Asunto(s)

RESUMEN

Introduction: Microvascular decompression is considered to be the most effective and onlyetiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascularcompression found in up to 95% of cases. This study aims to report the long-term outcomesand to identify prognostic factors in a series of patients with trigeminal neuralgia treated bymicrovascular decompression. Methods: A retrospective observational study of 152 consecutive patients operated bymicrovascular decompression with at least six months of follow-up. The surgical results, includ-ing pain relief according to the Barrow Neurological Institute pain scale, complications and themedical treatment during the follow-up period were reviewed. Binary regression analysis wasperformed to identify factors associated with a good long-term outcome. Results: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 monthswere included. At the final follow-up visit, 83% of the patients had achieved significant reliefof the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequentcomplications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age andhaving paroxysmal pain were associated with a long-term pain relief.(AU)

Introducción: La descompresión microvascular se considera el tratamiento quirúrgico etiológico más eficaz de la neuralgia clásica del trigémino, dirigido a aliviar la compresión neurovascular identificada hasta en un 95% de casos. Este estudio tiene como objetivo analizar los resultados quirúrgicos y la evolución a largo plazo de una serie de pacientes con neuralgia del trigémino tratados mediante descompresión microvascular, así como identificar factores pronósticos. Métodos: Estudio observacional retrospectivo de 152 pacientes consecutivos sometidos a descompresión microvascular y con un seguimiento posquirúrgico mínimo de seis meses. Analizamos los resultados quirúrgicos, clasificando el grado de dolor según la escala del Instituto Neurológico de Barrow, las complicaciones y el tratamiento médico requerido durante el período de seguimiento. Realizamos un análisis de regresión binaria para identificar factores asociados con un buen resultado a largo plazo. Resultados: Incluimos 152 pacientes con una edad media de 60 años y un seguimiento medio de 43 meses. En la última visita de seguimiento, el 83% de los pacientes había logrado un alivio significativo del dolor y el 63% pudo reducir la dosis absoluta de fármacos para la neuralgia en un 50% o más. Las complicaciones más frecuentes fueron infección de la herida (4,5%) y fístula de LCR (7%). La edad superior a 70 años y el dolor de predominio paroxístico se asociaron con un mejor pronóstico. Conclusiones: Nuestros resultados apoyan que la descompresión microvascular es una terapia efectiva y segura en pacientes con neuralgia del trigémino. La cirugía temprana puede ser beneficiosa en pacientes refractarios al tratamiento farmacológico.(AU)

Asunto(s)

RESUMEN

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Asunto(s)

RESUMEN

El tratamiento con radiofrecuencia pulsada del ganglio esfenopalatino es una opción importante a tener en cuenta respecto al tratamiento intervencionista en casos refractarios de neuralgia del trigémino o dolores faciales atípicos, dado el fácil acceso a su localización. A pesar de que las complicaciones de esta técnica son raras y es un procedimiento bastante seguro, a nivel oftalmológico cabe reseñar su importancia por las relaciones anatómicas de este ganglio (AU)

Pulsed radiofrequency treatment of the sphenopalatine ganglion is an important interventional treatment in refractory cases of trigeminal neuralgia or atypical facial pain, given the easy access to its location. Despite the fact that complications from this technique are rare and it is a fairly safe procedure, ophthalmologists should know about it due to the anatomical relations of this ganglion (AU)

Asunto(s)

RESUMEN

We sought to assess the efficacy of combining onabotulinumtoxinA (BoNTA) as add-on therapy to carbamazepine or oxcarbazepine in treatment-refractory patients with trigeminal neuralgia (TGN) who failed to respond (less than 30% response rate) to adequate monotherapy. We conducted a retrospective study on 15 patients with a definite diagnosis of TGN, according to the established criteria, and underwent BoNTA as part of their treatment plan. A single BoNTA session was administered subcutaneously, according to patients' perceived zone of pain, at different dosages ranging from 30 to 200 units (mean ± standard deviation: 87.3 ± 39.2). All patients (15/15; 100%) reported large reductions in the severity of their TGN-related neuropathic pain. The mean pain score on the VAS scale significantly decreased from 9.3 ± 1.1 to 3.7 ± 1.2 at 2 weeks after injecting BoNTA (p < 0.001) and remained stable at 4 and 24 weeks post-injection. Regarding the impact of BoNTA on patients' health-related quality of life, there were significant improvements in both the physical and mental health domains (p < 0.05) of SF-36 tool. BoNTA may be a safe and effective treatment option for patients with refractory TGN when added on to carbamazepine or oxcarbazepine. The use of a single BoNTA session for TGN treatment may be an alternative to surgical interventions and as add-on treatment to oral medications, providing patients with a minimally invasive, effective, safe and well-tolerated option.

