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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
Department of Neurology, Boston University School of Medicine, Boston University Medical Center, 72 E. Concord St, C3, Boston, MA 02118, United States of America
b
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 a b s t r a c t

Article history: Objective: After medication failure, patients with refractory trigeminal neuralgia (TGN) often present urgently
Received 13 May 2018 and seek more potent or invasive therapies such as opioids or surgical options. Peripheral nerve blocks, safe
Received in revised form 31 July 2018 and simple, may offer extended pain relief prior to opioid use or more invasive ganglion level procedures.
Accepted 7 August 2018 Methods: We report a retrospective case-series (urgent care, at a large urban medical center, over a 2 year period)
Available online xxxx
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 su-
Keywords:
Trigeminal neuralgia
praorbital, infraorbital, and mental foramens. 0.5 mL of 0.25% bupivicaine:1% lidocaine was injected locally at
Refractory trigeminal neuralgia all three foramens. Then, 1 mL of the above was injected in the region of the auriculotemporal nerve (see
Nerve block 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 tol-
erable 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 gasserian ganglion level procedures such as radiofrequency


thermocoagulation, balloon compression and glycerol gangliolysis
Trigeminal Neuralgia (TGN) is defined as sudden, unilateral, severe, have also been utilized. Although many of these procedures have dem-
brief, stabbing (lancinating), recurrent episodes of pain in the distribu- onstrated some effectiveness, they require expert level technical skill
tion of one or more branches of the trigeminal nerve (typical V2, and are neurodestructive by nature. Reported adverse effects include
3) [1,2]. With similar TGN definitions by the International Association sensory loss and dysesthesia [2].
for the Study of Pain, the International Headache Society, the Peripheral nerve procedures such as peripheral neurectomy, cryo-
American Academy of Neurology and the European Federation of Neu- therapy, and glycerol injections have been performed in patients in
rological Societies, severe paraoxysmal pain and poor quality of life which ganglion level procedures are contraindicated. These interven-
are considered typical [1,2]. The annual incidence of TGN is ~5 in tions tend to be safer, but their long term efficacy remains in question
100,000 [1]. The first line treatment for classic trigeminal TGN is phar- [2]. Peripheral trigeminal nerve blocks (PNTB) for TGN have also been
macotherapy. Patients with refractory pain often seek more invasive reported, [5] and can help avoid opioid therapy in the urgent care
therapies such as microvascular decompression, rhizotomy, radiosur- setting. We report a series of nine patients (Table 1) with intractable
gery and peripheral neurectomy [1,2]. Gasserian ganglion blocks have primary TGN who underwent PNTB in the urgent care setting
been utilized for the treatment of refractory TGN since the 1960s, but (Video 1), after failing conservative medical therapy.
there is limited data on the efficacy of the procedure [3,4]. Other
2. Materials and methods
☆ This study was done without any type of funding.Urgent care peripheral nerve blocks
for refractory trigeminal neuralgia. 2.1. Study design
⁎ 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: Michael.Perloff@bmc.org (M.D. Perloff).
This was a retrospective case-series, where patients received PTNB
1
Study supervision, video design and acquisition. for TGN that was not responding to medication trials. The Boston
2
Acquisition of data. 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 Emer-
gency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019
2 M.D. Perloff, J.S. Chung / American Journal of Emergency Medicine xxx (2018) xxx–xxx

2.2. Patients

Repeat injections, continued medical therapy

Repeat injections, continued medical therapy

Repeat injections, continued medical therapy


Only urgent care patients that met the definition for “classic” trigem-

Microvascular decompression surgery


inal neuralgia were included (pain being reported as N8/10), where pain

Balloon trigeminal gangliolysis

Balloon trigeminal gangliolysis


Balloon trigeminal gangliolysis
distribution was over V2 and V3 [1,2].

Continued medical therapy


Continued medical therapy
Post-injection therapy 2.3. Setting

Cases were retrospectively collected over 2 years in urgent care at a


large urban medical center.

2.4. Interventions
6 months

8 months

3 months

6 months
4 months
Duration

1 month

All patients had informed consent taken, risks including bleeding, in-
N/A

N/A

N/A

fection, eye droop and nerve damage were reviewed. Though the supra-
orbital nerve supplies V1, the intersection of V1–V2 (the eye) is a
Pain manageable with medication
Pain manageable with medication

Oxcarbazepine, nortriptyline, gabapentin Pain manageable with medication

common area of complaint, and the supraorbital foramen was included


in the PTNB. The supra/infraorbital foramens were palpated for orienta-
tion. After antiseptic skin preparation, a 30 g needle was inserted local-
izing to the supra and infraorbital foramen and advanced until the
Subacute outcomes

Mild improvement
No improvement

No improvement

No improvement

needle approached periosteum/bone. 0.5 mL of 0.25% bupivicaine:1% li-


docaine (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
Pain free

Pain free

above was injected in the region of the auriculotemporal nerve. All in-
jections were done on the side with TGN pain, by physicians with vary-
ing injection experience. The patients tolerated the procedure well, and
Carbamazepine, gabapentin, baclofen

appreciated immediate benefit. (Video 1).1


Gabapentin, Carbamazepine

2.5. Measure and outcomes

Patient demographics and medical history were recorded. Patients


Abbreviations: F, female; M, male; HA, headache; CVA, cerebral vascular accident/stroke; MEDS, medications; N/A, non-applicable.

were followed clinically: subjective pain relief, medication changes,


Carbamazepine
Oxcarbazepine

Oxcarbazepine
Current meds

procedures, and surgeries were recorded.


Topiramate

Baclofen
None

2.6. Data analysis


Oxcarbazepine, carbamazepine, baclofen

Patient subjective pain reports and need for additional procedural or


surgical interventions was analyzed. Statistical analysis was not
performed.
Carbamazepine, amitriptyline

3. Results
Previous meds/trials

Lidocaine, dilaudid

All nine patients experienced immediate (N50%) pain relief with 7 of


Carbamazepine

Oxcarbazepine

9 patient being pain free or just mild paresthesia; making TGN symp-
Gabapentin

toms acutely managed. 6 of 9 patients achieved sustained pain relief


None
None

None

lasting from 1 to 8 months. Of these six patients, three patients reported


pain that was now tolerable with adjunct medication and two patients
Neurosarcoid, schwannoma, fibromyalgia

reported being completely pain free. The three patients who did not
Patient demographics, medical history, and therapeutic outcomes.

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 com-
pression (Table 1).

4. Discussion
Chronic HA, CVA
Demographic information Medical history

The treatment paradigm for primary TGN remains unclear when a


patient fails conservative medical therapy. Accordingly, it is important
None
None
None

None
None
None
CVA

to tailor subsequent therapy to the patients' needs. Patients who are


averse to undergoing surgical procedures due to age or potential ad-
verse 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 signifi-
cant facial bleeding or scaring was seen in our case series. Physicians
Table 1

60 M

52 M

46 M
67 M
87 F

29 F

66 F
81 F

65 F

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 Emer-
gency 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 3

and while all patients reported unilateral acute facial numbness, acute Consent/ethics
placebo effects and relating to sustained benefit (beyond the duration
of bupivacaine) are certainly possible. 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 Both authors: study concept and design; analysis and interpretation
in the urgent care setting, but may provide subacute pain relief as of data; critical revision of manuscript for intellectual content.
well. PTNB can be a simple safe alternative compared to the opioids,
invasive ganglion level procedures, or surgery. References
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ajem.2018.08.019. [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.
Disclosures/competing interests [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
Drs. Perloff and Chung report no disclosures, no declarations, none. 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.
Conflicts of interest [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 Emer-
gency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.08.019