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Urgent care peripheral nerve blocks for refractory trigeminal neuralgia
YAJEM-57728; No of Pages 3 American Journal of Emergency Medicine xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Urgent care peripheral nerve blocks for refractory trigeminal neuralgia☆ Michael D. Perloff a,⁎,1, Justin S. Chung b,2 a b
Department of Neurology, Boston University School of Medicine, Boston University Medical Center, 72 E. Concord St, C3, Boston, MA 02118, United States of America Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street, Box 124, New York, NY 10065, United States of America
a r t i c l e
i n f o
Article history: Received 13 May 2018 Received in revised form 31 July 2018 Accepted 7 August 2018 Available online xxxx Keywords: Trigeminal neuralgia Refractory trigeminal neuralgia Nerve block
a b s t r a c t 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 N50% 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. © 2018 Elsevier Inc. All rights reserved.
1. Introduction Trigeminal Neuralgia (TGN) is defined as sudden, unilateral, severe, brief, stabbing (lancinating), recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve (typical V2, 3) [1,2]. With similar TGN definitions by the International Association for the Study of Pain, the International Headache Society, the American Academy of Neurology and the European Federation of Neurological Societies, severe paraoxysmal pain and poor quality of life are considered typical [1,2]. The annual incidence of TGN is ~5 in 100,000 [1]. The first line treatment for classic trigeminal TGN is pharmacotherapy. Patients with refractory pain often seek more invasive therapies such as microvascular decompression, rhizotomy, radiosurgery and peripheral neurectomy [1,2]. Gasserian ganglion blocks have been utilized for the treatment of refractory TGN since the 1960s, but there is limited data on the efficacy of the procedure [3,4]. Other
gasserian ganglion level procedures such as radiofrequency thermocoagulation, balloon compression and glycerol gangliolysis have also been utilized. Although many of these procedures have demonstrated some effectiveness, they require expert level technical skill and are neurodestructive by nature. Reported adverse effects include sensory loss and dysesthesia [2]. Peripheral nerve procedures such as peripheral neurectomy, cryotherapy, and glycerol injections have been performed in patients in which ganglion level procedures are contraindicated. These interventions tend to be safer, but their long term efficacy remains in question [2]. Peripheral trigeminal nerve blocks (PNTB) for TGN have also been reported, [5] and can help avoid opioid therapy in the urgent care setting. We report a series of nine patients (Table 1) with intractable primary TGN who underwent PNTB in the urgent care setting (Video 1), after failing conservative medical therapy. 2. Materials and methods
☆ This study was done without any type of funding.Urgent care peripheral nerve blocks for refractory trigeminal neuralgia. ⁎ Corresponding author at: Department of Neurology, Boston University School of Medicine, 72 E. Concord St, C3, Boston, MA 02118, United States of America. E-mail address: [email protected] (M.D. Perloff). 1 Study supervision, video design and acquisition. 2 Acquisition of data.
2.1. Study design This was a retrospective case-series, where patients received PTNB for TGN that was not responding to medication trials. The Boston Medical Center Institutional Review Board approved the study design.
https://doi.org/10.1016/j.ajem.2018.08.019 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
Continued medical therapy Continued medical therapy Microvascular decompression surgery Repeat injections, continued medical therapy Balloon trigeminal gangliolysis Repeat injections, continued medical therapy Balloon trigeminal gangliolysis Repeat injections, continued medical therapy Balloon trigeminal gangliolysis
2.2. Patients Only urgent care patients that met the definition for “classic” trigeminal neuralgia were included (pain being reported as N8/10), where pain distribution was over V2 and V3 [1,2]. 2.3. Setting Cases were retrospectively collected over 2 years in urgent care at a large urban medical center. 2.4. Interventions All patients had informed consent taken, risks including bleeding, infection, eye droop and nerve damage were reviewed. Though the supraorbital nerve supplies V1, the intersection of V1–V2 (the eye) is a common area of complaint, and the supraorbital foramen was included in the PTNB. The supra/infraorbital foramens were palpated for orientation. After antiseptic skin preparation, a 30 g needle was inserted localizing to the supra and infraorbital foramen and advanced until the needle approached periosteum/bone. 0.5 mL of 0.25% bupivicaine:1% lidocaine (2 mL bupivicaine,1 mL lidocaine) was injected (both sites) and another 0.5 mL in the area of the mental foramen. Also, 1 mL of the above was injected in the region of the auriculotemporal nerve. All injections were done on the side with TGN pain, by physicians with varying injection experience. The patients tolerated the procedure well, and appreciated immediate benefit. (Video 1).1 2.5. Measure and outcomes Abbreviations: F, female; M, male; HA, headache; CVA, cerebral vascular accident/stroke; MEDS, medications; N/A, non-applicable.