Asunto(s)

RESUMEN

Pulsed radiofrequency (PRF) treatment of the sphenopalatine ganglion is an important interventional treatment in refractory cases of trigeminal neuralgia (TN) or atypical facial pain, given the easy access to its location. Despite the fact that complications from this technique are rare and it is a fairly safe procedure, ophthalmologists should know about it due to the anatomical relations of this ganglion.

Asunto(s)

RESUMEN

Treatment refractory or recurrent trigeminal neuralgia (TN) is a severe chronic pain illness. Single-session repetitive transcranial magnetic stimulation (rTMS) has been shown to elicit analgesic effects in several craniofacial pain syndromes, including TN. However, the safety and long-term effect of multi-session rTMS for TN have yet to be fully explored. In this study, we present a case of a patient with medical treatment-refractory TN after microvascular decompression. The patient volunteered to undergo 73 sessions of 10 Hz rTMS over 23 months. Neurovagination was used for precise localization and stimulation of the hand and face representation at the left motor cortex. The numeric pain intensity scores derived using the visual analog scale served as a daily index of treatment efficacy. The patient experienced a significant weekly reduction in pain scores, cumulating in 70.89% overall pain relief. The medication dosages were reduced and then discontinued toward the end of the intervention period. No severe adverse events were reported. From our results, we can conclude that the longitudinal multi-session application of rTMS over the hand and face area of M1 is a safe and effective method for producing long-lasting pain relief in TN. Using rTMS may thus prove helpful as an adjunct to conventional methods for treating pain in TN.

RESUMEN

OBJECTIVE: To evaluate the effect of trigeminal nerve block (TNB) on patients' quality of life (QOL) 15 days after the procedure in patients with refractory TN. METHODS: This retrospective observational cohort study involved patients receiving TNB (levobupivacaine, clonidine, corticosteroid) between 2014 and 2018 at a postoperative pain clinic in France. Change in QOL from Day 0 (before block) to Day 15 was assessed according to SF-12. RESULTS: 21 patients (62 ± 14 y) were included in the study. Most patients (71%) were referred following surgery or dentistry. Of the 9 patients (43%) who exhibited >10% increase in SF-12 scores and so were deemed responders, SF12-physical and SF12-mental were increased by mean differences of 17 and 9 points, respectively. The mean duration of block lasted 15 ± 59 days (range 1 to 90 days) and no severe adverse effects were observed. CONCLUSION: Improved QOL was observed in approximately 50% of patients with trigeminal neuralgia (TN) two weeks after specific nerve block. The technique was easy to administer and well accepted by the patients.

Asunto(s)

RESUMEN

A 62-yr-old man with left cavernous sinus tumor presented with atypical trigeminal neuralgia refractory to medical treatment. He received Gamma Knife (Elekta) radiation for the tumor. However, the facial pain worsened after radiation. Neuropsychological testing done for memory problems had revealed mild neurocognitive disorder. Neurological examination showed trigeminal distribution numbness and partial abducens nerve paralysis. Imaging revealed an enhancing left cavernous sinus and supra-cavernous mass. Angiography revealed severe stenosis of the left cavernous internal carotid artery (ICA). Computed tomography (CT) perfusion study showed diminished blood flow on the left side, and ischemic changes were seen in fluid-attenuated inversion-recovery (FLAIR) magnetic resonance imaging (MRI). Surgical resection of the tumor was preferred over ablative treatment for trigeminal neuralgia because of its effectiveness in improving cranial nerve (CN) function.1 The patient underwent staged surgeries. In the first stage, the tumor was partially excised with decompression of the trigeminal ganglion and nerve root in the lateral cavernous sinus wall, Meckel's cave. Postoperatively, MR angiography revealed worsening of the left ICA caliber. Therefore, a high-flow bypass from the external carotid artery to the middle cerebral artery (MCA) was performed with an anterior tibial artery graft. The patient recovered initially but developed enterococcus meningitis postoperatively, which was promptly identified and treated with antibiotics. At 1-yr follow-up, the graft was patent, and the patient had significant relief of his facial pain and cognitively improved. This 2-dimensional video demonstrates the technique of partial excision of cavernous sinus meningioma with CN decompression, and the technique of a high-flow bypass from the external carotid artery to M2 MCA segment using an anterior tibial artery graft. The patient gave informed consent for surgery and video recording. All relevant patient identifiers have been removed from the video and accompanying radiology slides.

