Refractory Trigeminal Neuralgia: Successful Treatment with LINAC Based Stereotactic Radiosurgery (SRS): First Case in Bangladesh

Purpose: To present first case of refractory trigeminal Neuralgia treated with SRS in Bangladesh, procedural technique, and outcomes in terms of pain relief. Background: Trigeminal neuralgia (TN), classically known as tic doloureaux is a chronic and recurrent disabling pain syndrome, which described as episodes of lancinating pain over the face along the sensory distribution of trigeminal nerve. First line management of TN is medical with different permutation & combination to control the pain. After the failure of medical management, non-invasive SRS is an established modality to achieve long term pain control. Here, we are reporting a case of TN treated with LINAC based SRS. Case Presentation: A 61 years old, gentleman who developed piercing pain inside his left eye for a duration 1-1.5 sec, precipitated while shaving, brushing teeth in year 2015, occurred 4-5 time a day. He was diagnosed as left TN of V1, started on Carbamazepine, Pregabalin. In 3 years, pain progressed to involve all 3 branches. Even combination Carbamazepine, Gabapentin, Tramadol, Amitriptyline, Clonazepam, & Morphine could not control the pain. Pain was persisting all over the day and he also developed suicidal tendency. Later he has been referred to us for SRS. SRS was done in April-2019, a dose of 90Gy was delivered to the Distal Retrogasserian (RG) also called Marseille point of trigeminal nerve root. Eight months after the SRS patient is almost free of pain without any Medicine. Conclusions: LINAC based SRS is a non-invasive, frameless, and safe procedure with excellent pain control for refractory Trigeminal neuralgia. Bang. J Neurosurgery 2020; 10(1): 123-129

Clinical and Radiological Profile of Trigeminal Neuralgia- A Retrospective Study

Introduction: Trigeminal neuralgia is described as severe, stabbing unilateral pain along the distribution of trigeminal nerve branches. The three subtypes include- Classical, secondary and idiopathic. Aim: To study the clinical profile, presentation and radiological imaging features in trigeminal neuralgia patients. Materials and Methods: This cross-sectional study included outpatient medical records of 60 trigeminal neuralgia patients between June 2015 to June 2020 (five years) in a Tertiary care Medical College Hospital. Various parameters studied were: (a) Age; (b) Gender; (c) Dental treatment; (d) Pain severity; (e) Trigger factors; (f) Side and branch involved; (g) Sensory abnormalities; (h) MRI. Data was entered in Microsoft excel and analysed using SPSS statistical software 20.0. Chi-square test was used for categorical variables. Results: Among the 60 patients studied, the common demographic and clinical features were as follows: 34 were females (56.7%); 36 with right side presentation (60%); 25 had maxillary nerve division distribution (41.7%); 57 patients experienced shock/lancinating pain (95%); and 40 had numeric pain severity scale of 4-6 (66.7%). Classical Trigeminal Neuralgia was the most common subtype seen in 31 patients (51.7%). Involvement of dual divisions (maxillary and mandibular), absence of trigger factors and presence of hypoesthesia were more suggestive of Secondary Trigeminal Neuralgia (p<0.05). Based on MRI imaging, 31 (51.7%) showed neurovascular compression with atrophy or displacement of trigeminal nerve root. Only 5 (8.4%) had secondary causes (schwannoma, meningioma, demyelination, infarct). Conclusion: The key clinical features of trigeminal neuralgia include female preponderance, right side presentation, maxillary nerve division distribution, shock/lancinating pain with touch and breeze as common trigger factors. As some of them had a previous dental treatment or procedure, dentists need to be aware of this entity. Certain clinical features would help to differentiate the secondary from classic and idiopathic neuralgia subtype.

