TM2-4 Long term outcome of percutaneous balloon compression for trigeminal neuralgia

ObjectivesPercutaneous balloon compression (PBC) can be offered to medically refractory patients with trigeminal neuralgia who are unsuitable for microvascular decompression. Its associated with up to 4% risk of anaesthesia dolorosa which increases with duration and severity of compression and is more common with repeat procedures. We audited our outcomes for this procedure over last 7 years.DesignRetrospective audit of prospectively collected data.SubjectsAll patients undergoing PBC at our centre.MethodsTheatre and radiology records reviewed to identify patients. Case notes and radiology reviewed for history, diagnosis, details of procedure, immediate symptom relief, complications, further procedures and last follow up. Descriptive, comparative Kaplan Meir analysis undertaken.ResultsTotal 93 patients (4 b/l), 165 procedures. Average follow up 36 months. 24 patients had MS, 17 patients had atypical pain. All except 4 patients had good immediate pain relief. No patient developed anaesthesia dolorosa, 2 patients had transient diplopia, 1 maxillary hematoma and 1 infection. 56 experienced recurrence, 43 needed further surgical intervention. 25 PBC twice, 11 thrice, 4 four times and 1 five times. Average time to first recurrence=32 months. 85% pain free at 1 year and 70% at 2 years.ConclusionsPBC is an effective procedure. With conservative approach, this procedure can be safely repeated.

Autotomy

The landmark paper discussed in this chapter is ‘Autotomy following peripheral nerve lesions: Experimental anaesthesia dolorosa’, published by Wall et al. in 1979. This paper was the culmination of a series of studies in which Wall, together with a number of colleagues, investigated the underlying causes of neuropathic pain following peripheral nerve injury. In this paper, the authors used a variety of nerve injury models to show that the extent of resultant anaesthesia combined with ectopic firing from damaged axons in nerve-end neuromas correlated with the severity of self-mutilation (termed ‘autotomy’) observed in the affected hindlimb. The authors therefore suggested that these simple models might be suitable for studies of the prevention of irritations originating from chronic lesions of peripheral nerves. Indeed, this proved to be the case, sparking the development of numerous animal models of spontaneous pain following nerve injury and spawning a new field of neuropathic pain research.

Operative und interventionelle Therapieverfahren beim Cluster-Kopfschmerz

ZusammenfassungCluster-Kopfschmerz ist manchmal schwer zu therapieren und bei völligem Versagen der medikamentösen Therapien existieren operative Ansätze des Trigeminus. Bekannt ist, dass die Rezidivrate für diese Verfahren hoch ist. Zusätzlich besteht die Gefahr dauernder Funktionseinbußen oder einer anaesthesia dolorosa. In manchen Fällen ist die Leitungsanästhesie des Nervus occipitalis major erfolgreich und sollte daher auch bei Patienten mit chronischem ClusterKopfschmerz vor einer invasiven Therapie versucht werden. Als Prinzip gilt, jegliche chirurgische Prozedur von peripheren trigeminalen Strukturen beim episodischen ClusterKopfschmerz mit großer Vorsicht zu beurteilen, da die Erkrankung per definitionem remittiert. Kürzlich wurde auf der Basis von Bildgebungsverfahren erfolgreich die hypothalamische Tiefenhirnstimulation eingesetzt. Da es sich um eine experimentelle Therapie handelt, sollten die publizierten internationalen Konsensusrichtlinien für diese Prozedur bekannt sein und angewandt werden.

Two Cases of Medically and Surgically Intractable Sunct: A Reason for Caution and an Argument for A Central Mechanism

We report two cases of SUNCT that demonstrate the medically and surgically refractory nature of this disorder and support the hypothesis that the causative ‘lesion’ lies within the central nervous system. After both patients had failed medical therapies, the first underwent a glycerol rhizotomy, gammaknife radiosurgery and microvascular decompression of the trigeminal nerve. The second patient underwent gammaknife radiosurgery of the trigeminal root exit zone and two microvascular decompression surgeries. Neither patient benefited from these procedures. Currently, the first patient suffers from anaesthesia dolorosa and the second patient from unilateral deafness, chronic vertigo and dysequilibrium as a result of surgical trauma. These cases of SUNCT highlight the uncertainty regarding the role of surgery given the potential for significant morbidity. These cases also suggest that SUNCT originates and may be maintained from within the CNS and this central locus explains why SUNCT is not typically amenable to interventions aimed at the peripheral portion of the trigeminal nerve.