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 Facial Pain with Multiple Sclerosis and Tumors

Trigeminal Neuralgia Associated with Multiple Sclerosis

Trigeminal neuralgia associated with multiple sclerosis (TGN-MS) is difficult to alleviate due to multiple factors. Following are some facts and observations:

MVD fails to treat TGN-MS
Even the strongest advocates of MVD do not recommend this surgery for TGN-MS because of its high failure rate (32). 

Percutaneous destructive procedures can effectively treat TGN-MS, although a higher recurrence rate is anticipated
All percutaneous destructive procedures have successfully relieved pain of TGN-MS, but with a higher recurrence rate than primary TGN. This is especially true for glycerol rhizotomy (21,33). Denser levels of hypalgesia are needed to control pain of TGN-MS than in primary TGN. 

TGN-MS frequently involves multiple divisions or occurs bilaterally
TGN-MS may recur in different trigeminal divisions or on the contralateral side of the face. Therefore, it is appropriate to recommend a destructive procedure, such as PSR rhizotomy, which is most selective in achieving hypalgesia. 

Conclusion
Patients with TGN-MS are more difficult to treat. There is no role for MVD in such patients. PSR rhizotomy seems to be the most appropriate treatment for this condition because it is the most selective destructive procedure in tailoring the quantity and location of sensory deficit. The initial results of radiosurgery for TGN-MS have not been encouraging, with less than 50% of patients achieving acceptable pain control. Other techniques, such as motor cortex stimulation and percutaneous trigeminal nucleotomy-tractotomy, deserve investigation for multiple recurrent pain.  

Symptomatic Trigeminal Neuralgia Associated with Tumor

Although reports document that patients with TGN who harbor tumors, aneurysms, vascular malformations, or cysts (TGN-MASS) are young, have sensory deficits, and experience more atypical pain, the authors have observed patients with symptomatic lesions who have typical TGN. Similar observations have led others to advocate performing imaging studies on all patients with TGN (34). 

TGN-MASS can be effectively treated by tumor excision and MVD when vascular compression is found (34,35). In the series of Barker et al., pain relief was achieved in 81% of patients in 10 years following that approach (36). PSR rhizotomy has achieved similar results in patients who are not candidates for elective surgical removal of the lesion (34,37). Initial results of radiosurgery indicate a high rate of pain relief following radiation of tumors (23). Anecdotal data indicate that pain relief may follow embolization of arteriovenous malformations and clipping of aneurysms (36). The literature contains insufficient information to allow the comparison of the different techniques in treatment of TGN-MASS. 

Conclusion
In TGN-MASS, the authors recommend directing the treatment to the intracranial mass. Percutaneous destructive procedures can effectively control pain if surgery or radiosurgery to the tumor is not otherwise indicated.


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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