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Primary Experience with Ct Guided Mandibular Nerve Block in Patients with Trigeminal Neuralgia

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Primary Experience with Ct Guided Mandibular Nerve Block in Patients with Trigeminal Neuralgia Al-Azhar Med. J. Vol. 46(2), April, 2017, 383-390 DOI: 10.12816/0038261 PRIMARY EXPERIENCE WITH CT GUIDED MANDIBULAR NERVE BLOCK IN PATIENTS WITH TRIGEMINAL NEURALGIA By Samy M Abdelraouf *, Ashraf M Enite and Ola I Saleh Departments of Neurosurgery* and Radiodiagnosis, Al-Azhar Faculty of Medicine (Girls) ABSTRACT Background: Trigeminal neuralgia (TN) is a well-known facial pain syndrome characterized by excruciating paroxysmal shock pain attacks located in somato-sensensory distribution of trigeminal nerve. Mandibular affection is a common presentation of TN. Objectives: Studying the effect of injection of mandibular nerve with neurolytic solutions in trigeminal neuralgia that was unresponsive to pharmacotherapy. Patients and Method: This prospective study included 21 patients treated for mandibular neuralgia by percutaneous injection of absolute alcohol under guidance of CT image. Their ages ranged from 35-60 years and male to female was 3:4. All patients suffered from moderate to severe TN, and did not respond to medical treatment. Entry and trajectory of needle was planned by CT and after local anesthesia. Alcohol was injected at the exit of mandibular nerve from foramen ovale. Results: 85.7% of patients improved (71.4% became pain free and severity of pain decreased in 19%), while 9.6% of patients has no response after injection. The pain free patients became 61.9% after two years of follow up. Conclusion: CT guided mandibular nerve block by neurolytic agent as absolute alcohol and showed its effectiveness as minimal invasive treatment option for intractable trigeminal neuralgia. CT guidance provided a clear view to secure the safety, accuracy and selectivity of nerve block. Key words: Trigeminal neuralgia, computed tomography guided, nerve block. Abbreviations: BNI-PS= Barrow neurological institute pain scale, CT= computed tomography, HIV= human immunodeficiency virus, MRI= magnetic resonant image, MVD= microvascular decompression, RF= radiofrequency, TN= trigeminal neuralgia, TNB= trigeminal nerve block, VAS= visual analogue scale. INTRODUCTION Nerve blocks are an optional method Trigeminal neuralgia is a paroxysmal for relief of severe pain. Although lancinating pain lasting a few seconds, analgesic may reduce the pain, nerve often triggered by sensory stimuli block can completely stop pain. In confined to the distribution of one or more general, two types of nerve blocks are branches of trigeminal nerve on one side used, i.e. local anesthetic injection and of the face with no neurological deficit neuro-destructive methods. Because of (Greenberg, 2016). short duration of action of local anesthetic agents, it can be used to protect against 383 384 SAMY M ABDELRAOUF et al acute incidental pain and for diagnostic where 0 = no pain and 10 = the worst pain tests. Neuro-destructive blocks use imaginable. Our patients ranged from neurolytic agents as alcohol, phenol, moderate to severe pain. All of them did glycerol or radiofrequency thermo not respond to medical treatment. Pain coagulation for intractable pain (Curatolo chronicity and frequency varied from 3 and Bogduk, 2010). per day to 10 per hours. Pain triggers and TNB should be guided by radiological zone which was present in one half of the imaging as X-ray fluoroscopy or CT. X- patients, and often lied near the nose or ray fluoroscopy is the most commonly mouth. Chewing, talking, smiling and used form of image guidance in drinking cold or fluid may initiate the pain interventional pain therapy. It gives wide of TN. Assessment of muscles of field of view around target region and mastication was important (which continuous real time view when needed. supplied by mandibular nerve). In addition, the apparatus is not Examination was done for reflexes excessively expensive. The limitation to supplied by trigeminal nerve (absent fluoroscopy, however, is that it shows corneal reflex was the earliest sign of TN only bones. Therefore, it is suitable only when ophthalmic branch was affected). for target nerve with a dependable All patients underwent to MRI brain to relationship to bony landmark. Also, it exclude organic cause of TN. Laboratory gives only two dimensions picture, and its investigations as complete blood count, quality is not accurate as it with CT. CT bleeding time, coagulation profile, provides clear view vessels that should be hepatitis markers and HIV antibodies avoided by needle in addition to avoiding were done for all patients. inadvertent puncture of vital structure. It Inclusion criteria: allows accurate placement needle tip before injection of neurolytic agent with 1. Age 18-60 years old. clear view of muscle and soft tissues 2. Males and non-pregnant or lactating (Koizuka et al., 2014). females. PATIENTS AND METHODS 3. Subjects have mean attacks frequency of at least 3 episodes per day and VAS This study was completed at Al-Zahraʼa ≥ 5. University Hospital between August 2013 and September 2014 