MEDICINE Volume 9 • Number 7 • 2008

CASE REPORTS

Facial Pain: A Possible Therapy with Stellate Ganglion Block

Ilaria Salvaggio, MD,† Enrica Adducci, MD,* Lucrezia Dell’Aquila, MD,* Simona Rinaldi, MD,‡ Marco Marini, MD,* Luca Zappia, MD,* and Adriana Mascaro, MD* Downloaded from https://academic.oup.com/painmedicine/article/9/7/958/1862244 by guest on 30 September 2021 *Anaesthesiology and Intensive Care Institute, Catholic University, Medical School, †via valentino mazzola 12, ‡Plastic and Reconstructive Surgery, University La Sapienza, Rome, Italy

ABSTRACT

Objective. The goal of the present study is to verify the efficacy of stellate ganglion block (SGB) in the treatment of facial pain that can be found in different pathological syndromes, and also to examine whether the efficacy is dependent upon when this therapy is administered. Patients. Fifty patients (divided into two randomized groups) with facial pain caused by traumas, iatrogenic issues, herpes zoster, or neurological pathologies participated in this study. Design and Interventions. The first group (N = 25) was treated with SGB produced by 10 adminis- trations of 10 mg of levobupivacaine given every other day, followed by one administration per month for 6 months thereafter. The second group was treated with the drugs tramadol 100 mg/day and gabapentin 1800 mg/day orally for 6 months; during the 7th month they were given SGB therapy using the same methodology as that described for the first group. Results. Before treatment, the mean visual analog scale (VAS) pain score for the first group was 8.89; after the 10th block treatment it was just 0.2, and it remained at that reduced level for the 6th and 12th months. Before treatment, the mean VAS pain score for the second group was 8.83; after the 20th day on medication it was reduced to 4.1, after 6 months it was 5.7 and after 12 months it was 4.9. Conclusions. Our results indicate that patients must be treated with SGB therapy precociously to receive its full benefits.

Key Words. Gabapentin; Facial Pain; Stellate Ganglion Block; Sympathetic Nervous System; Neu- ropathy;

Introduction by traumatic injuries of the cranio-facial region, a acial pain can be due to iatrogenic complica- series of SGB treatments can be applied [4]. Kohji- F tions, injuries, varicella-zoster virus outbreaks tani observed a case in which facial pain presented (), or neurological pathologies, and par- with and dysesthesia after dental extrac- ticular care must be taken in choosing the best tion and was accompanied by shingles: The pain therapy for patients [1–3]. Because the sympa- lasted 45 days and then completely disappeared thetic nervous system is usually involved in this after SGB therapy [5]. In a study of 35 patients, pain, stellate ganglion block (SGB) may be an Matsuura observed that SGB therapy may be effective therapy. Melis asserted that in burning useful for the treatment of prolonged postopera- pain with hyperalgesia and caused tive ocular pain [6]. Lynch studied 17 patients with orofacial and treated them with SGBs; he noticed that 10 patients had tem- Reprint requests to: Ilaria Salvaggio, MD, Anaesthesiology and Intensive Care Institute, Catholic University, Medical porary improvement, five patients had prolonged School, Rome, Italy. Tel: 0039 06 30 15 45 07-43 86; Fax: improvement, and two patients had no benefit [7]. 0039 06 30 13 145; E-mail: [email protected]. Despite possible inaccuracies about the period of

© American Academy of Pain Medicine 1526-2375/08/$15.00/958 958–962 doi:10.1111/j.1526-4637.2008.00515.x Stellate Ganglion Block 959 the therapy and a lack of the appropriate electrodi- Treatments agnostic tests, the aims of the present study were The patients were randomly divided into two to verify whether SGB may be an effective therapy homogeneous groups (Tables 1 and 2). The first for treating different types of facial pain, and also group (N = 25) was administered SGB therapy to examine whether its efficacy is dependent upon according to Moore’s paratracheal technique. when it is administered. Briefly, the patients were first given 10 administra- tions of levobupivacaine (10 mg; one dose every Materials and Methods other day) then they were given monthly supple- mental blocks (also 10 mg) for 6 months. The

