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Article history: Objectives: Trigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterised by severe
Paper received 23 August 2010 paroxysmal pain in the face. The treatment for trigeminal neuropathic pain disorder continues to be
Accepted 31 March 2011 a major therapeutic challenge, as relief provided by medical therapy generally decreases over time. When
medical therapy fails either due to poor or diminishing responses to drugs or to unacceptable side effects,
Keywords: peripheral intervention or surgical management of TN should be considered.
Trigeminal neuralgia
Study design: Fourteen patients (eight men and six women) who were not responsive to further medical
Pain pump
treatment and who were diagnosed with TN previously at other health centres were selected for
Epidural catheter
treatment. For this purpose, the affected nerve was infused with 60 mL (1 mL h1) of 0.5% bupivacaine
HCl with a pain pump via an temporary epidural catheter. Patient’s visual analogue scores (VAS) were
recorded on the fifth preoperative day and on postoperative day 5, 2 weeks, 1, 3, 6 and 9 months.
Results: There was a significant difference between mean preoperative and postoperative VAS value at
day 5, 2 weeks, 1, 3, 6 and at the end of 9 months ((68.85 1.43) (13.57 6.68) (11.43 6.70)
(14.29 6.52) (20.71 6.41) (20.71 6.41) and (21.43 6.10) respectively; *P < 0.05). Two of 14 patients
did not show any pain relief.
Conclusions: Continuous administration of 60 mL of 0.5% bupivacaine HCl at 1 mL h1 with a pain pump
and epidural catheter can be used as a transition treatment for patients with side effects from high-dose
antiepileptic drugs and for patients awaiting neurosurgery or individuals who refuse cranial surgery. It
should not be considered as an alternative treatment of neurosurgical approaches, such as MVD, which
has a definite long-lasting results.
Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
doi:10.1016/j.jcms.2011.03.022
G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128 125
peripheral interventions and presenting a temporary solution for pump; Daiken Medical, Osaka, Japan), and 60 mL of 0.5% bupiva-
patients awaiting neurosurgery or individuals who refuse cranial caine HCl (Marcaine; AstraZeneca, Stockholm, Sweden) was
surgery. administered at a rate of 1 mL h1. The pain pump was hung on the
patient’s neck (Fig. 3). Spiramycin (3 MIU twice per day;
2. Materials and methods RovamycineÒ; Eczacibasi, Istanbul, Turkey) was prescribed post-
operatively to prevent infection via the catheter. The next day, the
2.1. Patient criteria pain pump was checked to ensure that it was working. After 60 h
the catheter was removed
The study involved fourteen patients (eight men and six women) Five days after the procedure, the patients were asked to record
with essential TN. Only patients suffering from paroxysmal pain their pain scores every 3 h. These recordings were repeated at 2
were included in order to standardize and focus the study. With this weeks, 1, 3, 6 and 9 months and mean values were evaluated.
aim an observational and prospective study was planned and the
patients were followed up at weekly and monthly intervals. The
2.4. Measurements and statistical methods
diagnosis of idiopathic TN was based on paroxysmal attacks of pain
in one or several branches of the trigeminal nerve with pain-free
Patients were stratified by gender and affected branch. Clinical
intervals trigger areas, pain-triggering stimuli and absence of
characteristics of the samples, and preoperative and postoperative
signs of a trigeminal nerve organic lesion. All patients complained of
VAS scores were evaluated by the two-sample paired t test. The
strong TN pain attacks, although they were using a maximal dose of
data were analysed using SPSS 11.0 (SPSS Inc., Chicago, IL, USA).
carbamazepine (about 1,400 mg day1). Patients were offered pain
pump intervention only when medications failed.
Patients diagnosed with TN at other health centres and who 3. Results
fulfilled the following inclusive criteria were selected. Unilateral
neuralgia in the distribution of the second and/or third branches of The mean age of the patients was 55.1 11.69 years (Table 1). In
the trigeminal nerve, no prior surgical management of TN, unilateral our study group, eight of the patients suffered from mandibular TN
pain in the trigeminal nerve region at any one time, abrupt onset pain, and six suffered from maxillary trigeminal neuralgia (Table 1)
and paroxysmal pain with a pain-free period between attacks, pain and had been taking carbamazepine for an average of (10 3
character described as shooting, electric shock-like, lightning and years). There were no significant differences in gender, age or
sharp usually with intensity defined as severe, and each episode of affected nerve branch. Nine patients complained of a lack of
pain lasting no more than 2 min (mostly a few seconds). Magnetic concentration, dizziness or drowsiness before the operation, but
resonance imaging (MRI) was performed to exclude organic factors, there were no such complaints after the intervention. Five patients
such as tumours or other brain lesions (for example multiple scle- experienced slight oedema postoperatively around the site of the
rosis). Pain provoking factors were always present, such as eating, block. There was a significant difference between mean preopera-
talking, washing of the face and brushing the teeth. Atypical facial tive and postoperative VAS value at day 5, 2 weeks, 1, 3, 6 and at the
pain, which has symptoms similar to TN, was excluded. The most end of 9 months ((68.85 1.43) (13.57 6.68) (11.43 6.70)
characteristic feature of atypical facial pain is continuous pain, (14.29 6.52) (20.71 6.41) (20.71 6.41) and (21.43 6.10)
although it showed paroxysmal pain similar to TN. respectively; *P < 0.05) (Table 2, Graph. 1). Two (n ¼ 2) (14.28%) of
All patients were confirmed to be suffering exclusively from the 14 patients did not show any pain relief. None of the patients
primary TN. Patients were offered our non-invasive option versus complained about sensory disturbances such as paraesthesia or any
surgery. The patients who preferred non-invasive technique were sensorial disturbance after this procedure.
