Management of Pain in Trigeminal Neuralgia

Management of Pain in Trigeminal Neuralgia Percutaneous management of pain in Trigeminal Neuralgia under computed tomography guidance Corersponding Author Dr. Mitesh Kumar Main Author Dr. Roy Santosham Co Authors Dr. Bhawna Dev Dr. Deepti Morais Dr. Rupesh Mandava Dr. R. Jeffrey Abstract Trigeminal Neuralgia (TN) is a brief, excruciating and perhaps the most severe pain known to man affecting the hemifacial region. It occurs mainly due to tortuous vessel compressing the trigeminal nerves, though in many cases, the exact etiology and pathogenesis remain undetermined. The first line therapeutic option for patients affected by TN is the medical line of management and patients refractory to the same, are offered various invasive procedures like balloon compression, gamma knife surgery, radiofrequency ablation, etc. In this paper, we present percutaneous management of the pain by injecting neurolytic drugs in the foramen ovale under Computed Tomography (CT) guidance as the new and promising technique of treatment in TN. Keywords Trigeminal Neuralgia, percutaneous management, CT guidance, neurolytic drugs Objective To evaluate the efficacy and safety of Computed Tomography guided percutaneous management of pain in trigeminal neuralgia using neurolytic drugs. Introduction Trigeminal Neuralgia is also known as tic douloureux, a term given to this painful disease by Nicolaus Andre in 1756 [1] . TN is a pain which typically is intense, brief, usually unilateral, recurrent shock like involving the branches of fifth cranial nerve [2]. It can be mainly classified into two types. First being, the classical TN (Type I), which is due to neurovascular compression, the most common vessel causing the same being superior cerebellar artery followed by anterior inferior cerebellar artery [3]. Second type is atypical TN (Type II), secondary to causes like trauma, tumor, multiple sclerosis or herpetic infections. The distinction between these two types is mainly based on clinical symptoms [4, 5] as Type I pain is episodic in nature whereas Type II pain is more constant. TN is often called by many as â€Å"the suicide disease† [6] as the patients who suffer from it would rather take their lives than bear the pain. The initial line of treatment for TN is medical management by drugs like Carbamazepine, Gabapentin, Oxcarbazepine among others. Patients of type I TN may also be advised microvascular decompression. Those patients who do not respond or have contraindications to the above mentioned drugs or experience no change in the intensity of the pain are called Refractory TN [7]. Such patients are advised invasive procedures like trigeminal nerve block neurolytic block, radiofrequency ablation, gamma knife surgery and balloon compression. We describe our experience in percutaneous management of pain by injecting neurolytic drugs in the foramen ovale under CT guidance in six patients, suffering from TN. Method and Materials used Pre procedural work up The pre procedural work up included clinical evaluation and thorough reading of the Magnetic Resonance Imaging (MRI) scans of all the patients to rule out any neurovascular conflict. Any patient with neurovascular conflict was considered an exclusion criterion in our study. These patients were reported taking the drugs for TN for over three months with no improvement in the pain. The pain score evaluation was done using Numeric Rating Scale [8] and Wong-Baker Faces Pain Rating Scale [9] as a baseline evaluating point to be compared to the same scoring system after the procedure. Routine investigations such as coagulation profile, liver function test, renal function test, HIV and HbsAg were done before the procedure. Numeric Rating Scale Patients rate pain on a number scale from 0-10, 0 being a depiction for no pain and 10 being the worst pain imaginable. Wong-Baker Faces Pain Rating Scale The Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 (No Pain) to a crying face at 10 (Worst Pain Possible). The patient must choose the face that best describes how they are feeling. In our study, we use the Wong Bakers scale to assess the patients’ pain before and after the procedure. The neurolytic drugs and materials used in the procedure were 22 G spinal needle for block, 25 G needle for skin infiltration, 2% xylocaine , Iohexol Non ionic contrast medium, 100% alcohol, 1ml syringe and normal saline solution. The patient was put in the supine position with head placed in reverse occipitomental position (chin up and neck extended), turned 