Efficacy and Safety of Radiofrequency Thermocoagulation with Different Puncture Methods for Treatment of V1 Trigeminal Neuralgia: A Prospective Study

BACKGROUND: Radiofrequency thermocoagulation through the supraorbital foramen with a different puncture method is a new approach for the treatment of ophthalmic division trigeminal neuralgia. OBJECTIVES: To compare the efficacy of the vertical puncture method and the transverse puncture method in the treatment of ophthalmic division trigeminal neuralgia during radiofrequency thermocoagulation through the supraorbital foramen. STUDY DESIGN: Randomized, longitudinal prospective, clinical research study. SETTING: Department of Anesthesiology and Pain Medicine, Jiaxing, China. METHODS: A total of 57 patients with ophthalmic division trigeminal neuralgia were enrolled in the study between October 2011 and April 2018, and prospectively randomized into the vertical puncture group (n = 29) or transverse puncture group (n = 28). All these patients received computed tomography guided radiofrequency thermocoagulation through the supraorbital foramen. Patients in the vertical puncture group were treated with a vertical puncture method; patients in the transverse puncture group received a transverse puncture method. Facial pain was evaluated using the Numeric Rating Scale preoperatively and at 1 day, 6 months, 1 year, and 2 years after treatment; facial numbness degree was analyzed at 1 day and 2 years after the treatments were recorded. The short-term and long-term complications during the period of postoperative follow-up were recorded. RESULTS: All surgical procedures were successfully completed. The Numeric Rating Scale scores at 6 months, 1 year, and 2 years after the treatment were significantly lower in the transverse puncture group compared to the vertical puncture group (P < 0.05), while no difference was observed on day one after the treatment (P > 0.05). The numbness degree at 2 years was significantly decreased compared to day one in both groups (P < 0.05). The radiofrequency thermocoagulation for ophthalmic division trigeminal neuralgia in the transverse puncture group showed better long-term outcomes than those in the vertical puncture group (P < 0.05). No short-term or long-term postoperative complications were observed in any of the groups. LIMITATIONS: Additional clinical data should be collected to preserve the results in future work. CONCLUSION: The transverse puncture method during radiofrequency thermocoagulation through the supraorbital foramen had better efficacy and fewer complications in comparison with the vertical puncture method when treating ophthalmic division trigeminal neuralgia. KEY WORDS: Trigeminal neuralgia, radiofrequency thermocoagulation, supraorbital foramen

LOCAL ANESTHETIC SPREAD TO THE CONTRALATERAL TRIGEMINAL GANGLION

Chronic neuropathic pain syndromes can severely affect a person’s quality of life. Trigeminal neuralgia is among these syndromes and involves the mandibular branch of the fifth cranial trigeminal nerve. Patients typically present with facial pain described as electrical and shock-like in nature, exacerbated by movements of the jaw such as talking and chewing. Many patients are unable to achieve adequate relief with medical management and therefore require interventions such as injections of local anesthetics, steroids, or glycerol. One method of injection uses ultrasound guidance for local anesthetic injection in the pterygopalatine fossa affecting the trigeminal ganglion. A 64-year-old woman with a history of trigeminal neuralgia presented for a trigeminal nerve block on her right side via ultrasound guidance. Following the injection, she experienced the desired effect of numbness on her right side in the distribution of the trigeminal nerve. In addition, the patient reported feeling the same effects on her left side despite no injection being done on that side. We describe a unique case in which local anesthetics spread through the pterygopalatine fossa and across the midline, affecting the contralateral trigeminal ganglion. Patients should be monitored for hemodynamic changes following this injection. Key words: Trigeminal neuralgia, trigeminal nerve block, pterygopalatine fossa, regional block, trigeminal ganglion

INFERIOR ALVEOLAR NERVE RADIOFREQUENCY ABLATION FOR REFRACTORY TRIGEMINAL NEURALGIA: A CASE REPORT

Trigeminal neuralgia, also known as tic douloureux, is a disorder characterized by pain in the distribution of the trigeminal nerve. Chronic pain secondary to this condition can have a significant negative impact on a patient’s quality of life. We present an educational case of refractory trigeminal neuralgia responsive to a novel painalleviating procedure. An 80-year-old man with recurrent trigeminal neuralgia presented with episodic pain refractory to multimodal pharmacologic treatment, as well as interventional pain procedures. Radiofrequency ablation (RFA) to the mandibular and maxillary branches of the trigeminal nerve was attempted, but deemed unsuccessful. In an attempt to relieve the patient’s pain in the mandibular region, an inferior alveolar nerve block with radiofrequency ablation was performed. The patient reported a significant longterm reduction of his pain and improved ability to perform activities of daily living. Key words: Trigeminal neuralgia, tic douloureux, radiofrequency ablation, trigeminal nerve, inferior alveolar nerve

Management of Refractory Trigeminal Neuralgia Using Extended Duration Pulsed Radiofrequency Application

Trigeminal neuralgia (TN) produces incapacitating facial pain that reduces quality of life in patients. Thermal radiofrequency (RF) ablation of gasserian ganglion (GG) is associated with masseter weakness and unpleasant sensations along the distribution of the ablated nerve. Pulsed radiofrequency (PRF) of GG has minimal side effects but literature is inconclusive regarding its benefit in refractory TN. Increasing the duration of PRF application to 6 minutes in TN produced encouraging results. PRF application to the saphenous nerve for 8 minutes reported improved pain relief and patient satisfaction. We report successful management of two patients of classic TN, which were refractory to medical management and interventional nerve blocks. The lesion site were confirmed with motor and sensory stimulation through a 22 G, 10 cm RF needle with 5 mm active tip. Both the patients received four cycles of PRF at 42 °C with each cycle of 120 seconds (8 minutres). The visual analogue scale (VAS) in case 1 reduced from pre block score of 80 to score 10 postblock, while in case 2 the VAS reduced from pre-block score of 85 to score 15 postblock. During follow up both the patients are now pain free with minimal dose of carbamazepine at 12 and 6 months respectively. We used PRF for longer duration (8 minutes) in these patients, which resulted in improved VAS and WHOQOL-BREF score in these patients. PRF of mandibular division of GG for extended duration provided long-term effective pain relief and quality of life in patients of refractory classic TN. Key words: Trigeminal neuralgia pain, pulsed radiofrequency ablation, interventional approach