Case: Trigeminal Neuralgia

[Nemo]

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I am a DC intern who has a 71 year old female patient with Trigeminal Neuralgia. She has had this condition for about 2 years and after several months of the onset, she had a negative MRI study. I assume this was to rule out epidermoid cysts, meningioma, etc at the cerebellopontine angle or perhaps a vessel compressing the nerve.

I am not having much success at all with her- I tried a number of different modalities. She had seen an MD but stated that she "doesn't want to be on drugs all the time"
and wants to find the cause. Oddly, she said that she responded well to manipulative therapy in the mid thoracic region performed by her previous intern but this has not been reproducible. The CN5 nucleus extends to C2. While CN5 fibers enter the cervical spine, I have no other reason to suspect any sort of compressive lesion. She gets the pain in all 3 three branches but only occaisionally in the ophthalmic- so it stands to reason that the problem is likely to be at or upstream from the ganglion.

Any ideas? To whom shall I refer her?

Thanks, Nemo

 

[MacGyver]

If she's not willing to take medicines, then theres nothing conventional medicine can do for her.

There's no surgery available for that condition.

Tell her to seek acupuncture or other alternative therapies because thats probably her only shot for feeling better without taking medicines

 

[Molly Maquire]

Sounds like a case for Osteopathic Manipulative Treatment 🙂

 

[Nemo]

Hi Molly!


I couldn't decide if you were being sarcastic or not so I will pursue it:

I am curious as to how OMT would make a difference. What do you suppose might be some possible causes and how would OMT fix it?

Why would OMT be of more value in this case than Chiropractic SMT? Personally I do not think either would help much but I am very teachable.

Best, Nemo

 

[ckent]

If she is unwilling to take any medicines, you might recommend surgical exploration and radiofrequency rhizotomy or something called a "gamma radiosurgery to the trigeminal root". I don't know who you should call, but I'd imagine that it'd be ENT or rad onc. You can look it up in your "current medical dx and treatment" if you want to read more about it.

 

[ajl102]

Has the patient tried carbamazepine? If so, how were the side effects? If not, I have been told they are tolerable, and she may be willing to ammend her statement...

Would she be interested in sub-c electrical stimulation? Any opinions on the track record of this procedure with CNV Neuralgia?

How about psychotherapy - could be something there.

Very interested in this thread...

 

[eddieberetta]

Originally posted by ckent
If she is unwilling to take any medicines, you might recommend surgical exploration and radiofrequency rhizotomy or something called a "gamma radiosurgery to the trigeminal root". I don't know who you should call, but I'd imagine that it'd be ENT or rad onc. You can look it up in your "current medical dx and treatment" if you want to read more about it.

It would typically be a neurosurgeon. There may be other surgical options and they may want to perform further imaging.

 

[ajl102]

Here's a paper I found on PubMed...

Arch Physiol Biochem. 2001 Oct;109(4):304-8. Related Articles, Links

Electrical stimulation of the trigeminal tract in chronic, intractable facial neuralgia.

Holsheimer J., Institute for Biomedical Technology, University of Twente, Enschede, The Netherlands. [email protected]

In this paper the treatment of patients with chronic, intractable trigeminal neuralgia by invasive electrical stimulation of the Gasserion ganglion is reviewed. Two different surgical techniques are employed in this treatment. Most frequently, a method similar to the traditional technique for percutaneous glycerol and radiofrequency trigeminal rhizolysis is used: a small percutaneous stimulation electrode is advanced under fluoroscopic control through a thin needle via the foramen ovale to the Gasserian cistern. Some neurosurgeons use an open surgical technique by which the Gasserian ganglion is approached subtemporally and extradurally, and the bipolar pad electrode is sutured to the dura. When percutaneous test stimulation is successful (at least 50% pain relief) the electrode is internalized and connected to a subcutaneous pulse generator or RF-receiver. Data from 8 clinical studies, including 267 patients have been reviewed. Of all 233 patients with medication-resistant atypical trigeminal neuralgia 48% had at least 50% long term pain relief. The result of test stimulation is a good predictor of the long term effect, because 83% of all patients with successful test stimulation had at least 50% long term relief, and 70% had at least 75% long term relief. Patients generally preferred this invasive method over TENS. The success rate in patients with postherpetic trigeminal neuralgia was very low (less than 10%). It is suggested that the likelihood of pain relief by electrical stimulation is inversely related to the degree of sensory loss. It is concluded that invasive stimulation of the Gasserian ganglion is a promising treatment modality for patients with chronic, intractable, atypical trigeminal neuralgia.

 

[Soca]

But, my mother and grandmother both suffered from Trigeminal Neuralgia. My mom was on medications for years that decreased her energy level. Eventually, the meds stopped working. She found out about this doctor in Pittsburgh that invented a procedure to eliminate trigeminal neuralgia. Post-surgery, she has no pain and the only negative side-effect is some numbness in her face. She is extremely happy with the result as she was in sever pain for most of her adult life. Just wanted everyone to know that there is a procedure that can potentially solve trigeminal neuralgia. PM me if you want more specific information.

 

[Ligament]

I was just browsing this forum. I'm a pain medicine doc by trade so thought I'd chip in...

You could always refer to a pain medicine specialist for a gasserian block or specify which trigeminal branch(s) you want blocked. Could even try pulsed radiofrequency of the gasserian for the hell of it; could not hurt. I've seen some great results. Worst case is no result and 20 minutes wasted on the fluoro table. Or death 😱 if there is a serious complication (very rare).

Another option would be motor cortex stimulation by neurosurgery. This reportedly is pretty effective for an otherwise very difficult to treat condition. But I'd still try some blocks first for so many obvious reasons, especially her age.

It is also possible to have a peripheral nerve stimulator placed at the foramen ovale. This is not done by many people but is an option.

Also, WHICH meds have been tried? If she's only been on opioids or carb then she's got a host of meds to try with lesser side effects. I've seen trigeminal patients that have never been put on anything other than Vicodin or Oxycontin and so it is understandable they would not want any other meds...they've been given useless ones for their condition.

Also, what is a DC intern?

 

[typhoonegator]

If it's true trigeminal neuralgia and not some form of atypical facial pain syndrome, then it may be worth re-imaging her with thin cuts through the temporal bone and skull base. There are some neurosurgeons who can perform microvascular decompression through a suboccipital craniotomy if there appears to be a vessel overlying or abutting the trigeminal nerve. With proper patient selection, this procedure can be quite useful.

 

[BrainBuff]

Fully agree with typhoonegator. Most patients that failed conservative treatment ( medications) end up doing very well with microvascular decompression. One of the latest procedures involves compression of the ganglion with a balloon. You do not need to have a visualized "compressive lesion" for this to work. The patient in question may very well benefit from this procedure since at her age she is likely to develop multiple side effects from higher dosages of the meds usuallly used to treat the neuralgia.