Efficacy and Safety of Computed Tomography-Guided Percutaneous Balloon Compression under Local Anesthesia for Recurrent Trigeminal Neuralgia: A Prospective Study.

Purpose: There are several ways to treat trigeminal neuralgia (TN); however, TN may recur after treatment. This study investigated the efficacy and safety of computed tomography (CT)-guided percutaneous balloon compression (PBC) under local anesthesia for treatment of recurrent trigeminal neuralgia. Patients and Methods. This is a prospective and nonrandomized controlled clinical study. Forty-eight patients with classical TN were scheduled to undergo PBC surgery at the pain department of our institution between January 2021 and June 2021. The patients were prospectively divided into an initial onset group, A (21 cases), and a recurrence group, B (27 cases). All surgeries were performed with CT guidance and under local anesthesia. Postoperative complications were also observed. Pain was assessed using the visual analog scale (VAS) and Barrow Neurological Institute (BNI) scale. Efficacy indices were evaluated at 3, 6, 12, and 18 months after surgery. Results: All participants reported complete pain relief at discharge. After 18 months of follow-up, the total effective rate of pain control was 89.5% (group A, 90.5%; group B, 88.8%). There was no significant difference in the BNI scores between the two groups before and after treatment. All patients had hypoesthesia on the affected side, and no severe complications such as diplopia, blindness, intracranial hemorrhage, or intracranial infection occurred. Conclusions: CT-guided PBC under local anesthesia is safe and effective for the treatment of recurrent TN and thus acts as an effective alternative for geriatric patients and those with high-risk factors.

Amelioration of central neurodegeneration by docosahexaenoic acid in trigeminal neuralgia rats through the regulation of central neuroinflammation.

Trigeminal neuralgia (TN) is a stubborn head and face neuropathic pain with complex pathogenesis. Patients with TN have a significantly increased risk of central neurodegeneration, which manifests as cognitive impairment and memory loss, but the specific mechanism underlying central nervous degeneration is still unclear. This study aimed to explore central neurodegeneration and its possible mechanism of action in TN rats based on changes in the brain fatty acid content and microglia-related neuroinflammation. Using a TN neuropathic pain model established by us, we found that TN rats have obvious cognitive impairment. Furthermore, changes in the brain fatty acid content were analyzed using gas chromatography-mass spectrometry (GC-MS). It was found that the docosahexaenoic acid (DHA) content in the central nervous system (CNS) of TN rats was significantly decreased compared to that in the CNS of Sham rats. An important component in maintaining brain cognition, DHA also plays a key role in regulating central neuroinflammation. Here, by continuous supplementation of DHA, the CNS DHA content was increased to a certain extent in TN rats. The cognitive impairment of TN rats was improved after restoring the central DHA level; this may be related to the improvement of neuroinflammation through the DHA-mediated regulation of microglial polarization. Overall, this study provides a theoretical basis for explaining the pathogenesis of central neurodegeneration in TN. It also suggests DHA as a target for protecting the CNS of patients with TN from damage.

Cardiovascular response to Gasserian ganglion ablation on trigeminal neuralgia under local anesthesia: a retrospective single-blind case-control study.

OBJECTIVE: Radiofrequency thermocoagulation of Gasserian ganglion brings with it the difficult problem of how to provide adequate acesodyne therapy for patients in order to make the treatment more comfortable. In our study, we assess the safety and efficacy of lidocaine local anesthesia in the treatment of trigeminal neuralgia. METHODS: From January, 2017 to December, 2020, 80 patients in our hospital who were suffering from trigeminal neuralgia were treated with radiofrequency thermocoagulation through oval foramen. They were all enrolled in our study and randomly divided into a study group and a placebo group. In the study group an appropriate concentration of lidocaine was given outside and inside of the oval foramen after puncturing in place, while in the placebo group the same dose of normal saline was given in the same way. We then recorded the mean arterial pressure (MAP), heart rate (HR) and visual analogue scale (VAS) at different treatment temperatures. RESULTS: The values of MAP and HR in the study group were generally lower than those in the placebo group, and the difference was statistically significant. Additionally, the two groups showed a significant difference in MAP, HR, and VAS at different treatment temperatures. There were significant differences in MAP and VAS between the study group at the baseline as well as each time point thereafter, and the range of MAP and HR in the study group were lower than those in the placebo group. CONCLUSION: Reasonable lidocaine local anesthesia can provide analgesic effects and prevent hypertension and arrhythmia during Gasserian ganglion radiofrequency thermocoagulation for the treatment of trigeminal neuralgia.

Cannabis. Usos y aplicaciones en la práctica odontológica diaria: revisión de la literatura / Cannabis. Uses and applications in daily dental practice: a review of the literature

