CASE REPORT

The Ochsner Journal 15:193195, 2015

Academic Division of Ochsner Clinic Foundation

Effective Management of Trigeminal Neuralgia by

Neurostimulation
Alaa A. Abd-Elsayed, MD, MPH,1 Ravi Grandhi, MBA,2 Harsh Sachdeva, MD2
1
Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 2Department of Anesthesiology,
University of Cincinnati, Cincinnati, OH

Background: Treatment of trigeminal neuralgia can be challenging for many physicians; patients who do not respond to
conventional treatments and traditional surgical approaches often continue to suffer with pain. The peripheral nerve stimulator
(PNS) has been used to treat many chronic pain conditions, but few reports exist about its use to treat trigeminal neuralgia.
Case Report: We present the case of a patient with trigeminal neuralgia resistant to conventional techniques of pain
management. Conservative pain management was attempted but was ineffective. As a result, a PNS was placed with minimally
invasive surgery. Pain scores were recorded before and after the procedure, and the patient reported complete resolution of her
pain.
Conclusion: PNS implantation can be a safe and effective method to treat trigeminal neuralgia. More research is needed to
define its mechanism of action.

Keywords: Chronic pain, electric stimulation therapy, peripheral nerves, trigeminal neuralgia

Address correspondence to Alaa A. Abd-Elsayed, MD, MPH, Department of Anesthesiology, University of Wisconsin School of
Medicine and Public Health, 600 Highland Ave., B6/319 CSC, Madison, WI 53792. Tel: (608) 263-8106.
Email: [email protected]

INTRODUCTION trigeminal neuralgia was first reported in the 1960s4 but did
The trigeminal nerve, a mixed facial nerve, carries tactile, not become a widely used modality until the 2000s. We
proprioceptive, and nociceptive afferents of the face, mouth, present a case of trigeminal neuralgia that was resistant to
and portions of the meninges. Injury or disease of the all medication and procedural modalities but was success-
trigeminal nerve can lead to trigeminal neuralgia.1 Trigem- fully managed by PNS.
inal neuralgia is a syndrome of cyclic, recurrent attacks of
intense, sharp, stabbing pain lasting minutes to hours that CASE REPORT
occurs in one of the branches of the fifth cranial nerve, most A 43-year-old woman with allergies to codeine,
often V2 (maxillary) or V3 (mandibular). The pain occurs Depo-Provera (medroxyprogesterone acetate), and penicil-
because of tactile stimulation such as brushing teeth, lin had a medical history of jaw fractures that led to
touching the face, hearing loud sounds, or even feeling a trigeminal neuralgia. She presented to our clinic complain-
breeze.2 These attacks are often unilateral and may last ing of severe right-sided facial pain. She experienced pain in
months to years, followed by periods of pain-free intervals. the posterior temporal right side and parietal right side. The
Approximately 15,000 new cases are diagnosed annually.3 patient scored her pain as 10/10 and described it as sharp,
The syndrome occurs more frequently in females, and its radiating over the right side of her face, relieved by nothing,
incidence decreases with increasing age.3 One of the key and impairing her daily activities.
risk factors is hypertension. Most often, trigeminal neural- We managed the patient at first conservatively; we tried
gia occurs where the nerve root is compressed near the drugs such as gabapentin, amitriptyline, carbamazepine,
pons.3 The syndrome is generally diagnosed via clinical hydrocodone/acetaminophen, and tramadol. We also tried
presentation and physical examination of V1, V2, and V3. physical therapy and a transcutaneous electrical nerve
The longer a patient goes without the correct diagnosis of stimulation unit. Our conservative management did not
trigeminal neuralgia, the harder it can be to reverse the relieve the patients pain to a satisfactory level. We then
pain. performed a trigeminal nerve block using bupivacaine
Pharmacologic therapy is the preferred treatment. Pa- 0.25% and triamcinolone acetonide 40 mg. The injection
tients for whom medication is ineffective can benefit from relieved the patients pain temporarily. The block was
surgery, but surgery usually provides only short-term pain repeated multiple times during the management course.
control. As a result, peripheral nerve stimulators (PNSs) are The patient also underwent multiple radiofrequency abla-
used with varying efficacy.3 Electrical stimulation for treating tions to the trigeminal nerve that provided temporary pain

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Management of Trigeminal Neuralgia by Neurostimulation

