Medical Technology

Trigeminal Neuralgia: Intraorbital Cuts Help Certain Patients

NEW ORLEANS — Intraorbitalfrontal nerve resection has been shown to be effective in some patients with Idiopathic trigeminal neuralgia in which the ophthalmic divide (V1) is involved, according to researchers.

The procedure offers long-term relief from an illness that prior surgical and medical treatments often only temporarily helped according to Susan Tucker, MD, an Oculoplastic Surgeon at Lahey Hospital and Medical Center, Peabody, Massachusetts.

“The results are outstanding,” she told Medscape Medical News. “If you know someone who suffers from trigeminal neuralgia in the first division and it only affects this peripheral part of the trigeminal nerve this is a great procedure and should be the very first treatment for it.”

However the procedure was not effective for patients with post-herpetic trigeminal neuralgia in the study Tucker presented at the American Society of Ophthalmic Plastic & Reconstructive Surgery Fall Scientific Symposium.

Around 4 to 5 people in 100,000 experience trigeminal nervegia. About 20% of patients are affected by the nerve’s ophthalmic division. Patients feel an electric shock-like sensation.

The condition is usually caused by compression and areas that are demyelinating. There is no loss of sensory function. Medical treatments like carbamazepine are commonly prescribed however, the effects are mild or temporary, Tucker said.

Percutaneous procedures include glycerol injections, with a 70% recurrence of pain after 5 years; radiofrequency thermal rhizotomy, with an increase of 40% in 5 years; and balloon microcompression, with 20% recurrence over 5 years, said Tucker.

She also said that the Gamma knife radiosurgery, a procedure in which gamma radiations from radioactive Cobalt pass through the skull and into the intracisternal region of the trigeminal nervous, has a 45% recurrence within 3 years.

According to Tucker, microvascular decompression relieves pain in approximately 70% of patients who suffer long-term. However, there are complications such as hearing loss as well as loss of cerebrospinal fluid and meningitis. Extraocular leakage motor dysfunction, anesthesia Dolorosa.

Postherpetic neuropathy is a different condition. It affects between 10 and 15% of patients with Shingles. That’s an average of 58 per 100,000. It causes constant burning pain, and significant sensory loss. There are a variety of treatments available, including antidepressants, anticonvulsants and Anesthetics for the skin.

“If you could remove an extensive segment intraoperatively of the frontal nerve and its branches, the expectation was that that will result in longer intervals without pain,” Tucker said.

Tucker explained that resection of the frontal nerves is an option for patients who experience discomfort in the V1. For instance, it provides direct access to the supraorbital and supratrochlear nerves. The operation takes only 15-20 minutes. There is minimal bleeding. There is no danger of corneal anesthesia since the nasociliary branches are not affected.

Although at first she did the procedure under general anesthesia, Tucker now uses intravenous or local anesthesia.

Tucker makes a small incision on Tucker’s upper eyelid for the procedure. “Through this skin crease cut, I go as far as is possible, and attempt to get to the principal branch of the frontal nerve and then cut off the biggest segment that I can,” she said.

Tucker presented at the conference and reviewed the medical records of eight patients who suffered from V1 or V2 pain for a minimum of 2 years. She underwent surgery between 2002 and 2008 and had a a mean follow up of 12.8 years.

She found that 5 of them had no recurrences of pain in the v1 division. One of them experienced pain recurrence on the v2 section. The 5 patients with no recurrences of pain included two who did not receive relief from prior surgery. The 3 patients who had a recurring V1 pain were able to control it by taking medication.

The three patients suffering from postherpetic pain had recurrence of pain after this procedure, even though the pain was less than before the procedure, Tucker said.

Tucker concluded by recommending the procedure as first-line treatment for frontal nerve trigeminal neuralgia with a distribution idiopathic.

However, she acknowledged that the procedure is restricted to a specific subset of patients suffering from trigeminal neuropathy and didn’t appear to be effective in treating postherpetic pain. There are complications that include permanent numbness and intermittent ptosis.

Jacques Morcos MD, a co-chair and professor of neurosurgery at the University of Miami, Florida is a specialist in vascular compression for patients suffering from trigeminal nerve pain. He was unsure if resecting the nerve in the frontal could resolve the pain. He said, “My skepticism would be that it’s too far downstream in the nerve for the physiologic mechanism to alleviate the pain.”

If the pain is located in the V1 division close to the orbit, this procedure might help, but such pain would not be classified as trigeminal neuralgia he said.

He also said that the study was not enough to be conclusive. “It’s going to require more than the number of patients studied and a very long-term follow-up to convince me that this works,” he said.

Tucker and Morcos have not disclosed any relevant financial relations.

American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) 2021 Fall Scientific Symposium. The symposium will be held on November 11, 2021.

Laird Harrison writes about health and science. His work has appeared in newspapers and magazines across the country as well as on websites and public radio. He is at work on a novel that explores alternate realities in physics. Harrison is a writer at Writers Grotto. Visit his website at lairdharrison.com or follow him on Twitter @LairdH

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