Trigeminal Neuralgia

Patient: A 75 yr-old man had a five -year history of facial pain, primarily on the left side, when he was initially seen by us.

Presenting Problem: When the patient's pain began five years prior, it was an intermittent sharp electric shock-like lancinating pain lasting seconds, which would be triggered by eating or touching his face or occasionally by talking. The pain at that time involved his mid-face and jaw with significant triggering from his upper lip.

At his first consultation, he was diagnosed with trigeminal neuralgia and was started on tegretol 200 mg 3 times a day. This resulted in complete relief of his symptoms for approximately six months. Following that, his pain recurred primarily in the jaw, but with similar trigger ability and quality. He reported and overall worsening of his symptoms. In addition, he began having mild symptoms involving the right jaw.

We discussed his options with him, which were occipital craniectomy for micro vascular decompression, partial central rhizotomy versus a percutaneous rhizotomy, or Gamma Knife radiosurgery. Given his past medical history of coronary artery disease with a myocardial infarction, and history of hypertension; Gamma Knife radiosurgery would likely be the best alternative, especially if his symptoms increase or if he begins to have significant side effects with his medication. Because of the five-year delay in onset of treatment, he could become severely refractory prior to the procedure should he wait longer. However, he opted to continue on medical intervention only.

Following up one month later he had increased his tegretol to 200 mg four times a day. This resulted in satisfactory relief. Occasionally when he felt a possible onset of pain, he would take an extra 1/2 of a tegretol, which generally controlled his symptoms. At that point, he was still satisfied with his level of relief. His recent MRI of the head was normal.

18 months later the patient called and was started on a slow increase of Neurontin. At his consultation a week later he said he had breakthrough pain even with the increase of medication. In addition, he was experiencing significant sedation as well as mild imbalance on the medication regimen. He did not have any associated sensory changes and on examination, his facial sensation was completely intact.

At this time the patient chose Gamma Knife radiosurgery and was scheduled for a radiation oncology consult. Two weeks later the patient received Gamma Knife radiosurgery.

Radiosurgery Treatment: The stereotactic head frame was applied and CT and MR scans were obtained. A Gamma plan with a single 4mm helmet shot was placed over the left fifth nerve entry zone. A prescription dose of 43.50 cGy at the 50% isodose line was given and the isodose curves reviewed. Patient tolerated well, frame was removed and patient was discharged ambulatory shortly after.

Clinical Outcome: Approximately six weeks status post Gamma Knife radiosurgery of left trigeminal neuralgia the patient had almost complete resolution of his pain. He said he noticed an occasional mild pain but stated he had some relief almost immediately after the procedure.

On examination, his facial sensation was intact to light touch and pinprick. At this point he is pain free. His medication regimen was tapered and the patient was told if he has any recurrent pain while tapering he should resume the previous dose which controlled his symptoms.

On five months status post Gamma Knife he had complete resolution of his pain. He was still taking one tegretol in the morning and one neurontin at night. He has not had any pain for 3 months and is not experiencing any side-effects from his current medication regimen. Facial sensation is completely intact.

On 18 months and at 27 months status post Gamma Knife patient continues regimen of one tegretol in the morning and one neurontin at night. Patient stated he is pain free and with facial sensation completely intact. It is likely that he will be able to taper off of his last medication, as he is pain free. Patient is to contact us for any recurrence of his pain and is to be seen on an as-needed basis.