eruptions were located in the areas of innervation of the first branch of the trigeminal nerve. In acute period of the disease there were used aciclovir, helepin or alpisarinum, antiherpetic immunoglobulin, deoxyribonuclease, non-narcotic analgetics were used. Of 28 patients residual PHN was observed in 6 cases, delayed PHN (during 3 months)--in 2 patients. The PHN development was characteristic for elderly patients, delayed request for medical care, concomitant diseases, eruptions with hemorrhagic component and secondary pyodermia and considerable residual sensory deficit. In therapy of PHN the most effective drugs were amitriptylin, non-narcotic analgetics, anticonvulsants as well as acupuncture and electroacupuncture. Relief of a typical deafferentation of pain syndrome was achieved by means of ultrasonic destruction of the trigeminal nucleus (one case). Early therapy of acute herpes zoster does not prevent completely PHN development, but it decreased considerably probability of its forming as well as the severity of its course.

Trigeminal neuralgia: mechanisms of treatment

BACKGROUND

Mechanisms of the surgical treatment of trigeminal neuralgia are considered.

RESULTS

Trigeminal neuralgia is effectively treated by microvascular decompression (MVD) and other surgical procedures. These procedures often cause reactivation of herpes simplex virus (HSV), which is latent in trigeminal ganglion neurons.

CONCLUSION

MVD and other surgical procedures alter ganglion neuron transcription, as indicated by HSV reactivation. Controlled injury of the trigeminal root-ganglion probably occurs with the disparate surgical procedures, and this is likely the means of their effectiveness.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain

Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one-quarter of the primary dermatome, as severe when they covered more than three-quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years (P < 0.01 and P < 0.001) and for patients with thoracic (P < 0.001) and lumbosacral (P < 0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.01 and P < 0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30-59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.05 and P < 0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher (P < 0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase (r = 0.412), age (r = 0.277) and the involved region (r = -0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than "being aged' and "trigeminal involvement' itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.