Post-injection therapy Subacute outcomes Current meds
Oxcarbazepine Pain manageable with medication Topiramate Pain manageable with medication Carbamazepine, gabapentin, baclofen No improvement Carbamazepine Pain free None No improvement Oxcarbazepine Pain free Gabapentin, Carbamazepine No improvement Oxcarbazepine, nortriptyline, gabapentin Pain manageable with medication Baclofen Mild improvement
Previous meds/trials
87 F 60 M 29 F 52 M 66 F 81 F 46 M 67 M 65 F
Demographic information Medical history
Table 1 Patient demographics, medical history, and therapeutic outcomes.
Chronic HA, CVA Neurosarcoid, schwannoma, fibromyalgia None None None CVA None None None
Gabapentin Oxcarbazepine, carbamazepine, baclofen None None Lidocaine, dilaudid Carbamazepine None Carbamazepine, amitriptyline Oxcarbazepine
1 month 6 months N/A 8 months N/A 3 months N/A 6 months 4 months
M.D. Perloff, J.S. Chung / American Journal of Emergency Medicine xxx (2018) xxx–xxx
Duration
2
Patient demographics and medical history were recorded. Patients were followed clinically: subjective pain relief, medication changes, procedures, and surgeries were recorded. 2.6. Data analysis Patient subjective pain reports and need for additional procedural or surgical interventions was analyzed. Statistical analysis was not performed. 3. Results All nine patients experienced immediate (N50%) pain relief with 7 of 9 patient being pain free or just mild paresthesia; making TGN symptoms acutely managed. 6 of 9 patients achieved sustained pain relief lasting from 1 to 8 months. Of these six patients, three patients reported pain that was now tolerable with adjunct medication and two patients reported being completely pain free. The three patients who did not achieve benefit went on to Gasserian Ganglion balloon compression or surgical decompression for pain relief, but only one of the six patients who received benefit from PTNB required more invasive balloon compression (Table 1). 4. Discussion The treatment paradigm for primary TGN remains unclear when a patient fails conservative medical therapy. Accordingly, it is important to tailor subsequent therapy to the patients' needs. Patients who are averse to undergoing surgical procedures due to age or potential adverse effects may want to explore less invasive methods. PTNB require minimal expertise to perform and are fast and safe compared to invasive ganglion level procedures [2]. Furthermore, in the urgent care setting PTNB provide pain relief without use of opioid medication. No significant facial bleeding or scaring was seen in our case series. Physicians performing peripheral blocks had varying experience, and this did not appear to affect outcomes. No placebo or sham trials were performed,
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
M.D. Perloff, J.S. Chung / American Journal of Emergency Medicine xxx (2018) xxx–xxx
and while all patients reported unilateral acute facial numbness, acute placebo effects and relating to sustained benefit (beyond the duration of bupivacaine) are certainly possible.
3
Consent/ethics Patient consent was taken for the video portion of the submission. Case series data was not collected, part of routine clinical care, IRB approval.
5. Conclusions Author contributions The treatment paradigm for TGN remains unclear when a patient fails conservative medical therapy. PTNB can provide acute pain relief in the urgent care setting, but may provide subacute pain relief as well. PTNB can be a simple safe alternative compared to the opioids, invasive ganglion level procedures, or surgery. Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2018.08.019.
Disclosures/competing interests Drs. Perloff and Chung report no disclosures, no declarations, none.
Conflicts of interest
Both authors: study concept and design; analysis and interpretation of data; critical revision of manuscript for intellectual content. References [1] Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71(15):1183–90. [2] Peters G, Nurmikko TJ. Peripheral and gasserian ganglion-level procedures for the treatment of trigeminal neuralgia. Clin J Pain 2002;18(1):28–34. [3] Adler P. The use of bupivacaine for blocking the Gasserian ganglion in major trigeminal neuralgia. Int J Oral Surg 1975;4(6):251–7. [4] Greenberg C, Papper EM. The indications for gasserian ganglion block for trigeminal neuralgia. Anesthesiology 1969 Dec;31(6):566–73. [5] Goto F, Ishizaki K, Yoshikawa D, Obata H, Arii H, Terada M. The long lasting effects of peripheral nerve blocks for trigeminal neuralgia using high concentration of tetracaine dissolved in bupivacaine. Pain 1999;79(1):101–3.