30 ° to the opposite side of the block. The foramen ovale was identified under CT guidance and a virtual track was made starting from a point which was 2-3cms lateral to the angle of mouth on the skin to foramen ovale (Figure 1). Once the trajectory of the needle and the foramen ovale was confirmed on CT scan, the skin at the point of entry was infiltrated by 2ml of 2% xylocaine using a 25G needle. Then, a 22G spinal needle was inserted at the same point and aimed in the direction of planned trajectory towards the foramen ovale (Figure 2). To prevent the needle from entering the oral cavity, a finger from inside the mouth can be used to guide the same [10]. Though, we did not apply this in any of our patients. Following this, negative aspiration was attempted to check for Cerebro Spinal Fluid (CSF) or blood aspirate. If the aspirate contained CSF or blood then the needle had to be readjusted. Then 0.5ml of mixture made from 1ml of iohexol and 2ml of 2% xylocaine was injected into the target site in order to check the spread of injectant and exact needle tip position. Once the tip of the needle touches the mandibular nerve root, the patient might complain of the exact similar pain which he/she has been suffering, thus confirming the accurate needle tip location. This injectant acts as a diagnostic block if the trigeminal ganglion is the pain generator with xylocaine providing anesthesia prior to alcohol injection. A mixture containing 3ml of 100% alcohol, 1ml of iohexol and 1 ml of saline was made. Of this 1ml of the mixture was injected into the foramen ovale (Figure 3 and 4). Post procedure check scan was performed to rule out any complication. Result Exact position of the needle tip in the foramen ovale was seen in all the six patients thus achieving 100% technical success. All these patients achieved a significant level of relief with an average pain score of two immediately after the procedure. Twenty four hours after the procedure, they rated their reduction of pain at an average pain score of one. Four out of the six patients ie Patient No. 1, 2, 4 and 6 were completely relieved of their pain with one year follow up without taking any medication. In Patient No. 3, the procedure was abandoned as during the diagnostic block, the injectant was seen tracking into CSF cistern and fourth ventricle. Patient No. 5 reported with a similar pain of TN within three months with a pain score of five, little less than the pre-procedure pain score of six. The pain was more severe in the pterygopalatine segment, hence a pterygopalatine block was carried out and the patient had a pain score of one twenty four hours after the procedure. Hence, the initial trigeminal neurolysis was partially successful in this patient. No post procedural complication was seen in any of our patients. Discussion The trigeminal nerve arises from the lateral pons at its superior to mid portion. It travels forward in posterior fossa and merges with the trigeminal ganglion in the Meckels cave. The trigeminal ganglion is located lateral to the cavernous sinus. It gives three divisions ophthalmic (V1) segment which emerges from superior orbital fissure, maxillary (V2) from foramen rotundum and mandibular (V3) from foramen ovale. The trigeminal nerve provides sensation for the face, mouth and supplies the muscles of mastication. TN mostly involves maxillary division and mandibular division of trigeminal nerve though it may also involve the ophthalmic division as well. The reported annual incidence rate of TN is about 4.5 per 100,000 persons [11] but the actual figures may be even much higher because of diagnostic challenges associated with the disease. TN is more common in females than males with a ratio of 3:2 and is usually seen after 50 years of age [11]. Trigeminal nerve block is an upcoming treatment in TN patients who are refractory to medical line of management. It relieves the pain and also reduces the side effects of drugs which are used for the treatment. Earlier studies were mainly done using x-ray or fluoroscopic guidance which had its own limitations in terms of image quality and two dimensional views. In contrast to this, CT scan provides excellent and direct visualization of foramen ovale leading to correct placement of needle [12] and thus scoring over fluoroscopy. This reduces the chances of injecting neurolytic agents at improper locations and thereby reduces the side effects. In our cases, initial check CT scan was done by injecting 1ml of iohexol to determine whether the needle is in exact location. This