Evidence-Based Interventional Pain Medicine

According to Clinical Diagnoses

Jan Van Zundert, Jacob Patijn, Craig Hartrick, Arno Lataster, Frank Huygen, Nagy Mekhail, Maarten van Kleef, Jan Van Zundert, Jacob Patijn, Craig Hartrick, Arno Lataster, Frank Huygen, Nagy Mekhail, Maarten van Kleef

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9780470671306
• eBook ISBN: 9781119968351
• Edition: 1
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

Unrelieved chronic pain is a worldwide epidemic

Chronic pain has been subject to multiple international initiatives through the World Health Organization. Interventional Pain Medicine, the use of minimally invasive techniques to relieve pain, is the best approach when simpler measures such as physical therapy or medications fail. However, these procedures can be associated with significant risk and expense. Establishing uniformity in diagnostic criteria and procedural performance can reduce both morbidity and unnecessary procedures, and hence healthcare expenditures.

While other texts explain how to perform these procedures, little focus has been given to diagnostic considerations: if and when these procedures should be performed. Evidence-Based Interventional Pain Medicine focuses on a balance between effectiveness and safety of interventional management for specific diagnoses, across all areas of chronic pain including:

• Head, neck and shoulder pain
• Lower back pain
• Neuropathic pain syndromes
• Complex Regional Pain Syndrome
• Pain in patients with cancer
• Vascular and visceral pain

Evidence-Based Interventional Pain Medicine provides essential knowledge for anyone who uses, or intends to use, interventional pain techniques.

1

Trigeminal Neuralgia

Maarten van Kleef, Wilco E. van Genderen, Samer Narouze, Turo J. Nurmikko, Jan Van Zundert, José W. Geurts and Nagy Mekhail

Introduction

“Trigeminal Neuralgia is the worst pain in the world,” declared Peter J. Jannetta, MD in “Striking Back!”, a layman’s guide for facial pain patients.¹ Trigeminal neuralgia, or “Tic Doloureux”, is a painful condition of the face. This pain has been known since ancient times; there are descriptions of facial pain by Ibn Sina (980–1073) in an Arabic text. An example of early interventional treatment is that by Locke in 1677, who applied sulphuric acid to the face of the Duchess of Northumberland in an attempt to treat her trigeminal neuralgia.

A survey conducted in 6 European countries indicated that trigeminal neuralgia significantly impacted the quality of life and the socioeconomic functioning of affected patients.² Trigeminal neuralgia is the most common form of facial pain in people older than 50 years of age. Various epidemiological studies have shown the annual incidence to be about 4–5 new patients per 100,000. The highest incidence occurs in the ages between 50 and 70 years; in 90% of the cases the symptoms begin after the age of 40 years. Trigeminal neuralgia is more prevalent in women than men with a ratio of 1.5:1.³

The pathophysiology is unclear. Based on clinical observations, compression of the nervus trigeminus near the origin of the brain stem, the so-called root entry zone, by blood vessels or tumor, may cause trigeminal neuralgia. Local pressure causes demyelination that leads to abnormal depolarization resulting in ectopic impulses.

Symptoms

Trigeminal neuralgia is recognized by unilateral short-lived, strong, sharp, shooting pains in 1 or more branches of the fifth cranial nerve. The description of the pain is very important; it must be sharp, shooting, lancinating, and “electric shock”. The pain can be brought on by ordinary stimuli, such as eating, washing, shaving, cold, warmth, and draught. The distribution of the pain in the various branches of the nervus trigeminus is given in Table 1.1.

Table 1.1. Pain distribution in the various nerve branches in trigeminal neuralgia.

See Rozen.³

V1 only	4%
V2 only	17%
V3 only	15%
V2 + V3	32%
V1 + V2	14%
V1 + V2 + V3	17%

In the case history, 6 questions should be asked:

1 Does the pain occur in attacks?

2 Are most of the attacks of short duration (seconds to minutes)?

3 Do you sometimes have extremely short attacks?

4 Are the attacks unilateral?

5 Do the attacks occur in the region of the nervus trigeminus?

6 Are there unilateral autonomic symptoms?

In this way, a differential diagnosis can be made relatively quickly and an impression can be formed of whether it is essential trigeminal neuralgia.

Physical Examination

Neurological examination seldom reveals any abnormalities in patients with idiopathic trigeminal neuralgia, but all cranial nerves do need to be tested. Patients who have neurological disorders often have a so-called secondary trigeminal neuralgia whereby the trigeminal neuralgia is a symptom of another disease, e.g., tumor of the angulus pontocerebellaris or multiple sclerosis.