RESUMEN

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

RESUMEN

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.

Asunto(s)

RESUMEN

Objective: To analyze the prognosis and untoward effect in recurrent refractory trigeminal neuralgia (RRTN) patients who underwent repeat Gamma Knife Radiosurgery treatment (GKRS) retrospectively, and to summarize the experience of repeat Gamma Knife Radiosurgery treatment of recurrent refractory trigeminal neuralgia. Methods: RRTN patients who treated with repeat GKRS during 1998.8.1 to 2014.10.1 in Gamma Knife treatment Center of the Fifth Affiliated Hospital of Zhengzhou University were involved. The factors influencing long-term prognosis and facial numbness adverse reactions were statistically analyzed. Results: Therapeutic dose was an independent factor that influence long-term prognosis of RRTN patients. Therapeutic dose was a dangerous factor that influence long-term facial numbness. Interval time between twice GKRS treatment was a favorable factor for facial numbness. Long-term prognosis of repeat GKRS treatment was positively correlated with therapeutic dose. Untoward effect of facial numbness after repeat GKRS treatment was positively correlated with therapeutic dose and negatively correlated with interval time between twice GKRS treatment. Conclusions: Repeat GKRS for RRTN patients is safe and effective, but personalized treatment plan should be given according to the patient's own condition.

Asunto(s)

RESUMEN

OBJECTIVEPatients with multiple sclerosis (MS)-associated trigeminal neuralgia (TN) have higher recurrence and retreatment rates than non-MS patients. The optimal management strategy and role for microsurgical rhizotomy (MSR) for MS-TN remains to be determined. The aim of this study was to report time to treatment failure (TTF) and pain scores following MSR compared to percutaneous and Gamma Knife procedures.METHODSTime to treatment failure was analyzed after MSR (n = 14) versus prior procedures (n = 53) among MS-TN patients. Kaplan-Meier curves and log-rank test were utilized to compare TTF after MSR versus prior procedures using the same cohort of patients as their own control group. Subsequent analysis compared TTF after MSR to TTF after 93 other procedures among a second cohort of 18 MS-TN patients not undergoing MSR. BNI pain scores were compared between MSR and other procedures among the MS-TN cohort using a chi-square test.RESULTSTTF was significantly longer after MSR than after other procedures in the MSR cohort (median TTF 79 vs 10 months, respectively, p < 0.0001). Similarly, TTF was longer after MSR than after prior procedures in the non-MSR cohort (median TTF 79 vs 13 months, respectively, p < 0.001). MSR resulted in a higher proportion of excellent pain scores when compared to other procedures in the non-MSR cohort (77% vs 29%, p < 0.001). Probability of treatment survival was higher after MSR than after other procedures at all time points (3, 6, 12, 24, 36, and 48 months). There were no deaths or major complications after MSR.CONCLUSIONSTTF was significantly longer following MSR compared to prior procedures in MS-TN patients. Additionally, a higher proportion of patients achieved excellent BNI pain scores after MSR.

