Trigeminal Neuralgia and SCS

[oyabun]

Is anyone on the board using neuromodulation to treat trigeminal neuralgia? A patient is being referred by her PCP for consideration of spinal cord stim for trigeminal neuralgia refractory to med mgmt, 2 gamma knife procedures and what the PCP describes as "rhizotomy". For those of you who have tried stim, any success? any pearls? Thanks

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[lobelsteve]

Is anyone on the board using neuromodulation to treat trigeminal neuralgia? A patient is being referred by her PCP for consideration of spinal cord stim for trigeminal neuralgia refractory to med mgmt, 2 gamma knife procedures and what the PCP describes as "rhizotomy". For those of you who have tried stim, any success? any pearls? Thanks

Question the diagnosis- is it TN or AFP?
Is there substance abuse?
What division of the TN?

TN and stim does not make empirical sense owing to the 20-120 second bouts of pain. AFP makes more sense for stim, but reports are spotty as far as success rates. I have a PHN patient on the books for tomorrow for right V1.

 

[oyabun]

AFP sounds more consistent with the notes supplied by her PCP. Started with a spontaneous and gradual onset 3 yrs ago. Localizes pain in the V3 distribution. Describes it as constant, burning, stabbing. Does have a history of MS. No imaging studies available. Will likely start off with MRI of brain to r/o any other causes of AFP

 

[lobelsteve]

AFP sounds more consistent with the notes supplied by her PCP. Started with a spontaneous and gradual onset 3 yrs ago. Localizes pain in the V3 distribution. Describes it as constant, burning, stabbing. Does have a history of MS. No imaging studies available. Will likely start off with MRI of brain to r/o any other causes of AFP

V3 can get stim paresthesia via gutter and/or paramedian stim at C2 as far as SCS. 1 lead goes there, the other lead can be used as either an octrode or dual quads PNS.

This is all off label and not endorsed by SJM/BS/Medtronic. The opinions are my own and I do not represent SJM/BS/Medtronic for the purposes of this thread.


SML

 

[Disciple]

Are there technique descriptions for this?

Where would you tunnel? Or would you refer to a plastic surgeon to dig around in the patient's face?

 

[Tenesma]

try deep brain stim (functional neurosurg. does this).

 

[lobelsteve]

Are there technique descriptions for this?

Where would you tunnel? Or would you refer to a plastic surgeon to dig around in the patient's face?

Netter is your friend for the face and scalp.
Make sure you tunnel over the clavicle.
I hear the percustay cath is a great tunneling tool, but I have not yet tried it.

This is the kind of stuff to ask about at an advanced course from one of the big three.

 

[ParaVert]

why not repeat a glycerol rhizotomy or do RF? Sure, you've got to distinguish between atypical facial pain and TN (or at least try), MS patients often require repeat lesioning.

I've seen 2 patients who have had glycerol and got only a few months of relief. On exam they have no numbness, basically the have no evidence of neurolysis. Traditional RF worked well for both with > 1 year of relief so far.

Conversely, if the patient is numb and painful, dolorosa is nothing to go messing around with. Last thing anyone needs is a dolorosa patient with ipsilateral blindness after chronic corneal abrasion. Hard to defend...

Trigeminal RF is easy, fast, pays well, works. SCS for TN is off-label, nearly impossible, no better than a crap shoot.

 

[lobelsteve]

why not repeat a glycerol rhizotomy or do RF? Sure, you've got to distinguish between atypical facial pain and TN (or at least try), MS patients often require repeat lesioning.

I've seen 2 patients who have had glycerol and got only a few months of relief. On exam they have no numbness, basically the have no evidence of neurolysis. Traditional RF worked well for both with > 1 year of relief so far.

Conversely, if the patient is numb and painful, dolorosa is nothing to go messing around with. Last thing anyone needs is a dolorosa patient with ipsilateral blindness after chronic corneal abrasion. Hard to defend...

Trigeminal RF is easy, fast, pays well, works. SCS for TN is off-label, nearly impossible, no better than a crap shoot.

I think there is a role for trigeminal RF, but it is not without risk. I base this on the attached article and references on complications. I would much rather do a trial PNS with fingers crossed then burn a facial nerve just mm's from the brain.

No one's ever going to die from sliding some wires under the skin.

 

[ParaVert]

Well, I guess you're right regarding the notion that peripheral stim logically seems lower risk than trigeminal RF. That being said, I don't understand the hesitancy to perform a procedure with an established track record of efficacy. Sure, putting a needle through the foramen ovale is not for the untrained, but it works. I've never heard of a neurosurgeon shying away from RF or even an MVD because of the accepted risk of the procedure in an otherwise healthy patient. People have certainly died during and after MVD, but the procedure is done every day.

I cannot make an argument against peripheral SCS for TN based on risk, but since there is virtually no data to demonstrate efficacy, I just don't see the point. You could rub on some Head On, doubt that would hurt anything... maybe some mandibular prolotherapy!