Abstract
BackgroundFacial pain may be divided into several distinct categories, each requiring a specific treatment approach. In some cases, however, such categorization is difficult and treatment is ineffective. We reviewed our extensive clinical experience and designed an algorithmic approach to the treatment of medically intractable facial pain that can be treated through surgical intervention.MethodsOur treatment algorithm is based on taking into account underlying pathological processes, the anatomical distribution of pain, pain characteristics, the patient's age and medical condition, associated medical problems, the history of previous surgical interventions, and, in some cases, the results of psychological evaluation. The treatment modalities involved in this algorithm include diagnostic blocks, peripheral denervation procedures, craniotomy for microvascular decompression of cranial nerves, percutaneous rhizotomies using radiofrequency ablation, glycerol injection, balloon compression, peripheral nerve stimulation procedures, stereotactic radiosurgery, percutaneous trigeminal tractotomy, and motor cortex stimulation. We recommend that some patients not receive surgery at all, but rather be referred for other medical or psychological treatment.ResultsOur algorithmic approach was used in more than 100 consecutive patients with medically intractable facial pain. Clinical evaluations and diagnostic workups were followed in each case by the systematic choice of the appropriate intervention. The algorithm has proved easy to follow, and the recommendations include the identification of the optimal surgery for each patient with other options reserved for failures or recurrences. Our overall success rate in eliminating facial pain presently reaches 96%, which is higher than that observed in most clinical series reported to dateConclusionThis treatment algorithm for the intractable facial pain appears to be effective for patients with a wide variety of painful conditions and may be recommended for use in other institutions.
Highlights
Facial pain may be divided into several distinct categories, each requiring a specific treatment approach
The analysis presented here was derived from a prospective study of patients with facial pain that was approved by our Institutional Review Board few years ago [7]
Importance of detection of the underlying pathological processes may be illustrated by difference in surgical management of various possible causes of symptomatic trigeminal neuralgia (TN) that would require definitive treatment in order to obtain pain control [8], or symptomatic TN caused by demyelination (as in multiple sclerosis (MS)) for which destructive procedures are considered to be a preferred treatment approach
Summary
Facial pain may be divided into several distinct categories, each requiring a specific treatment approach. We reviewed our extensive clinical experience and designed an algorithmic approach to the treatment of medically intractable facial pain that can be treated through surgical intervention. As to the available procedures for treatment of the medically intractable facial pain, the spectrum of interventions includes a wide variety of procedures starting from nondestructive approaches (such as microvascular decompression (MVD) of trigeminal and other cranial nerves) to percutaneous interventions (radiofrequency (RF) gangliolysis, glycerol injection, balloon compression) to less invasive destructive procedures (stereotactic radiosurgery) and to neuromodulation surgeries (peripheral and central neurostimulation) as well as central destructive surgeries (tractotomy, etc.) (Table 3.). We reviewed our single-institution experience with the treatment of the facial pain according to our definition of multimodality approach
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