None.
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Urgent care peripheral nerve blocks for refractory trigeminal neuralgia☆ Michael D. Perloff a,⁎,1, Justin S. Chung b,2 a b
Department of Neurology, Boston University School of Medicine, Boston University Medical Center, 72 E. Concord St, C3, Boston, MA 02118, United States of America Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th Street, Box 124, New York, NY 10065, United States of America
a r t i c l e
i n f o
Article history: Received 13 May 2018 Received in revised form 31 July 2018 Accepted 7 August 2018 Available online xxxx Keywords: Trigeminal neuralgia Refractory trigeminal neuralgia Nerve block
a b s t r a c t 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 N50% 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. © 2018 Elsevier Inc. All rights reserved.
1. Introduction Trigeminal Neuralgia (TGN) is defined as sudden, unilateral, severe, brief, stabbing (lancinating), recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve (typical V2, 3) [1,2]. With similar TGN definitions by the International Association for the Study of Pain, the International Headache Society, the American Academy of Neurology and the European Federation of Neurological Societies, severe paraoxysmal pain and poor quality of life are considered typical [1,2]. The annual incidence of TGN is ~5 in 100,000 [1]. The first line treatment for classic trigeminal TGN is pharmacotherapy. Patients with refractory pain often seek more invasive therapies such as microvascular decompression, rhizotomy, radiosurgery and peripheral neurectomy [1,2]. Gasserian ganglion blocks have been utilized for the treatment of refractory TGN since the 1960s, but there is limited data on the efficacy of the procedure [3,4]. Other
gasserian ganglion level procedures such as radiofrequency thermocoagulation, balloon compression and glycerol gangliolysis have also been utilized. Although many of these procedures have demonstrated some effectiveness, they require expert level technical skill and are neurodestructive by nature. Reported adverse effects include sensory loss and dysesthesia [2]. Peripheral nerve procedures such as peripheral neurectomy, cryotherapy, and glycerol injections have been performed in patients in which ganglion level procedures are contraindicated. These interventions tend to be safer, but their long term efficacy remains in question [2]. Peripheral trigeminal nerve blocks (PNTB) for TGN have also been reported, [5] and can help avoid opioid therapy in the urgent care setting. We report a series of nine patients (Table 1) with intractable primary TGN who underwent PNTB in the urgent care setting (Video 1), after failing conservative medical therapy. 2. Materials and methods
☆ This study was done without any type of funding.Urgent care peripheral nerve blocks for refractory trigeminal neuralgia. ⁎ Corresponding author at: Department of Neurology, Boston University School of Medicine, 72 E. Concord St, C3, Boston, MA 02118, United States of America. E-mail address: [email protected] (M.D. Perloff). 1 Study supervision, video design and acquisition. 2 Acquisition of data.
2.1. Study design This was a retrospective case-series, where patients received PTNB for TGN that was not responding to medication trials. The Boston Medical Center Institutional Review Board approved the study design.
https://doi.org/10.1016/j.ajem.2018.08.019 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
Continued medical therapy Continued medical therapy Microvascular decompression surgery Repeat injections, continued medical therapy Balloon trigeminal gangliolysis Repeat injections, continued medical therapy Balloon trigeminal gangliolysis Repeat injections, continued medical therapy Balloon trigeminal gangliolysis
2.2. Patients Only urgent care patients that met the definition for “classic” trigeminal neuralgia were included (pain being reported as N8/10), where pain distribution was over V2 and V3 [1,2]. 2.3. Setting Cases were retrospectively collected over 2 years in urgent care at a large urban medical center. 2.4. Interventions All patients had informed consent taken, risks including bleeding, infection, eye droop and nerve damage were reviewed. Though the supraorbital nerve supplies V1, the intersection of V1–V2 (the eye) is a common area of complaint, and the supraorbital foramen was included in the PTNB. The supra/infraorbital foramens were palpated for orientation. After antiseptic skin preparation, a 30 g needle was inserted localizing to the supra and infraorbital foramen and advanced until the needle approached periosteum/bone. 0.5 mL of 0.25% bupivicaine:1% lidocaine (2 mL bupivicaine,1 mL lidocaine) was injected (both sites) and another 0.5 mL in the area of the mental foramen. Also, 1 mL of the above was injected in the region of the auriculotemporal nerve. All injections were done on the side with TGN pain, by physicians with varying injection experience. The patients tolerated the procedure well, and appreciated immediate benefit. (Video 1).1 2.5. Measure and outcomes Abbreviations: F, female; M, male; HA, headache; CVA, cerebral vascular accident/stroke; MEDS, medications; N/A, non-applicable.