included to our study.
2.2. Evaluation
Table 1
Distribution of patients age, gender and effected branch of trigeminal nerve.
Fig. 2. The catheter was connected to a disposable infusion pump and 60 mL of 0.5%
bupivacaine HCl was administered at a rate of 1 mL h1. Patient Age Gender Affected nerve Time of
name disease
H.A. 52 Female Maxillary 11
M.A. 49 Male Mandibular 8
A.B. 55 Male Mandibular 12
Ö.Ş. 37 Male Mandibular 7
Z.E. 50 Male Maxillary 9
K.T. 41 Male Mandibular 11
K.D 43 Male Maxillary 7
K.S. 62 Female Mandibular 11
A.Ö. 71 Male Maxillary 13
B.B. 46 Female Mandibular 8
M.Y. 78 Female Mandibular 12
S.D. 57 Male Maxillary 13
C.K. 61 Female Maxillary 10
M.U. 70 Female Mandibular 8
Table 2
Comparison of preoperative VAS scores with postoperative 5 days, 2 week, 1, 3, 6, 9
months VAS score means.
Fig. 3. The pain pump was hung on the patient’s neck. * means highly significant.
G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128 127
goal of managing TN is to achieve long-term total analgesia, while Ashkan K, Marsh H: Microvascular decompression for trigeminal neuralgia in the
elderly: a review of the safety and efficacy. Neurosurgery 55: 840e848, 2004
preserving the sensory functions of the trigeminal nerve. We were
Barker 2nd FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD: The long-term
able to provide pain relief to 11 of 14 patients (Graph 1) for up to 9 outcome of microvascular decompression for trigeminal neuralgia. N Engl J
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attributable to the continuous administration through a pain pump clinical evaluation of an “obsolete” treatment. J Craniomaxillofac Surg 37:
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and epidural catheter, which delivered a continuous high concen- Fardy MJ, Patton DW: Complications associated with peripheral alcohol injection C
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Fields HL: Treatment of trigeminal neuralgia. N Engl J Med 334: 1125e1126, 1996
5. Conclusion Goto F, Ishizaki K, Yoshikawa D, Obata H, Arii H, Terada M: The long lasting effects of
peripheral nerve blocks for trigeminal neuralgia using a high concentration of
The continuous administration of 60 mL of 0.25% bupivacaine tetracaine dissolved in bupivacaine. Pain 79: 101e103, 1999
HCl at 1 mL h1 with a pain pump and temporary epidural catheter
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drugs. We observed a significant improvement in pain relief with trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia:
this method without surgery. Our intervention has minimal risk for 25-year experience with 1600 p.tients. Neurosurgery 48: 524e532, 2001
complications in comparison with cranial neurosurgery. Peripheral Keyoumars A, Henry M: Microvascular decompression for trigeminal neuralgia in
the elderly: a review of the safety and efficacy. Neurosurgery 55: 840e850,
surgical treatments such as alcohol injection minimize such risks, 2004
but repeatability, fibrous tissue formation, tissue necrosis, and Konishi R, Mitsuhata H, Akazawa S, Shimizu R: Temporary severe vertigo associated
neuropathic pain related to alcohol injection are concerns. This with mandibular nerve block with absolute alcohol for treatment of trigeminal
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However, the repeatability of our method is an important issue that
J Pain 12: 311e315, 1996
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Radwan IAM, Saito S, Goto F: High-concentration tetracaine for the management of
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Funding source peripheral nerve block. Clin J Pain 17: 323e326, 2001
None. Richardson MF, Straka JA: Alcohol block of the mandibular nerve: report of
a complication. J Natl Med Assoc 65: 63e64, 1973
Conflict of interest Spatz AL, Zakrzewska JM, Kay EJ: Decision analysis of medical and surgical treat-
None. ments for trigeminal neuralgia: how patient evaluations of benefits and risks
affect the utility of treatment decisions. Pain 131: 302e310, 2007
Stajcic Z, Juniper RP, Todorovic U: Peripheral streptomycin/ lidocaine injections
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