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Neurosurgical pain management of drug-resistant trigeminal neuralgia (TN) is highly challenging.
Trigeminal
neuralgia (TN)/tic douloureux, is a frequent neuropathic condition in which
sudden severe episodes of lancinating or electric pain along the distribution
of cranial nerve V (CNV) is observed. In this study, subcutaneous trigeminal
nerve field stimulation technique has been efficient in deducing the positive
results for refractory trigeminal pain.
Neurosurgical
pain management of drug-resistant trigeminal neuralgia (TN) is highly
challenging. Microvascular decompression is a first-line neurosurgical approach
for classical TN with neurovascular conflict, but can show clinical relapse
despite proper decompression. Second-line destructive techniques like
radiofrequency thermocoagulation have become reluctantly used due to their
potential for irreversible side effects. Subcutaneous peripheral nerve field
stimulation (sPNFS) is a minimally invasive neuromodulatory technique which has
been shown to be effective for chronic localized pain conditions. Reports on
sPNFS for the treatment of trigeminal pain (sTNFS) are still sparse and
primarily focused on pain intensity as outcome measure. Detailed data on the
impact of sTNFS on attack frequency are currently not available.
Patients were
classified according to the International Headache Society classification
(ICHD-3-beta). Three patients had classical TN without (n = 3) and another
three TN with concomitant persistent facial pain (n = 3). Two patients suffered
from post-herpetic trigeminal neuropathy (n = 2). All eight patients underwent
a trial stimulation of at least 7 days with subcutaneous leads in the affected trigeminal
area connected to an external neurostimulator. Of those, six patients received
permanent implantation of a neurostimulator. During the follow-up (6–29 months,
mean 15.2), VAS-scores, attack frequencies, oral drug intake, complications and
side effects were documented.
Seven out of
eight patients responded to sTNFS (i.e. ≥50 % pain reduction) during the test
trial. The pain intensity (according to VAS) was reduced by 83 ± 16 % (mean ±
SD) and the number of attacks decreased by 73 ± 26 % (mean ± SD). Five out of
six patients were able to reduce or stop pain medication. One patient developed
device infection. Two patients developed stimulation-related side effects which
could be resolved by reprogramming.
Treatment by
sTNFS is a beneficial option for patients with refractory trigeminal pain.
Prospective randomized trials are required to systematically evaluate efficacy
rates and safety of this low-invasive neurosurgical technique.
Acta neurochirurgica
Subcutaneous trigeminal nerve field stimulation for refractory trigeminal pain: a cohort analysis
Martin Jakobs et al.
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