Background:

Trigeminal neuralgia (TN) pain is typically characterized by an abrupt, unilateral shock-like or sharp pain

Pathophysiology: Compression of the trigeminal nerve by a blood vessel

First line treatment: Na channel blockers, lamotrigine, baclofen, pregabalin, or gabapentin

Surgical intervention: Microvascular decompression

Acute abortive treatment: IV antiepileptics, peripheral nerve interventions including botulinum toxin injections and local anesthetic trigeminal nerve blocks

We present the case of an acute flair of TN pain s/p microvascular decompression and escalating medication management managed with the use of a trigeminal nerve block

 

Case Description:

21yo F fibromyalgia, Ehlers-Danlos syndrome, trigeminal neuralgia, and minor glossopharyngeal neuralgia (L>R) presented to the inpatient pain service with acute right sided facial pain following left rectosigmoid craniectomy for microvascular decompression of cranial nerve 5,7,9, and 10

Current medication regimen: acetaminophen 975 mg q8h, gabapentin 600 mg qid, tizanidine 4mg bid, and baclofen 10 mg q6h

Breakthrough medications: IV pushes of levetiracetam, fosphenytoin, fentanyl, and hydromorphone

Procedure:

Right pterygopalatine fossa located using ultrasound

2 mL of lidocaine 1% to anesthetize the skin and subcutaneous tissue

22 gauge Pajunk needle was advanced into the pterygopalatine fossa lateral to the maxillary artery

7 mL of 0.25% ropivacaine administered

100% pain relief on the right side for 2-3 days

Repeat procedure on the left 2 days after, no acute pain relief

 

Discussion:

Bilateral trigeminal nerve blocks are typically administered in the outpatient setting

Inpatient administration when IV opioids and antiepileptics are failing

Microvascular decompression, Gamma knife surgery, glycerol rhizotomy, radiofrequency ablation, or balloon compression associated with longer term improvement

Some literature reports nearly 80% relief of pain for at least 2 weeks after local blocks with less medication use

Trigeminal nerve blocks are less invasive, and should be further explored and emphasized as the next line or interim treatment

Stellate ganglion block can also provide pain relief, yet more research is needed

Reduce the use of higher-risk medications such as antiepileptics and opioids, and improve patients’ pain even if only temporary

 

References:

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2. Barker FG 2nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med. 1996;334(17):1077-1083. doi:10.1056/NEJM199604253341701 

3. Seo HJ, Park CK, Choi MK, Ryu J, Park BJ. Clinical Outcome of Percutaneous Trigeminal Nerve Block in Elderly Patients in Outpatient Clinics. J Korean Neurosurg Soc. 2020;63(6):814-820. doi:10.3340/jkns.2020.0139 

4. Jacques N, Karoutsos S, Marais L, Nathan-Denizot N. Quality of life after trigeminal nerve block in refractory trigeminal neuralgia: A retrospective cohort study and literature review. J Int Med Res. 2022;50(10):3000605221132027. doi:10.1177/03000605221132027 

5. Lopes CA, Fischer L. A case of severe trigeminal neuralgia: recovery by means of stellate ganglion block with procaine. Discussion of possible mechanisms of action. J Int Med Res. 2023;51(4):3000605231164479. doi:10.1177/03000605231164479