Primary Nongestational Ovarian Choriocarcinoma Mistaken for Ectopic Pregnancy: A Case Report

Trigeminal neuralgia (TN) or tic douloureux is one of the commonest cause of fascial pain after 50 years of age. It is characterized by recurrent, episodic, lancinating pain over the distribution of trigeminal nerve. There is a lack of certainty regarding the aetiology and pathophysiology of TN. Evidence suggests that the likely etiology is vascular compression of the trigeminal nerve leading to focal demyelination and aberrant neural discharge. Secondary causes such as multiple sclerosis or brain tumors can also produce symptomatic TN. The treatment of TN can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best. For patients refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife surgery and microvascular decompression are the most promising invasive treatment options. Among them three common interventions commonly carried out by interventional pain physician to provide pain relief are balloon compression, Glycerol rhizolysis and RF rhizotomy. J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 73-77

Trigeminal Neuralgia: Role of Interventional Pain Physician

Trigeminal neuralgia (TN) or tic douloureux is one of the commonest cause of fascial pain after 50 years of age. It is characterized by recurrent, episodic, lancinating pain over the distribution of trigeminal nerve. There is a lack of certainty regarding the aetiology and pathophysiology of TN. Evidence suggests that the likely etiology is vascular compression of the trigeminal nerve leading to focal demyelination and aberrant neural discharge. Secondary causes such as multiple sclerosis or brain tumors can also produce symptomatic TN. The treatment of TN can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best. For patients refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife surgery and microvascular decompression are the most promising invasive treatment options. Among them three common interventions commonly carried out by interventional pain physician to provide pain relief are balloon compression, Glycerol rhizolysis and RF rhizotomy. J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 73-77

C1-C4 Unilateral Dorsal Root Entry Zone Rhizotomy (Drez) for Treatment of Refractory Post-Herpetic Occipital Neuralgia

INTRODUCTION Occipital neuralgia (ON) is a neuropathic pain condition that usually present as sharp, stabbing, paroxysmal pain. It involves the occiput and posterior scalp in the distribution of the greater, and/or lesser occipital nerve. Treatment usually takes a stepwise fashion starting with medical therapy then progress to a more invasive methods such as peripheral nerve stimulation, spinal cord epidural stimulation, C2-C3 ganglionectomy, or dorsal root entry zone rhizotomy (DREZ). Here, we present a case of a patient with postherpetic ON that was treated with C1-C4 DREZ due to failure of other therapies. METHODS A 37-yr-old female with history of several episodes of shingles involving the left neck and occiput. The episodes resolved after an extended period of valacyclovir. Subsequently, developed severe lancinating pain of the neck and the occiput. She was treated initially with oxcarbazepine but was stopped due to cognitive side effects. Then the patient underwent implantation of a spinal cord stimulator, which did produce relief for several years; however, it was removed due to breakage of the electrodes. She underwent a left sided C1-C2 hemilaminectomy with C1 C4 DREZ. RESULTS Postoperatively, the patient developed a mild new motor weakness 4 + /5, and decreased sensation to light touch and proprioception. In addition, she had unsteady gait. Six weeks postop the patient endorsed significant improvement in her ON pain, muscle strength, sensation and balance. On exam: she had pronounced numbness of the left side of the occiput and neck down to the clavicle, but the rest of her exam improved to preoperative baseline. CONCLUSION C1-C4 DREZ can be an efficacious treatment option for refractory ON.

Geniculate Neuralgia

Geniculate neuralgia is a rare syndrome of episodic, lancinating pain located within the ear canal. There may be a trigger point within the canal and associated with disorders of tearing, taste, and salivation. It is important to distinguish geniculate neuralgia from other causes of inner ear pain, including structural lesions and glossopharyngeal or trigeminal neuralgia. MRI may show vascular conflict with CN VII/VIII complex. Typical treatment is with carbamazepine. Surgery is reserved for those patients who have an incomplete response to medication. Surgery is directed at microvascular decompression of the CN VII/VIII complex with or without sectioning of the nervus intermedius. The entry zones of CN IX and X may also be explored. Complications and management are discussed.