DISCUSSION
Diagnosis of trigeminal neuralgia can be difficult, but a
variety of treatments helps prevent disease flare-ups.
The most prevalent treatment modality is carbamazepine,
an anticonvulsant often used for epilepsy and seizure
control that stabilizes the inactivated sodium channels.
Anticonvulsants used less frequently include clonazepam
and gabapentin. Another treatment modality is antispas-
modic medications such as baclofen, which is a gamma-
aminobutyric acid derivative. Anticonvulsants and antispas-
modics are often used in combination to achieve maximum
pain control. However, medical management can some-
times be ineffective or cause patients to experience too
many adverse effects, leading to noncompliance or a desire
to seek alternative therapies. Side effects associated with
anticonvulsants and antispasmodics include dizziness,
confusion, and drowsiness. These effects can be additive,
causing significant impairment in functional ability.5 Some-
Figure. X-ray showing percutaneous lead placement in times pain medications such as hydrocodone/acetamino-
the supraorbital and infraorbital locations. phen and acetaminophen/oxycodone can be used, but the
addictive potential and occasional lack of efficacy can leave
patients desiring higher doses.
relief. However, none of these methods provided satisfac- If medications are not effective, surgery can provide a
tory pain relief to the patient, and the pain continued to short-term solution to the problem. The most effective
impair her work and daily activities. After discussing the surgery is microvascular decompression, a procedure in
risks and benefits of placing a PNS, the patient agreed to which the physician surgically separates the blood vessel
the procedure. We performed a 1-week trial during which near the trigeminal nerve from the trigeminal nerve.3
we placed 2 percutaneous leads in the supraorbital and Patients who undergo this operation have significant pain
infraorbital locations under fluoroscopy (Figure). The patient relief in the short term; however, in the long term, the pain
had complete resolution of pain, and she agreed to proceed control decreases, causing individuals to seek different
with the permanent PNS implant. treatments or repeat surgeries that may lead to increased
The patient was placed under general endotracheal complications.4 Another procedure often used is a nerve
anesthesia, and local anesthesia was infiltrated within the rhizotomy that selectively destroys nerve roots with a
incisions. Dissection was performed to place the battery in glycerol injection, balloon compression, or a thermal lesion
the right subclavicular region. We tunneled to place a to help relieve neuromuscular conditions. All of these
bifurcated extension on the right side and connected a procedures damage the trigeminal nerve to achieve pain
single 1 3 8 Octad electrode (Medtronic, Inc.) directly to the relief. However, one of the side effects of damaging the
right neck area. Three needles were placed through a trigeminal nerve is facial numbness, so patients often do
temporal incision: one at the supraorbital location, one at not prefer such procedures.5 Another procedure used to
the infraorbital location, and one at the frontoparietal treat trigeminal neuralgia is gamma knife radiosurgery, a
junction. Two Quad Plus electrodes (Medtronic, Inc.) were procedure in which the surgeon directs a beam of
placed in the infraorbital and frontoparietal regions, and a 1 electricity at the trigeminal nerve and destroys it. Pain
3 8 Octad electrode was placed in the supraorbital region. relief occurs weeks after the procedure. Gamma knife
Electrodes were secured to the fascia via 2-0 silk sutures. radiosurgery is often the preferred surgical procedure
Once we tunneled to the parietal incision, 2 Quad Plus because it can be repeated without additional harm to the
electrodes were connected to the bifurcated extension, and patient.5
the 1 3 8 Octad electrode was tunneled directly to the Because surgery lacks long-term efficacy, alternative
battery via the superior port. After double-checking that all medical therapies have emerged, including the off-label
the connections were made correctly and completing the use of PNSs. PNSs have been used effectively to treat
intraoperative electronic testing, we placed a strain relief coil chronic pain localized to a peripheral nerve distribution. In
in the temporal incision and parietal incision and closed the the procedure, an electric current is applied to a nerve to
wounds. The patient was discharged the same day after we cause neuromodulation of pain. Electrodes attached to the
determined no obvious complications were present. nerve provide weak electrical stimulation that causes a
The patient returned to our clinic 3 weeks after surgery for tingling sensation. This process has two steps. First, a trial
a follow-up visit and indicated her pain was well controlled. electrode is placed for which the patient can control the
She reported being able to perform her daily activities amount of current needed to effectively relieve pain. Once
without any discomfort, to sleep on the right side of her face, the level of current needed to relieve the pain is determined,
to walk and exercise, to attend social and family events, and a permanent electrode with an internal battery pack is
to work more efficiently. This improvement in pain scores placed via a minimally invasive surgical procedure to
and function was the same as she had reported during the provide long-term relief. After the nerve stimulator is placed,
1-week trial. the patient can resume normal activities.

194 The Ochsner Journal

 Abd-Elsayed, AA

During the 1900s, our understanding of the phenomenon CONCLUSION

of pain transformed from one based on physical/sensory Trigeminal neuralgia can be managed in many ways, but
manifestations (peripheral pain pattern theory) to one more when all other treatments fail, the off-label use of neuro-
related to the emotions and mood of the individual (gate modulation via PNS is indicated. While PNS implantation
control theory). The mechanism of gate control theory has been shown to be safe and effective for a wide array of
involves the dorsal horns in the spinal cord that inhibit or diseases, more research is needed to define its mechanism
facilitate transmission from the body to the brain because of of action.
the diameter of active peripheral nerves and the dynamic
processes of the brain.6 In times of stress or anxiety, the ACKNOWLEDGMENTS
brain sends signals that open or close the nerve gates in the The authors have no financial or proprietary interest in the
peripheral nervous system. When the gates are open, the subject matter of this article.
perception of pain is amplified significantly. Closing these
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This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical
Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.

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