Case Report Pain Management

Case Report: Pain Management Trigeminal Neuralgia & Trigeminal Deafferentation By WiLL Wei Chief Complaint • Persistent Rt. half face numbness, tightness, and “ants crawling” sensation. History of Present Illness 1. This 59 y/o post-menopausal women with a previous diagnosis of trigeminal neuralgia came to the clinic to seek help for her hemi facial numbness and parethesis. 2. 1 month prior, she underwent her second balloon compression therapy. 3. Pt. recalled an episode of herpes eruption at the angle of the mouth and nasal alar immediately Post OP. History of Present Illness 4.Patient describes a persistent, vague, “ants-crawling” sensation, and tight sensation localized to the areas covered by V2 and V3. 5.This parethesis is less bothersome than the original trigeminal pain. However, the persistent nature of this numbness is the cause of pt’s distress. History of Present Illness 5.Pt notes coldness as the main aggravating factor. 6.Pt also notes aggravation of symptoms at night. 7.Hand compression of face offers minor relief. Past Medical History 1.Trigeminal neuralgia dx at age 45 2.Atypical depression secondary to chronic pain developed at age 55 3.Ankylosing Spondylitis(AS) dx at age 40 4.Duodenal ulcer at 33, resulting in a hospital stay of 3days Past Surgical History 1.Microvascular decompression: 1990 2.1st Balloon compression: 1998 3.Mandibular branch nerve block with xylocaine: 2004 4.2nd Balloon compression: 200 Social History 1.Substance use: • No tabacco use • No illicit drug use • No etOH use 2.Occupation: fashion designer, House wife. 3.Self-reported stress level: high 4.Married, with 2 kids via NSVD Allergy History • Allergic to all common household allergens, except for dog and cat hair. • Carbamazepine(Tegretol): skin rash. Pruritis • Dilantin: skin rash. pruritis Medications • • • • • HRT Gabapentin(neurontin) 200mg BID PRN Stilnox PRN Xanax PRN Multi-vitamin Physical Examination • HEENT: no ptosis of eyelid or any facial asymmetry noted. • Trigeminal Nerve: symmetrical sensation to pin-prick, temperature. • masetter muscle strength symmetric. Impression & Differential Diagnosis 1. Trigeminal deafferentation neuralgia 2. Post herpetic neuralgia 3. Recurrent Trigeminal Neuralgia 4. Other cranial nerve neuralgias 5. Psychogenic pain Trigeminal Deafferentation • Traumatic deafferentation (TD) is defined as a continuous pain following complete or partial damage to a peripheral nerve, such as in surgery. The pain is described as a continuous, burning numbness and often pulling pain. • female patients in their forties predominate in TD. The reason for this is undetermined. • Dx Criteria: hx of trauma, continuous pain, allodynia, temperature change in affected area. Trigeminal Neuralgia (TN) classically presents as a painful, unilateral affliction of the face, characterized by brief electric-shock-like pain, limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli, including washing, shaving, smoking, talking and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination may remit for varying periods. Possible Etiology of TN • peripheral injury or disease of the trigeminal nerve increases afferent firing in the nerve perhaps by transmission between afferent unmyelinated axons and partially damaged myelinated axons • failure of central inhibitory mechanisms • Blood vessel-nerve cross compression, aneurysms, chronic meningeal inflammation, tumors, or other lesions may irritate trigeminal nerve roots along the pons. Treatment Options • Medical • Surgical • Alternative Medical Tx • Antispastic agents - baclofen. Safest but not as effective as anticonvulsants. • Anticonvulsant drugs - carbamazepine, gabapentin, phenytoin, Depakote (sodium valporate) • Benzopiazepines - clonazepam. Second lined drugs • Antidepressant drugs - tricyclic antidepressants, amitriptyline. • Opioids - short-term use only, especially in critical cases. Trigeminal neuralgia is classically resistant to opioids. Surgical Tx 1.Non-invasive: nerve block 2.Invasive: 1.Non-destructive: Microvascular decompression 2.Destructive: various ablating methods Nerve Block • Injection of steroid or local anesthesia into Gasserion ganglion or one of its branches • Complicated localization method, requires experience. Nerve Block Complication: Vascular access to local anesthesia Mild:dizziness, vertigo, tinnitus, headache, anxiety, tachycardia, hypertension, tachypnea, dysarthria, metallic taste, and nausea. Severe:hypotension, coma, brachycardia. Respiratory depression and cardiac arrest. Nerve block • Advantages: less invasive. • Relief is only temporary. QuickT i me™ and a T IFF (Uncompressed) decompressor are needed to see this picture. Non-Destructive Microvascular Decompression • Visualize with microscope • Advantage: no numbness • If pain continues, control with anticonvulsants or repeat MVD or one of the destructive procedures. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Destructive Surgery • The most commonly performed: glycerol injections, gamma knife radiation, electrocoagulation, and balloon compression. • More numbness. • Possible weakness of masseter muscle. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Quic kTime™ and a TIFF (Unc ompres sed) decompres sor are needed t o s ee t his pict ure. Alternative Tx • Acupuncture • Hypnotherapy Pain, What is it? How do we Manage it? ……And what happens when all treatments FAIL……. Components of suffering • Nociception: an physical property, which can be studied and quantified. I.e. Aδfiber, c-fiber, nerve conduction, pain pathway in dorsal column, etc. • pain: unpleasant emotional response to actual or potential tissue damage, which is highly subjective and difficult be quantify. Why do we care about pain? High Cost of Chronic Pain • • • • • • Loss of days work Stress on family members Decline in pleasure seeking activities Social withdraw Depression Decline in health due to inactivity Chronic Pain Management Goals • Improvements in nociception, not curing. • Decrease pain and suffering • Increase daily activity. • Instill hope Improvement of nociception • Latest knowledge and technology in nociception. • Your absolute knowledge and medical performance may not correlated well with patient satisfaction level..… • This is where the science of medicine becomes the art of medicine…… Improvement of nociception • Must educate patients to have reasonable expectations. • Must keep a pain scale log to remind patients of their last visits’ pain level • Setting up unreasonable expectation that cannot be met are grounds for…..LAW SUITS!! Decrease Pain & Suffering • Must never deny Pt’s suffering. • It is a subjective feeling and it must be acknowledged. • Personal tragic story of denying pt’s pain in ER…….. Decrease Pain & Suffering • Be a good listener. Do not cut off pt’s sentence. • Talking about pain with someone who shows empathy and understanding has undeniable therapeutic effects. Increase Daily Activity • Encourage pt to engage in more activities so as divert attention from focusing on the pain. • Physical activity also increases the release of endorphin which may modulate the pain as well. Instilling Hope • Never tell patient that there is nothing more you can do. • Always explain treatment plans and tell patients that there are many more options to try but each treatment scheme requires times and their cooperation. • Keeps them coming back for more. Happy Pt. = Happy Doc. ~ fin ~