Facial pain, a comparison of treatments Open print version

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.


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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

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