Effectiveness of high-frequency cervical spinal cord stimulation in the treatment of refractory trigeminal neuropathy

Abstract

Rationale: Treatment of chronic neuropathic pain in the head and face regions presents a challenge for pain specialists due to the lack of reliable medical and surgical approaches. Patient concerns: A 62-year-old patient came to our attention for an intense facial pain secondary to a lesion of the right trigeminal nerve (all branches) due to a petroclival meningioma. Diagnoses: The patient also presented with gait impairment as well as a deficit of the right facial, auditory, trochlear and abducens cranial nerves. Interventions: Conventional medical management (CMM) as well as tonic SCS were already adopted but they all dramatically failed. We intervened with the use of high-frequency (10 kHz) spinal cord stimulation (HFSCS) at the cervicomedullary junction (CMJ). The patient was thus provided with HFSCS at the CMJ. Pain and quality of life (QoL) were assessed 1 and 3 months after implantation. We also tested the trigeminal-facial reflex responses. Outcomes: HFSCS led to a full relief from the debilitating electric shocks like pain in the right hemiface, even though a background dull pain appeared. The gradual addition of pregabalin helped in fully relieving the painful symptomatology, with a significant improvement in QoL. Moreover, sensitivity amelioration on the inner portion of the mouth allowed the patient to start feeding again also using that side of the mouth. These findings were paralleled by a significant reshape of trigeminal-facial reflex responses suggesting an inhibition of nociceptive sensory inputs at brainstem level following HFSCS. Lessons: This is the first report suggesting the usefulness of HFSCS at the CMJ in neuropathic pain due to trigeminal nerve neuropathy non-responsive to tonic SCS and CMM.

Trends in spinal cord stimulation utilization: change, growth and implications for the future

“…There are numerous contributing factors including but not limited to increased awareness of SCS therapy, efforts to minimize or reduce opioid use, emphasis on minimally invasive treatment options, discovery of more diseases amenable to SCS therapy, more physicians trained in utilization of SCS and improved neuromodulation technology. Though SCS was initially used for management of FBSS, its use has expanded to successfully treat other pain syndromes, including but not limited to trigeminal neuropathy,22 chronic abdominal pain,23 post-thoracotomy pain,24 painful diabetic neuropathy25 and non-surgical refractory back pain 26. The success of SCS in treatment of these different pain syndromes has encouraged clinicians and researchers to continue to discover additional pain syndromes that may respond to SCS therapy.…”

Percutaneous high cervical spinal cord stimulation for refractory trigeminal neuralgia

“…Only eight other case reports[ 1 , 10 , 15 , 22 , 24 , 25 , 28 ] have described pain relief of at least 50% in a total of 28 patients associated with RTN SCS treatment; furthermore, only two reports detailed permanent implants placed by percutaneous technique with pain relief estimated at about 70%. [ 10 , 26 ] This minimally invasive procedure is not associated with high rates of infections, lead migrations, or skin erosions as reported on gasserian ganglion/peripheral stimulation (26.4%, 17.6%, and 29.4%, respectively),[ 26 ] and does not require an upper cervical or suboccipital incision with the expected surgical site pain as in paddle lead placement and associated morbidity. The reports of these case series collaborate with evidence given.…”

“…Research by Peirs et al on mice populations provided limited evidence of such neural networks within the dorsal horn laminae and suggested that the nociceptive fibers were likely to terminate in superficial laminae I and II, while nonnociceptive sensory neurons were likely to innervate the deep laminae III-IV. [23] Only eight other case reports [1,10,15,22,24,25,28] have described pain relief of at least 50% in a total of 28 patients associated with RTN SCS treatment; furthermore, only two reports detailed permanent implants placed by percutaneous technique with pain relief estimated at about 70%. [10,26] is minimally invasive procedure is not associated with high rates of infections, lead migrations, or skin erosions as reported on gasserian ganglion/peripheral stimulation (26.4%, 17.6%, and 29.4%, respectively), [26] and does not require an upper cervical or suboccipital incision with the expected surgical site pain as in paddle lead placement and associated morbidity.…”