Interventional Management of Refractory Trigeminal Neuropathic Pain: A Prospective Audit of a Novel Management Pathway in 70 Patients

Abstract

Background: Trigeminal neuropathic pain (TNP) can present as a constant, unremitting unilateral facial pain. Current management is based on expert recommendation that includes pharmacologic agents and psychological therapy. However, treatment success with pharmacologic management is poor. We adopted a novel strategy that proved to be effective in providing durable relief. Objectives: Prospectively audit a novel strategy in the management of refractory TNP. Study Design: The authors present a prospective audit of a novel structured management pathway in the treatment of refractory TNP. Setting: Multidisciplinary facial pain clinic at a University Teaching Hospital. Methods: Over a 4-year period, 70 patients with unilateral TNP were prospectively audited at a tertiary care university hospital. Initial treatment was based on pharmacologic therapy while the patient awaited psychological therapy. Patients who failed to respond were offered a novel set of interventions that included ultrasound-guided trigeminal nerve block with depot steroids. Results: Patient satisfaction with the novel pathway was high. Only 13 patients (13/70, 18%) responded to standard treatment. Of the 57 patients who were offered the novel intervention, 50 patients consented to undergo the intervention. Forty-two patients (42/50, 84%) reported clinically significant pain relief at 3 months, and 27 patients (27/50, 54%) reported on-going durable relief at 6 months. Treatment failure with the novel intervention was 16%. Out of 54 patients in the employable age, 45 patients (45/54, 83%) were able to maintain gainful employment. Limitations: Open-label, nonrandomized observational design. Conclusions: Standard treatment of TNP is ineffective. The novel set of interventions based on empirical evidence may have a role in managing patients with refractory TNP. Key words: Trigeminal neuropathic pain, ultrasound-guided trigeminal nerve block, intermediate cervical plexus block :