Subjects Downloaded from https://academic.oup.com/painmedicine/article/9/7/958/1862244 by guest on 30 September 2021 Fifty patients at the Physiopathology and Pain number of blocks used was chosen to be that Therapy Center of the Catholic University sufficient to produce an effect, but not so much as Medical School in Rome who presented with facial to traumatize the patients. The second group was pain due to ophthalmic zoster (10 patients), dental treated pharmacologically with tramadol (100 mg/ extraction or devitalization (10 patients), multiple day, per os) and gabapentin (1800 mg/day, per sclerosis (10 patients), orbit or chin fractures os, after a titration of a week starting with 300 mg) (10 patients), dental implant (six patients), tonsil- for 6 months. At the 7th month, the delivery of lectomy (two patients), and of the these medications was suspended and SGB therapy glossopharyngeal nerve (two patients), between was initiated according to the protocol applied to February 1998 and December 2005 were included the first group (10 blocks given every other day and in this study. Almost all had spontaneous pain with then one block per month for 6 months). duration inferior to 15 days, allodinia, hyperalge- sia, a visual analog scale (VAS) score between 7 and Scoring of Pain 10 and had been taking a nonsteroidal anti- In the first group, VAS scores were assessed before inflammatory medication (Ketorolac, 30 mg/day the therapy (T0), after the first (T1), the fifth (T5) or Nimesulide 100 mg/day). Patients with pain and the tenth (T10) blocks, after 6 months and started more than 15 days before or treated with after 12 months. In the second group, VAS scores neuro-damaging techniques were excluded. were assessed before the pharmacological therapy

Table 1 First group: 25 patients treated with stellate ganglion block

T0 T1 T5 T10 6 Months 12 Months Ophtalmic herpes zoster VAS 10 8 6 0 0 0 884000 1094111 883000 985000 or devitalization VAS 7 7 5 0 0 0 996111 742000 1085100 964000 Multiple sclerosis VAS 10 8 6 2 1 1 764111 976000 986000 1095000 Orbit or chin fractures VAS 10 8 4 0 0 0 864000 885000 762000 986111 Dental implant VAS 8 7 4 0 0 0 631000 752000 Tonsillectomy VAS 8 7 2 0 0 0 Neuralgia of the glossopharyngeal nerve VAS 10 5 2 0 0 0 Mean value 8.52 7.04 4.12 0.28 0.20 0.20 SD 1.2288206 1.5673757 1.5631165 0.5416026 0.4082483 0.4082483

VAS = visual analog scale. 960 Salvaggio et al.

Table 2 Second group: 25 patients treated with tramadol and ketorolac and later with stellate ganglion block

T0 T1 T5 T10 6 Months 12 Months Ophtalmic herpes zoster VAS 1086565 763354 976575 1086575 985466 Dental extraction or devitalization VAS 8 75455 976564 764344

875454 Downloaded from https://academic.oup.com/painmedicine/article/9/7/958/1862244 by guest on 30 September 2021 976465 Multiple sclerosis VAS 9 86577 865466 965454 986576 764344 Orbit or chin fractures VAS 9 86454 1087576 864354 754354 875466 Dental implant VAS 8 76455 764333 765344 Tonsillectomy VAS 8 75455 Neuralgia of the glossopharyngeal nerve VAS 9 86576 Mean value 8.36 6.92 5.2 4.04 5.52 4.84 SD 0.9949874 0.9092121 0.9574271 0.7895146 1.1224972 0.9865766

VAS = visual analog scale.

(T0), after 1 day of therapy (T1), after 5 days of applied to detect significant effects. Specifically, therapy (T5), after 20 days (T10), after 6 months we compared the VAS scores between consecutive and after 12 months. For each group, the mean time points (i.e., T1 vs T5) within each group and values and the standard deviations were calculated between the groups at T0, T10, 6 months, and 12 for each time point and student’s tests were months (Tables 3 and 4).

