Overview
Several disorders that cause facial pain can be successfully treated by neurosurgical procedures. It is important to accurately diagnose the disorder and identify the best treatment for each disorder. In the absence of randomized prospective studies, standardized methods of reporting, and standardized outcome criteria, it is difficult to compare the results of various surgical procedures and the different reported series of the same surgical procedure. Nevertheless, several important observations emerge from reviews of the literature and personal experience.
General Observations on Facial Pain
- Accurate diagnosis is required.
- The diagnosis of typical Trigeminal Neuralgia (TGN) is seldom difficult.
- In general, the length of the list of the patients symptoms is directly proportional to the likelihood of treatment failure.
- Medical treatment should be explored before surgery is contemplated.
- There is no successful surgical procedure for treatment of atypical facial pain.
- It is more difficult to treat neuropathic than neuralgic pain.
- Patients with dysesthetic pain seldom respond to ablative surgery.
- There is no single superior treatment for facial pain. The treatment should be individualized. Patients should have access to a broad spectrum of treatment options.
- The results of surgical treatment diminish as facial pain becomes more chronic.
Results for Cluster Headache
The surgical treatment of chronic cluster headache is difficult,
but worthy of consideration after an appropriate medical therapy has been explored.
Two systems are implicated in the pathogenesis of cluster headache: the trigeminovascular
system and the nervus intermedius-superficial petrosal-sphenopalatine system.
Surgery directed to one or both of these systems include percutaneous destructive
procedures (PSR trigeminal
rhizotomy, glycerol rhizotomy, balloon compression), open trigeminal rhizotomy,
MVD of the trigeminal root, superficial petrosal neurectomy, section of the
nervus intermedius, MVD of the nervus intermedius, and caudalis DREZ surgery.
The authors review the following facts and observations:
Surgery of either system can be successful
In combined series (38,45-48), long-term pain control was achieved in 62% of
210 patients who underwent surgery of the trigeminovascular system (Table 7)
and in 54% of 203 patients who underwent surgery of the nervus intermedius-superficial
petrosal-sphenopalatine system (Table 8). Results of small series of surgery
on both systems suggest rates of pain control approximating 80% (38). Regardless
of the surgery that is performed, good pain control rather than complete pain
relief is expected.
Glycerol rhizotomy and MVD are the least effective procedures
for the trigeminovascular system
In a review of combined series, long-term pain control was achieved in 62% patients
who underwent PSR trigeminal rhizotomy, in 68% of patients who underwent open
trigeminal rhizotomy, and in only 33% of patients who underwent glycerol rhizotomy.
Glycerol rhizotomy is not recommended for the treatment of cluster headache
by some authorities (21). Limited experience with isolated MVD of the trigeminal
rootlets has been disappointing (38).
In patients with cluster headache who undergo PSR rhizotomy, pain
is best controlled when a dense sensory lesion is made in the V-1 and V-2 regions
(38). Experience with glycerol rhizotomy has been similar (38). Patients who
undergo open trigeminal rhizotomy require section of the rostral part of the
nerve for good pain control (38,45). Major sensory loss is associated with increased
risks of keratitis and dysesthesia that can be up to 12% (38). For this reason,
balloon compression may be worthy of consideration for the treatment of cluster
headache; however, results have not been reported.
Surgeries to the nervus intermedius-superficial petrosal-sphenopalatine
system seem equally effective
In combined series, long-term pain control was achieved in 54% of patients who
underwent superficial petrosal neurectomy, in 50% of patients who underwent
section of the nervus intermedius, and in 56% of patients who underwent percutaneous
PSR sphenopalatine gangliolysis. Limited experience with isolated MVD of the
nervus intermedius has been disappointing (38).
Cluster headache is occasionally associated with intracranial
pathology
There are anecdotal reports of patients with chronic cluster headache who achieve
pain relief following surgery for tentorial meningiomas, pituitary tumors, arteriovenous
malformations, and aneurysms (38). These patients most likely experience referred
pain along the ophthalmic or maxillary divisions that can mimic pain of chronic
cluster headache.
Innovative treatments
There may be a role for newer surgical approaches for cluster headache. Initial
results of radiosurgery have been encouraging, with pain controlled in 6 of
8 patients followed for 8-14 months (49). Recently, ultrasonic trigeminal nucleotomy-tractotomy
has achieved pain control in 11 of 12 patients (46). The authors, however, are
aware of several patients who underwent caudalis DREZ surgery with only transient
pain relief.
Conclusion
In cluster headache, pain can be controlled by surgery to either the trigeminal
system or nervus intermedius-superficial petrosal-sphenopalatine system. With
both approaches, the pain is rarely cured. In the authorís experience, periorbital
pain is best relieved by PSR trigeminal rhizotomy or open intracranial rhizotomy
with section of the nervus intermedius if pain radiates to the temple-ear region.
To avoid sensory loss, surgeons may combine MVD with section of the nervus intermedius
with less successful results. Other approaches, such as balloon compression,
radiosurgery, and trigeminal nucleotomy-tractotomy require further investigation.
next>>Bibliography
Sources
Through the Trigeminal Neuralgia Association (TNA), local support groups are available. The support group provides an opportunity for patients and their families to share experiences, receive support, and learn about advances in treatments, pain control, and medications. Additional information is available on the web at www.tna-support.org or facial-neuralgia.org
If you would like information about the Greater Cincinnati Trigeminal Neuralgia Support Group, please call the Mayfield Clinic at (513)569-5290. For support outside Greater Cincinnati, please contact the Trigeminal Neuralgia Association at 800-923-3608.
The following journal articles and books formed the basis of our observations along with our own personal experience. Bibliography listing.
updated: 6.2004
originally published > Tew JM, Taha JM: Therapeutic Decisions in Facial Pain. Clinical Neurosurgery 46:410-431, 2000 |