V144D Mutation ofSPTLC1Can Present with Both Painful and Painless Phenotypes in Hereditary Sensory and Autonomic Neuropathies Type I

Hereditary sensory and autonomic neuropathy type I (HSAN I) is an autosomal dominant disease characterized by distal sensory loss, pain insensitivity, and autonomic disturbances. The major underlying causes of HSAN I are point mutations in the SPTLC1 gene. Patients with mutations in the SPTLC1 genes typically exhibit dense sensory loss and incidence of lancinating pain. Although most of these mutations produce sensory loss, it is unclear which mutations would lead to the painful phenotype. In this case series, we report that the V144D mutation in SPTLC1 gene may relate to both painful and painless peripheral neuropathies. The unique clinical phenotype of this mutation may guide clinical workup and treatment for patients with painful and painless neuropathies.

Facial solitary morphea profunda presenting with painful trigeminal neuropathy: A case report

Background Localized facial scleroderma usually presents as frontal linear morphea or progressive hemifacial atrophy. Only isolated cases of trigeminal painful neuropathy have been described. Case report A 43-year-old woman developed an oval lesion on the right cheek. After 1 year, she noticed constant “pulling” pain and episodes of lancinating pain, both spontaneous and triggered by chewing and cold drinks. She was diagnosed with solitary morphea profunda and CT scan, ultrasonography, cranial MRI and biopsy were completed. Methylprednisolone (1 gr/day for 3 days) was prescribed. For pain, gabapentin, oxcarbazepine, amitryptiline, pregabalin and eslicarbacepine were all ineffective. A capsaicin patch was placed with prolonged benefit. Later on, the pain slightly worsened; occipital blockade was effective and methotrexate was recommended. Conclusion This is the first case of solitary morphea profunda associated with painful trigeminal neuropathy. Treatment should include immunosuppressants and treatment of neuropathic pain, in which local therapies seem particularly beneficial.

Caso Clínico: Luxación Controlada de Cadera. Epifisiólisis de Cabeza Femoral

BACKGROUND: The epiphysiolysis of the femoral head is the displacement of the epiphysis with respect to the metaphysis, in anterosuperior direction; it is etiology is unknown, frequent in adolescents, peripubertal period, and with high body mass index, average age between 12 and 18 years. It is incidence is variable, 0.2 (Japan) to 10 (United States) per 100 000 inhabitants. It is characterized by progressive pain in the hip, with irradiation to the groin or knee, is associated with lameness; with the early detection, an adequate treatment can be established, the most accepted one is the in situ fixation with central screws. CASE REPORT: A 14-year-old female patient with no pathological history attended the Children's Orthopedic Service due to the chronic lancinating pain of the right hip, which increases with walking, it is diagnosed by clinical examination and complementary exams of femoral head epiphysiolysis. Surgical dislocation of the hip and anatomical open reduction with placement of spongy screws was performed. EVOLUTION: On the third day of surgery, hospital discharge is decided; walking with crutches and without support during a postoperative month. The osteosynthesis remained for a year with monthly controls and corresponding physiotherapy; it has been evidenced favorable evolution; hip mobility arches preserved, normal ambulation, without complications CONCLUSIONS: The initial treatment of a patient with epiphysiolysis of stable femoral head depends on the evolution time and is done by fixing with screws or needles with of anatomical dislocation of the hip and osteoplasty of femoral neck remodeling. Most patients do not develop necrosis or chondro- lysis and long-term results with in situ fixation are usually excellent, unlike patients with late diagnosis.

Neuropathic Pain

Neuropathic pain is a common condition that arises from injury anywhere along the somatosensory axis. Although the presentation may vary based on mechanisms and locations of injury, most patients have characteristic burning, shocklike, lancinating pain, most often in the distribution of peripheral and spinal nerves or distal extremities. Various peripheral and central processes aggravate pain through abnormal impulse generation, modulation, and processing. Common conditions include complex regional pain syndrome, diabetic neuropathy, postherpetic neuralgia, spondylotic radiculopathy, and central pain syndromes. A detailed history and physical examination will aid in differentiating various neuropathic pain conditions. Neuropathic pain is best managed using a true multidisciplinary approach.