Table 3 First group: Type and localization of pain

Number of Patients Pathology Symptoms Localization 5 Ophtalmic herpes zoster Spontaneous pain and allodynia Infraorbital and sovraorbital nerve 5 Dental extraction/devitalization Spontaneous pain and allodynia Mandibular nerve 5 Multiple sclerosis Spontaneous pain, allodynia and hyperalgesia Mandibular and maxillar nerve 5 Orbit or chin fractures treated via Spontaneous pain and allodynia Infraorbital nerve maxillo-facial, plastic and reconstructive techniques 3 Dental implant Spontaneous pain Mandibular nerve 1 Glossopharingeal neuralgia (after Spontaneous pain Glossopharingeal nerve tonsillectomy) 1 Glossopharingeal neuralgia (with Spontaneous pain, allodynia and hyperalgesia Glossopharingeal nerve neurovascular conflict) 5 Ophtalmic herpes zoster Spontaneous pain and allodynia Infraorbital and sovraorbital nerve 5 Dental extraction/devitalization Spontaneous pain and allodynia Mandibular nerve 5 Multiple sclerosis Spontaneous pain, allodynia and hyperalgesia Mandibular and maxillar nerve 5 Orbit or chin fractures treated via Spontaneous pain and allodynia Infraorbital nerve maxillo-facial, plastic and reconstructive techniques 3 Dental implant Spontaneous pain Mandibular nerve 1 Glossopharingeal neuralgia (after Spontaneous pain Glossopharingeal nerve tonsillectomy) 1 Glossopharingeal neuralgia (with Spontaneous pain, allodynia and hyperalgesia Glossopharingeal nerve neurovascular conflict) Stellate Ganglion Block 961

Table 4 Second group: Type and localization of pain

Number of Patients Pathology Symptoms Localization 5 Ophtalmic herpes zoster Spontaneous pain and allodynia Infraorbital and sovraorbital nerve and nearby areas 5 Dental extraction/devitalization Spontaneous pain and allodynia Mandibular nerve 5 Multiple sclerosis Spontaneous pain, allodynia, and hyperalgesia Mandibular and maxillar nerve 5 Orbit or chin fractures treated via Spontaneous pain and allodynia Infraorbital nerve and nearby areas maxillo-facial, plastic and reconstructive techniques

3 Dental implant Spontaneous pain Mandibular nerve Downloaded from https://academic.oup.com/painmedicine/article/9/7/958/1862244 by guest on 30 September 2021 1 Glossopharingeal neuralgia Spontaneous pain Glossopharingeal nerve (after tonsillectomy) 1 Glossopharingeal neuralgia Spontaneous pain, allodynia, and hyperalgesia Glossopharingeal nerve and nearby (with neurovascular conflict) areas

The present study was approved by the Catho- increased pain (VAS = 5.7) relative to their prior lic University’s IRB. All the patients did sign an assessment. After 12 months the mean VAS score appropriate informed consent paper. for the first group remained close to 0, while the mean VAS score for the second group remained elevated (VAS = 4.9). In the first group, allodinia Results and hyperalgesia disappeared and insomnia was Before commencing treatment, both patient deeply reduced; in the second group, hyperalgesia groups had similarly high VAS mean scores disappeared but allodinia remained unvaried. (VAS = 8.89 for the first group and VAS = 8.33 for Moreover, the second group did not respond to the second group). In the first group, after 10 the SGB therapy they were given beginning in blocks the mean VAS score had been reduced to the 7th month. These results indicate that only 0.2; and in the second group, after 20 days of patients precociously treated with SGBs can therapy the mean VAS had been reduced less benefit from the therapy (Figure 2). During the markedly to 4.10. The VAS scores during the first study no complications occurred. 6 months were significantly affected by the SGB treatment regimen in the first group (P < 0.05), but not by the pharmacological treatment in the Discussion second group (Figure 1). After 6 months of therapy, the first group did not report any pain Our findings that the first, but not the second, (VAS = 0.1), while the second group reported experimental group benefited from the SGB therapy indicates that different types of facial pain only benefit from SGB therapy if it is administered 9 8 7 12 6 10 5