doubly ensured us about the location as well as the spread of injectant. This was different from previous studies done using fluoroscopy where a diagnostic block using xylocaine had to be given in order to confirm the location of the needle tip. We used a mixture of 3ml of 100% alcohol, 1ml of iohexol and 1ml of saline for trigeminal neurolysis however, Han et al stated that trigeminal nerve block with high concentration of lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain and shorter duration of pain prior to the procedure [13]. Alcohol spreads easily and should be used cautiously. The other agents which can be used but were not used in our study are phenol and glycerol. The side effects that may follow the procedure are numbness and hypoesthesia in the entire trigeminal nerve distribution. There can be abolition of corneal reflexes which can produce exposure keratitis and dryness of eyes. Improper injection of alcohol into CSF space can lead to arachnoiditis/ meningitis. CASE 1, 2, 4 and 6 These patients were suffering from trigeminal neuralgia with pain score ranging from six to eight before the procedure. All these patients have been taking carbamazepine for more than three months with no relief from pain. MRI showed no neurovascular conflict. These patients had a significant relief of pain with pain score at three months and twelve months being zero. None of these patients had to take oral medicines after the procedures. Fig 1: Site marked for needle Fig 2: Tip of the needle in foramen insertion ovale Fig 3: Dispersion of injectant in Fig 4: 3D reconstruction showing the foramen ovale needle tip in foramen ovale. Case 3 This eighty year old male came with complains of left sided trigeminal neuralgia. He had been taking carbamazepine for four months with no change in pain intensity. The procedure had to be abandoned as after injecting the diagnostic block, the injectant was seen tracking into the CSF cistern in the cerebello pontine angle and fourth ventricle (Figure 5). Fig 5: CT scan showing needle tip in the left foramen ovale Case 5 This forty seven year old female came with complains of right sided trigeminal neuralgia. She had been taking carbamazepine for three months without any relief in pain. MRI scans showed no neurovascular conflict. The procedure was successful with pain score of one immediately after and at twenty four hours after the procedure (Figure 6). However, this patient came back within three months of the procedure complaining of pain, which was more in the pterygopalatine segment. A pterygopalatine block was done with resultant pain score of one at twenty four hours after the procedure and two at nine months of the procedure. Hence, this patient showed partial response to trigeminal neurolysis carried out initially. Fig 6: CT scan showing the tip of the needle in right foramen ovale. Conclusion Percutaneous injection of alcohol, iohexol and saline mixture at the verge of foramen ovale under CT guidance is an effective and promising method to relieve pain in patients of TN refractory to medical line of management. This technique is inexpensive, cost effective and a relatively painless procedure. Being a minimally invasive technique, the chances of any infection and other post operative complications are less. Since our study involved only six patients, this technique needs to be further evaluated on a large sample size to substantiate the result of this procedure. Having said the above, we would like to emphasize that our initial experience of this procedure was quite impressing. Abbreviations TN Trigeminal Neuralgia CT Computed Tomography CSF Cerebro Spinal Fluid MRI – Magnetic Resonance Imaging References Andre ´ N. Traite ´ sur les maladies de l’ure`thre. Paris: Delaguette, 1756 Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994. P. 59-71 Jannetta PJ. Microvascular decompression of the trigeminal nerve for tic doloreux. In: Youmans ed. Neurological surgery 4th edn. WB Saunders Co. Philadelphia. 1996: 3404-15 Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008; 15 (10): 1013-28 Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008; 71 (15): 1183-90 Michael D. Chan, Edward G. Shaw, Stephen B. Tatter. Radiosurgical Management of Trigeminal Neuralgia. In: editor Pollock Bruce, Intracranial Stereotactic Radiosurgery, an Issue of Neurosurgery Clinics. Elseiver Health Sciences. 2013. pp. 613-621 Cruccu G, Truini A. Refractory Trigeminal Neuralgia. Non-surgical treatment options. CNS Drugs. 