RESUMEN

INTRODUCTION: The antinociceptive effect of botulinum toxin-A (BTX-A) in trigeminal neuralgia (TN) has been described. We evaluated effects of BTX-A in relieving pain in patients with refractory TN at National Hospital of Sri Lanka. MATERIALS AND METHODS: Pain in patients with TN was assessed using a visual analog from 0 to 10. Three months after commencement of drug therapy with ≥2 drugs including one first-line drug (carbamazepine/oxcarbazepine), pain scores were re-assessed. Twenty-two patients who did not report improvement of ≥50% at 90 days' posttreatment were recruited. They were given adjunct BTX-A directly to the trigger point (if identified) or intradermal. Pain scores were assessed at 10, 20, 30, 60, and 90 days' posttreatment. RESULTS: There was a statistically significant improvement in mean pain scores at 10, 20, 30, 60, and 90 days' posttreatment (5.59 [standard deviation (SD) = 2.7], 5.68 [SD = 2.6], 5.27 [SD = 3.2], 4.77 [SD = 3.7], and 5.32 [SD = 4.0]) compared to pre-BTX-A treatment (7.14, SD = 2.2). Percentage reduction in mean pain score ranged from 20.4% to 33.1%. Maximum response was at day 60 post-BTX-A (50% had ≥50% reduction in pain). No significant difference was found in response with higher doses and injection strategy. CONCLUSION: Consistent statistically significant reductions in pain scores at the aforesaid intervals compared to pretreatment means that there is a place for BTX in refractory TN.

RESUMEN

Classic trigeminal neuralgia (TN) causes severe facial pain. Several treatment options exist for classic TN refractory to medical therapy, including stereotactic radiosurgery (SRS). Most studies in the medical literature used a frame-based SRS technique. Improvements in linear accelerator-based treatment systems and image guidance have led to the use of frameless SRS as a safe and feasible alternative to the frame-based technique for the treatment of refractory TN. We present a case of refractory TN successfully treated with frameless SRS.

RESUMEN

OBJECTIVE: To investigate adequate radiation doses for repeat Gamma Knife radiosurgery (GKS) for trigeminal neuralgia in our series and meta-analysis. METHODS: Fourteen patients treated by ipsilateral repeat GKS for trigeminal neuralgia were included. Median age of patients was 65 years (range, 28-78), the median target dose, 140-180). Patients were followed a median of 10.8 months (range, 1-151) after the second gamma-knife surgery. Brainstem dose analysis and vote-counting meta-analysis of 19 studies were performed. RESULTS: After the second gamma-knife radiosurgeries, pain was relieved effectively in 12 patients (86%; Barrow Neurological Institute Pain Intensity Score I-III). Post-gamma-knife radiosurgery trigeminal nerve deficits were mild in 5 patients. No serious anesthesia dolorosa was occurred. The second GKS radiation dose ≤ 60 Gy was significantly associated with worse pain control outcome (P = 0.018 in our series, permutation analysis of variance, and P = 0.009 in the meta-analysis, 2-tailed Fisher's exact test). Cumulative dose ≤ 140-150 Gy was significantly associated with poor pain control outcome (P = 0.033 in our series and P = 0.013 in the meta-analysis, 2-tailed Fisher's exact test). A cumulative brainstem edge dose >12 Gy tended to be associated with trigeminal nerve deficit (P = 0.077). CONCLUSION: Our study suggests that the second GKS dose is a potentially important factor.

Asunto(s)

RESUMEN

BACKGROUND: Carbamazepine (CBZ) formed the gold standard drug in trigeminal neuralgia (TN) treatment but faces high therapeutic failure. This defined the need to explore a second line of drug therapy. The study aimed at comparing two alternate drugs i.e. Lamotrigine (LTG) and Pregabalin (PGB), in the management of TN refractory to therapeutic doses of CBZ. METHODS: Twenty-two patients with diagnosis of refractory TN were enrolled and randomly allotted into 2 groups of 11 each. Each group was subjected to a crossover analysis using LTG and PGB together with CBZ, for a period of 6 weeks. Patients maintained a pain diary, the scores of which, along with global evaluation scores, determined the primary outcome. Reevaluation of symptoms after 6 months was done to assess long term efficacy with study drugs. RESULTS: Both LTG and PGB were effective over CBZ alone (p < 0.05); however, statistically insignificant difference (p > 0.05) was observed between the two groups using Mann-Whitney tests. Unlike LTG, side effects like nausea, insomnia and concentration loss were minimal with PGB thus exhibiting greater patient compliance. Secondary analysis showed complete relief in 4 patients on PGB (mean dose 240.68 mg/day) while 6 had partial relief. Three patients on LTG (mean dose 310.90 mg/day) reported relapse of acute symptoms and required peripheral alcohol blocks. CONCLUSION: Pregabalin has potential anti-neuralgia properties comparable to LTG. However, the level of patient's tolerance seen with PGB exceeds that with LTG. 6 months follow-up records suggest that PGB together with CBZ offers a more reliable pain control than with LTG.