Peripheral nerve stimulation for trigeminal neuropathic pain

Abstract

Facial pain is a complex disease with a number of possible etiologies. Trigeminal neuropathic pain (TNP) is defined as pain caused by a lesion or disease of the trigeminal branch of the peripheral nervous system resulting in chronic facial pain over the distribution of the injured nerve. First line treatment of TNP includes management with anticonvulsant medication (carbamazepine, phenytoin, gabapentin, etc.), baclofen, and analgesics. TNP, however, can be a condition difficult to adequately treat with medical management alone. Patients with TNP can suffer from significant morbidity as a result of inadequate treatment or the side effects of pharmacologic therapy. TNP refractory to medical management can be considered for treatment with a growing number of invasive procedures. Peripheral nerve stimulation (PNS) is a minimally invasive option that has been shown to effectively treat medically intractable TNP. We present a case series of common causes of TNP successfully treated with PNS with up to a 2 year follow-up. Only one patient required implantation of new electrode leads secondary to electrode migration. The patients in this case series continue to have significant symptomatic relief, demonstrating PNS as an effective treatment option for intractable TNP. Though there are no randomized trials, peripheral neuromodulation has been shown to be an effective means of treating TNP refractory to medical management in a growing number of case series. PNS is a safe procedure that can be performed even on patients that are not optimal surgical candidates and should be considered for patients suffering from TNP that have failed medical management.

Fig. 1

Anteroposterior fluoroscopic radiograph of Case 1 showing placement of 2 quadripolar electrodes in the left supraorbital and infraorbital positions.

Fig. 2

(A) Post-surgical CT 3D reconstruction of Case 2 showing significant left facial fractures that have been fixated with titanium plates. Of note, a titanium plate is partially obstructing the left inferior orbital foramen and was later removed. (B) Anteroposterior fluoroscopic radiograph of Case 2 showing placement of 2 quadripolar electrodes in the left supraorbital and infra-orbital positions.

Fig. 3

(A) Anteroposterior fluoroscopic radiograph of Case 3 showing placement of 2 quadripolar electrodes in the right supraorbital position. The patient reported a 60% reduction of pain for his postherpetic neuropathy. (B) Anteroposterior fluoroscopic radiograph of the right infraclavicular fossa demonstrating migration of the leads from the forehead region to a coiled position around the implanted pulse generator. New electrodes were later implanted in the same V1 position and attached to the same implanted pulse generator. These new electrodes were secured with plastic anchors to prevent future lead migration.