Additional Test

When the diagnosis of trigeminal neuralgia is made, the patient needs to undergo an magnetic resonance imaging (MRI) scan to exclude specific pathologies such as a tumor or multiple sclerosis, which could cause a secondary trigeminal neuralgia. The MRI scan can also be used if there is a suspected compression of the nervus trigeminus in the fossa cranialis posterior. Sometimes the MRI scan is sensitive enough to detect blood vessels that have come in contact with the nervus trigeminus. The role of venous compression in the pathogenesis of trigeminal neuralgia is controversial.^4,5 Notably, on MRI scanning, compressing blood vessels are seen in one-third of asymptomatic patients. A recent evidence-based review concluded that there is insufficient evidence to support or deny the usefulness of MRI to identify neurovascular compression.⁶

Differential Diagnosis

Less frequently trigeminal neuralgia is seen in younger patients. It is important that multiple sclerosis always be considered in the differential diagnosis, especially in bilateral cases. The International Headache Society described the following criteria for essential trigeminal neuralgia.⁷

A Paroxysmal pain that lasts from a fraction of a second to 2 minutes, occurring in 1 or more branches of the nervus trigeminus, and fulfilling criteria B and C.

B The pain has at least one of the following characteristics:

1 intense, sharp, superficial or stabbing.

2 precipitated from trigger areas or by trigger factors.

C The attacks are stereotypically described by the patient.

D There are no signs of neurological disorders.

E The attacks are not caused by other disorders.

The International Headache Society have suggested their own diagnostic criteria for trigeminal neuralgia (Table 1.2).⁸ The differential diagnosis of essential trigeminal neuralgia is extensive and involves all unilateral pain in the pathway of the nervus trigeminus. The most important differential diagnostic considerations are specific facial pain, nonspecific facial pain, temporomandibular arthrosis, dental disorders, and vascular migraine. A detailed overview of the differential diagnosis of facial pain can be found in Table 1.3.⁹

Table 1.2. Trigeminal neuralgia: clinical diagnostic criteria.

Characteristic	Description
Character	Shooting, like an electric shock, stabbing, superficial
Seriousness	Moderate to very intense
Duration	Each pain attack lasts seconds but a number of different attacks can occur simultaneously after which there is a pain free interval
Periodicity	Periods of weeks to months without pain
Location	Distribution of T. neuralgia, mainly unilateral
Emanation	Within the area of the trigeminal nerve
Trigger factors	Light touching, such as when eating, talking or washing
Alleviating factors	Frequent sleep, anti-epileptics
Accompanying characteristics	Trigger zones, weight loss, poor quality of life, depression

Table 1.3. Differential diagnosis of trigeminal neuralgia.

See Nurmikko.³²

Treatment Options

Conservative Treatments

The selection of the pharmacological treatment is based on a systematic review of data of relatively older studies¹⁰ or on a more up-to-date Cochrane database.¹¹ The medication of choice is carbamazepine. From an observational study, it appears that carbamazepine can reduce the pain symptoms in about 70% of the cases. Oxcarbazepine has shown similar efficacy.⁶ Other medications that can be tried, although there is no clinical evidence for their efficacy, are gabapentin, pregabalin, and baclofen. Rozen summarized the recommendations for the medical treatment of trigeminal neuralgia in Table 1.4.³

Table 1.4. Medical treatments for trigeminal neuralgia.

See Rozen.^3...

Table of contents

• Cover
• Title page
• Copyright page
• Contributor List
• Foreword
• Introduction
• 1 Trigeminal Neuralgia
• 2 Cluster Headache
• 3 Persistent Idiopathic Facial Pain
• 4 Cervical Radicular Pain
• 5 Cervical Facet Pain
• 6 Cervicogenic Headache
• 7 Whiplash-Associated Disorders
• 8 Occipital Neuralgia
• 9 Painful Shoulder Complaints
• 10 Thoracic Pain
• 11 Lumbosacral Radicular Pain
• 12 Pain Originating from the Lumbar Facet Joints
• 13 Sacroiliac Joint Pain
• 14 Coccygodynia
• 15 Discogenic Low Back Pain
• 16 Complex Regional Pain Syndrome
• 17 Herpes Zoster and Post-Herpetic Neuralgia
• 18 Painful Diabetic Polyneuropathy
• 19 Carpal Tunnel Syndrome
• 20 Meralgia Paresthetica
• 21 Phantom Pain
• 22 Traumatic Plexus Lesion
• 23 Pain in Patients with Cancer
• 24 Chronic Refractory Angina Pectoris
• 25 Ischemic Pain in the Extremities and Raynaud’s Phenomenon
• 26 Pain in Chronic Pancreatitis
• Index