2013 Feb;27(2):91-6. doi: 10.1007/s40263-012-0023-0. Hartrick CT, Kovan JP, Shapiro S (December 2003). The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 3 (4): 310–6. doi:10.1111/j.1530-7085.2003.03034.x. PMID 17166126. Wong-Baker FACES Pain Rating Scale Foundation: Retrieved 6 December 2009. Michael J. Cousins In: trigeminal nerve block. Cousins and Bridenbaughs Neural Blockade in Clinical Anesthesia and Pain Medicine. Lippincott Williams Wilkins, 29-Mar-2012, 410 Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen, Jeffrey J. Schaider, Ghazala Q. Sharieff. In: Bell’s palsy and trigeminal neuralgia. Harwood-Nuss Clinical Practice of Emergency Medicine. Lippincott Williams Wilkins. June 23, 2009, 786 Và ­ctor Whizar-Lugo MD, Francisco Anzorena-Vallarino MD, Roberto Cisneros-Corral MD, Ricardo Valdez-Jeres MD, Rogelio Hernà ¡ndez-Velazco DDS. Use of Computed Tomography Guide for Trigeminal Alcohol Neurolysis. Anestesia en Mexico: Volume 20 No. 1 (January-April 2008) Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008 Feb;62 (2):248-54. Epub 2007 Nov 23.

Family is an extraordinarily important aspect of my life Essay

My mother, above everyone else in my life, has had a significant influence on me. My mom has said that if the whole world turns their back on you, your family will always be there for you. She has always been there for me. She is an absolutely amazing human being and a great role model. Everyday I see how she handles having four children, manages a household and a career. Through her example, I have learned to make good decisions and be very responsible. My mother inspires me everyday. She has taught me to not only respect other people’s opinions, but to formulate my own opinions as well. She showed me that I can do anything I put my mind to and has told me to always stand up for myself. I started to play soccer when I was in second grade and I came to love it. Years ago when I was playing soccer, I was not getting much playing time during games. I was not one of the strongest players but I played well. I was disappointed about the games and talked to my mom about it. She said rather than her talking to the coach I should remind the coach that I was not getting enough playing time. During the next game I stood by the coach and asked to be put in. It worked. I got more playing time and the coach noticed how well I played. He complimented me on my game and from that point on I didn’t have to ask for more playing time. I am glad that she encouraged me to stand up for myself. From this experience, I learned that in life you have to fight for what you want. My mom has shown me that we should not only take from the community, but also give back. I volunteer with the Girl Scouts and at a local church as much as possible. With my church youth group I have visited a Veteran’s home to talk with the residents and keep them company. We also have done a rake and run where we rake the leaves of elderly or disabled people. I was voted onto a core team by my peers. On the core team I help the advisers lead the group at meetings and volunteer services. Because of my mom’s encouragement, I work extremely hard at school and everything I do. She has inspired me to push myself to the limit and beyond. My mom has taught me to live my life to its fullest. Life is a journey and my mom has taught me many things along the way. College is the next step in my journey and I am going to take everything I have learned along with me. My mom has not only influenced my life, but is my absolute hero. The lessons she has taught me will be instilled in me foreve

Northern Life Editor

When there is an ever enduring effort for global health care and health and nutrition for all by WHO,   in Canada the government incurs   less than 10 per cent   of GDP on the contribution   of health care services.   According to the Annual Report 2004-2005 of Canada Health Act (CHA), the Government is providing a range of health services viz., health policy,   physician services, hospital   services, extended health care services, dental services wherein each of the service is insured on pre-paid basis in order to make the accessibility of services for all the eligible residents of Canada. Further the Government has also made a Health plan up to the period of 2013-2014 with the framework of Canada Health Transfer (CHT). In spite of these efforts, the Government of Canada is still challenged with some of the critical issues of rising diabetes, rheumatoid arthritis among aging population which will increase from 13-15 per cent by 2011. Also a fund of $ 262,000 has been allocated for treatment of meningitis among children. The above facts disclose that there is a severe need of health care professionals, as most of the present staff are retiring, it increases the load of work.   