VAS 8 4 3 6 ** 2 4

1 2 0 0 T0 T1 T5 T10 6 Months 12 Months T0 T1 T5 T10 TIME first group second group Figure 2 SGB therapy efficacy in facial pain syndrome. Mean value of VAS from patients treated precociously Figure 1 The variation of VAS during the treatment with (black bars) with SGB, compared with mean value of VAS stellate ganglion block (first group) and with pharmacologi- from patients treated in a second time with SBG. cal therapy (second group; P < 0.05). VAS = visual analog *P < 0.001. VAS = visual analog scale; SGB = stellate gan- scale. glion block. 962 Salvaggio et al. precociously upon the onset of the first symptoms. 3 Klein RN, Burt DT, Chase PF. Anatomically and This result suggests that the sympathetic nervous physiologically based guidelines for use of the system may be critically involved in only the first sphenopalatine ganglion block versus the stellate phase of acute inflammation. However, the phys- ganglion block to reduce . Cranio iopathology of neuropathic pain is probably quite 2001;19(1):48–55. 4 Melis M, Zawawi K, Badawi E, Lobolobo S, Metha complex and not reducible to a single peripheral N. Complex regional pain syndrome in the head and mechanism such as the transmittal of noradrener- neck: A review of the literature. J Orofac Pain gic postgangliar neuronal impulses to afferent 2002;16(2):93–104. nociceptive neurons [8–9]. The ability of the SGB 5 Kohjitani A, Miyawaki T, Kasuya K, Shimada M. therapy to alleviate pain symptoms in the first Sympathetic activity-mediated neuropathic facial Downloaded from https://academic.oup.com/painmedicine/article/9/7/958/1862244 by guest on 30 September 2021 group leads us to consider how central sensitiza- pain following simple tooth extraction: A case tion of chronic pain may be prevented. Indeed, report. Cranio 2002;20(2):135–8. chronic stimulation of nociceptive system may 6 Matsuura M, Ando F, Sahashi K, ToriiY, Hirose H. lead to a demyelination and axonal dysfunction in The effect of stellate ganglion block on prolonged addition to a overactivation of central sensory post-operative ocular pain. Nippon Ganka Gakkai transmission [10,11]. This would bring to an Zasshi 2003;107(10):607–12. 7 Lynch ME, Elgeneidy AK. The role of sympathetic atypical chronic pain instead of a typical neuralgia activity in neuropathic . J Orofac Pain [11]. Thus, stopping this vicious circuit ahead of 1996;10(4):297–305. time may be a key of the positive response that we 8 Drummond PD, Finch PM. Persistence of pain show after SGB therapy in the first group of induced by startle and forehead cooling after sym- patients. Our findings, based only on clinical but pathetic blockade in patients with complex regional not experimental evidence, may be informative for pain syndrome. J Neurol Neurosurg Psychiatry future studies examining the role of the sympa- 2004;75(1):98–102. thetic nervous system in the pain. 9 Baron R, Pain Janig W. Syndromes with causal participation of the sympathetic nervous system. Anaesthesist 1998;47(1):4–23. 10 Obermann M, Yoon MS, Ese D, et al. Impaired References trigeminal nociceptive processing in patients with 1 Du Pont JS, JR. Neuritic . Gen Dent . 2007;69(9):835– 2001;49(2):178–1. 41. 2 Maier C, Hoffmeister B. Management and treat- 11 Meng ID, Cao L. From to chronic daily ment of patients with atypical facial pain. Dtsch headache: The biological basis of headache transfor- Zahnarztl Z 1989;44(12):977–83. mation. Headache 2007;47(8):1251–8.