after the approval of 4. Diagnosis of classical TN using inter- the hospital local health committee and national classification of headache written informed consents were obtained. disorders (ICHD-II). Twenty one patients of different ages 5. Subjects on stable dose of concomitant ranging from 35-60 years were included in preventive medication for treatment of this work. They suffered from TN along TN for at least four weeks prior to mandibular branch distribution. All intervention. patients were evaluated regarding history, pain localization which was confirmed to 6. Subjects who required "rescue" analgesic mandibular nerve, severity of pain medication during study were allowed to use their current (pre-study) opioid evaluated by visual analogue scale (VAS), 385 PRIMARY EXPERIENCE WITH CT GUIDED MANDIBULAR NERVE BLOCK... and/or non-opioid analgesic as the target position by clear CT image, and clinically indicated, e.g. NSAIDs and confirmed by injection of 0.5 ml of 10% topical analgesics. diluted iodine contrast material. We used 7. Subjects were prohibited, willing and Iopamidol (Io-pamiro 300, 300 mg of able to abstain from initiating and iodine/ml; Bracoo Diagnostic Princeion, alternative therapy, e.g. acupuncture, Newjersy, USA). Also, mandibular massage or physical therapy, for pain paresthesia can be elicited by injection of relief during the study. 0.2-0.3 ml of lidocaine 1%. A series of CT scan slides were done immediately to Exclusion criteria: confirm the needle tip position. The 1. Symptomatic TN. needle tip was then walked carefully into the foramen ovale. A negative test for 2. Serious hepatic, respiratory, hemato- CSF and blood aspiration was proved, a logic, cardiovascular or renal condi- 0.1 to 0.2 ml increment of dehydrated tions. absolute ethanol were injected every 30 3. Neurologic pain other than TN except seconds up to 1 ml. for occasional migraine or tension Patient reported outcome scales (PRO): headache (<4 headaches per month). The visual analogue scale (VAS) and 4. Psychiatric or medical condition that Barrow Neurological Institute pain scale might compromise participation in (BNI-ps) were the 2 PRO measures used study as determined by investigator. in this study. VAS provided an estimate of 5. Administration of any interventional pain intensity on a continuous scale, with drug within month prior to screening. a score 0 representing no pain and a score 10 representing worst pain. The BNI-ps 6. Substance abuse or alcoholism. rates pain on a scale of 1 to 5, Technique: All patients were monitored incorporating degree of dependence on with continous electrocardiogram (ECG), medication, as a score 1 representing no pulse monitoring and intermittent pain and no medication, while a score 5 noninvasive blood pressure. An representing sever pain or no pain relief intravenous line was inserted. 1 to 5 mg (John, 2016). I.V. midazolam, 25-50 mg fentanyl were After the procedure, patient was given to produce slight sedation and observed in recovery room, or short stay analgesia during the procedure. The block unit for 1-2 hours depending on the was performed with the patient in supine patient condition. All patients were position on CT table, and skin disinfection clinically evaluated before and after was done by betadine (bovidone iodine) injection at 1 to 3 days, 2 weeks and 6 solution. Under local anesthesia, 2-3 ml of months by using VAS and BNI -ps. 1% lidocaine, using the standard anatomical landmark and under CT Trigeminal sensory function was guidance, 22 gauge, 3.5 inches, 0.7 × 90 evaluated on the pain side and mm pd spinal needle was inserted to reach contralaterally by testing for light touch the foramen ovale at the base of skull. We and pin prick. The response was ranked should be sure that the needle tip was at according to four grade scale (normal, 386 SAMY M ABDELRAOUF et al slightly decreased, severely decreased and Values of P < 0.05 were considered totally impaired). significant. In pain free patients, a further follow RESULTS up was conducted by telephone and in Twenty one patients who fulfilled pain persistent patients. Repeated inclusion criteria were studied, male to injection was done or referral to other female was 3:4, and their ages ranged option of management in more resistant from 35 to 60 years. They presented by cases. A pain free condition was defined moderate to severe pain along the as, the patient being completely free from distribution of mandibular nerve (Table trigeminal pain without medication. 1). Statistical analysis: Kaplan-Meier Adequate pain relief was obtained in analysis was used to construct pain free eighteen of them, and they stopped or survival curves for censored survival data, decreased (fourteen stopped and four and the log rank test was used to compare decreased) their pain medications. the survival curves. The relationships between independent preoperative Three patients did not improve and still variables and treatment outcomes were complaining of pain as pre-procedure. analyzed with Wilcoxon singed ranks test. Repeated injection was done, two of them Other side effects were with Fisher exact had a good response but the third did not test.
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