Also acute care and attention is required for each patient using technology in diagnosis, as the expectations of patients are always on higher side.   These necessarily evolve a system of human resource restructuring, to appoint new staff by way of work contracts or temporary staff workers for skilled areas, which require a top priority resolution. Further implementation of tele-medical advice and services would assist both the Government and health-seekers. Lack of adequate trained technicians, physicians, surgeons, anesthetists and supporting nurses with other administrative staff, would place Government of Canada in helpless state, in spite of its vigorous efforts to help citizens in health services.  Ã‚   Health and Community Services Act (1993) can induct medical students as trainees and other related workers into various hospitals, health centers for facilitating access to medical treatment for meeting long term sickness and emergency needs. Conclusion Considering the facts of above scenario, Government of Canada with the assistance of CHT must consider all the facts and develop a framework of human resources taking the advantage of globalization and migration work services and increase humanitarian as well as medical services for the residents of Canada and allow the continuance of good sense prevail as ever. (Cash contribution of $ 12,650 billion for the fiscal year 2004-2005) . Conclusively,   urging the Government to look into the issue. Sincerely, Brunnette Medical Student No.30 Backstreet Toronto References Tony Clement, Minister of Health Accessed 6 November, 2006 http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/2004-05_e.pdf         

The Role of Eve in Paradise Lost - 1589 Words

The importance Milton attached to Eve’s role in Paradise Lost and in the Garden of Eden is now recognised and acknowledged. (Green, 1996) Milton’s treatment of Adam and Eve’s relationship is complex. Sometimes referring to them in ways that indicate equality, (ibid) sometimes stressing their separateness as individuals (ibid) and other times they are complementary halves of a whole. (ibid) Taking on the view that many support; that Milton intended Eve to seem completely inferior to Adam, we can examine Eves role in the fall. Traditionally, readers and critics have responded to Eves actions with compassion and concern. (Revard, 1973) Two critics who particularly react this way are Dennis Burden and Fresdon Bowes. (ibid) A.J.A Waldock has†¦show more content†¦If Adam had forced Eve to stay with him, he would have Eve’s without free choice. This would have tarnished the liberty of Eden. (ibid) Adam has tried to make clear to Eve what her responsibilities are and what her place is in the garden. He has also warned her of the dangers in the garden. Eve knows also of the dangers of Satan by overhearing Raphael talking about them â€Å"as in a shady nook I stood behind.† (Levi, 1996) Eve is clearly at a disadvantage in encountering Satan in an intellectual debate; however Milton does lead the reader to question the role of intelligence in the poem. It wasn’t the intellectually able angles â€Å"the politically astute Beelzebub and the rhetorically expert Belial† (Revard, 1973 p.76) who unmasked Satan in Book V. Many feel that Adam is guilty of negligence; however, others feel that he is merely an ineffective leader. (Revard, 1973) Stella p.Revard goes as far as saying that God is in fact to blame. Since refusing Eve the permission to leave would break the rules of free will â€Å"then God is blameworthy for having left uncompelled the wills of human bein gs in the first place and having permitted Satan the opportunity to try them.† (Revard, 1973 p.74) Is it only Milton’s portrayal of Eve that is the cause of so much controversy? In examining two different examples of the portrayal of Eve, the reader can decide if it was Milton who created the controversy surrounding Eve, or if theShow MoreRelatedFeminist Analysis Of Paradise Lost By John Milton1124 Words   |  5 PagesAkejah McLaughlin Professor Jennifer Rohrer-Walsh HON 2010 7 November 2017 Feminist Analysis of Paradise Lost The Book of Genesis is an introductive biblical passage in the Old Testament that summarizes the creation of the universe, humanity, and the downfall of man. 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