Post-injection therapy Subacute outcomes Current meds
Oxcarbazepine Pain manageable with medication Topiramate Pain manageable with medication Carbamazepine, gabapentin, baclofen No improvement Carbamazepine Pain free None No improvement Oxcarbazepine Pain free Gabapentin, Carbamazepine No improvement Oxcarbazepine, nortriptyline, gabapentin Pain manageable with medication Baclofen Mild improvement
Previous meds/trials
87 F 60 M 29 F 52 M 66 F 81 F 46 M 67 M 65 F
Demographic information Medical history
Table 1 Patient demographics, medical history, and therapeutic outcomes.
Chronic HA, CVA Neurosarcoid, schwannoma, fibromyalgia None None None CVA None None None
Gabapentin Oxcarbazepine, carbamazepine, baclofen None None Lidocaine, dilaudid Carbamazepine None Carbamazepine, amitriptyline Oxcarbazepine
1 month 6 months N/A 8 months N/A 3 months N/A 6 months 4 months
M.D. Perloff, J.S. Chung / American Journal of Emergency Medicine xxx (2018) xxx–xxx
Duration
2
Patient demographics and medical history were recorded. Patients were followed clinically: subjective pain relief, medication changes, procedures, and surgeries were recorded. 2.6. Data analysis Patient subjective pain reports and need for additional procedural or surgical interventions was analyzed. Statistical analysis was not performed. 3. Results All nine patients experienced immediate (N50%) pain relief with 7 of 9 patient being pain free or just mild paresthesia; making TGN symptoms acutely managed. 6 of 9 patients achieved sustained pain relief lasting from 1 to 8 months. Of these six patients, three patients reported pain that was now tolerable with adjunct medication and two patients reported being completely pain free. The three patients who did not achieve benefit went on to Gasserian Ganglion balloon compression or surgical decompression for pain relief, but only one of the six patients who received benefit from PTNB required more invasive balloon compression (Table 1). 4. Discussion The treatment paradigm for primary TGN remains unclear when a patient fails conservative medical therapy. Accordingly, it is important to tailor subsequent therapy to the patients' needs. Patients who are averse to undergoing surgical procedures due to age or potential adverse effects may want to explore less invasive methods. PTNB require minimal expertise to perform and are fast and safe compared to invasive ganglion level procedures [2]. Furthermore, in the urgent care setting PTNB provide pain relief without use of opioid medication. No significant facial bleeding or scaring was seen in our case series. Physicians performing peripheral blocks had varying experience, and this did not appear to affect outcomes. No placebo or sham trials were performed,
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
M.D. Perloff, J.S. Chung / American Journal of Emergency Medicine xxx (2018) xxx–xxx
and while all patients reported unilateral acute facial numbness, acute placebo effects and relating to sustained benefit (beyond the duration of bupivacaine) are certainly possible.
3
Consent/ethics Patient consent was taken for the video portion of the submission. Case series data was not collected, part of routine clinical care, IRB approval.
5. Conclusions Author contributions The treatment paradigm for TGN remains unclear when a patient fails conservative medical therapy. PTNB can provide acute pain relief in the urgent care setting, but may provide subacute pain relief as well. PTNB can be a simple safe alternative compared to the opioids, invasive ganglion level procedures, or surgery. Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2018.08.019.
Disclosures/competing interests Drs. Perloff and Chung report no disclosures, no declarations, none.
Conflicts of interest
Both authors: study concept and design; analysis and interpretation of data; critical revision of manuscript for intellectual content. References [1] Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71(15):1183–90. [2] Peters G, Nurmikko TJ. Peripheral and gasserian ganglion-level procedures for the treatment of trigeminal neuralgia. Clin J Pain 2002;18(1):28–34. [3] Adler P. The use of bupivacaine for blocking the Gasserian ganglion in major trigeminal neuralgia. Int J Oral Surg 1975;4(6):251–7. [4] Greenberg C, Papper EM. The indications for gasserian ganglion block for trigeminal neuralgia. Anesthesiology 1969 Dec;31(6):566–73. [5] Goto F, Ishizaki K, Yoshikawa D, Obata H, Arii H, Terada M. The long lasting effects of peripheral nerve blocks for trigeminal neuralgia using high concentration of tetracaine dissolved in bupivacaine. Pain 1999;79(1):101–3.
None.
Please cite this article as: Perloff MD, Chung JS, Urgent care peripheral nerve blocks for refractory trigeminal neuralgia, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019