La evidencia científica presente en la literatura indica que el cannabis puede ser utilizado con fines terapéuticos para tratar distintas afecciones odontológicas. Dado el acceso sencillo a la cavidad bucal, las distintas formulaciones de cannabis pueden aplicarse de forma tópica. La aplicación local de dosis bajas de cannabis ha demostrado alta efectividad para tratar distintas afecciones bucales, constituyendo un tratamiento seguro con baja probabilidad de generar repercusiones sistémicas indeseadas. En la actualidad, está siendo incorporado a materiales convencionales de uso e higiene odontológica con la finalidad de aprovechar sus efectos terapéuticos. El cannabis tiene múltiples usos en odontología: como componen-te de enjuagues bucales y soluciones para la desinfección de conductos radiculares, en tratamientos de trastornos de ansiedad bucal, como complemento en terapias oncológicas, como analgésico para atenuar el dolor inflamatorio y el neuropático, como miorrelajante y condroprotector para tratar trastornos de articulación témporomandibular (ATM) y bruxismo, como osteomodulador para el tratamiento de patologías que comprometen la integridad ósea, como la enfermedad periodontal y la osteoporosis, y para la cicatrización ósea asociada a fracturas, extracciones dentarias e implantes, y como inmunomodulador con potencial terapéutico para tratar patologías autoinmunes como las enfermedades reumáticas. El trata-miento local con cannabis es efectivo, bien tolerado por el paciente y con pocos efectos adversos. Por lo tanto, se puede concluir que el cannabis aporta un enorme abanico de posibilidades terapéuticas para tratar distintas afecciones odontológicas, aunque aún se requiere mayor cantidad de estudios científicos que avalen su utilización en cada situación fisiopatológica particular (AU)

The scientific evidence present in the literature indicates that cannabis can be used for therapeutic purposes to treat different dental conditions. Given the easy access to the oral cavity, the different cannabis formulations can be applied topically. The local application of low doses of cannabis has shown high effectiveness in treating different oral conditions, constituting a safe treatment with a low probability of generating unwanted systemic repercussions. It is currently being incorporated into conventional materials for dental use and hygiene in order to take advantage of its therapeutic effects. Cannabis has multiple uses in dentistry: as a component of mouthwashes and solutions for disinfecting root canals, in the treatment of oral anxiety disorders, as a complement in oncological therapies, as an analgesic to reduce inflammatory and neuropathic pain, as a muscle relaxant and chondroprotective to treat temporomandibular joint disorders and bruxism, as an osteomodulator for the treatment of pathologies that compromise bone integrity, such as periodontal disease and osteoporosis, and or bone healing associated with fractures, dental extractions and implants, and as immunomodulator with therapeutic potential to treat autoimmune pathologies such as rheumatic diseases. Local treatment with cannabis is effective, well tolerated by the patient and with few adverse effects. Local treatment with cannabis is effective, well tolerated by the patient and with few adverse effects. Therefore, it can be concluded that cannabis provides an enormous range of therapeutic possibilities to treat different dental conditions, although more scientific studies are still required to support its use in each particular pathophysiological situation (AU)

Effects of Botulinum Toxin Type A on Pain among Trigeminal Neuralgia, Myofascial Temporomandibular Disorders, and Oromandibular Dystonia.

The differences in analgesic effects of botulinum toxin type A were compared in 28 patients with trigeminal neuralgia, 53 patients with myofascial temporomandibular disorders, and 89 patients with the jaw closing oromandibular dystonia. The patients were treated by injection of botulinum toxin type A into the masseter, temporalis, medial pterygoid, and other muscles based on the symptoms of each patient. The pain severity was evaluated using the visual analog scale, pain frequency, and pain scale of the oromandibular dystonia rating scale. Botulinum toxin injection was performed 1068 times in all patients without significant adverse effects. The visual analog, pain frequency, and pain scales at baseline were reduced (p < 0.001) after two, four, eight, and 12 weeks after the first botulinum toxin therapy and at the endpoint. The effects differed significantly (p < 0.001) among the groups (repeated-measures analysis of variance). The mean improvement (0%, no effect; 100%, complete recovery) at the endpoint was 86.8% for trigeminal neuralgia, 80.8% for myofascial pain, and 75.4% for oromandibular dystonia. Injection of the botulinum toxin can be a highly effective and safe method to treat trigeminal neuralgia, myofascial pain, and oromandibular dystonia.

Pain Management in Neurosurgery: Back and Lower Extremity Pain, Trigeminal Neuralgia.

Interventional anesthetic techniques are an integral component of a biopsychosocial approach and multidisciplinary treatment. Injection techniques are often used to diagnose disorders, decrease the need for surgery, or increase the time to surgery. The role of neural blockade techniques using local anesthetics and steroids in the assessment and treatment of pain continues to be refined. With the current opioid crisis and an aging population with increasing medical comorbidities, there is an emphasis on the use of nonopioid, nonsurgical, and multimodal therapies to treat chronic pain. This article reviews indications, goals, and methods of common injection techniques.

Cognitive and sensorimotor function in participants being treated for trigeminal neuralgia pain.

BACKGROUND: Trigeminal neuralgia (TN) is an orofacial condition defined by reoccurring, spontaneous, short-lived but excruciating stabbing pain. Pharmacological interventions constitute the first-line treatment for TN, with antiepileptic drugs commonly prescribed. People treated for TN pain with antiepileptic drugs describe cognitive and motor difficulties affecting activities of daily living, and report poorer quality of life. We undertook the first comprehensive objective evaluation of sensorimotor and cognitive performance in participants being treated for TN pain with antiepileptic drugs relative to age-matched controls. METHODS: Participants (43 TN, 41 control) completed a battery of sensorimotor (steering, aiming and tracking) and cognitive (working memory, processing speed, inhibition) tasks. RESULTS: The TN group performed significantly worse than controls on the sensorimotor tracking and aiming tasks and across all cognitive measures. CONCLUSIONS: The data explain why patients treated with antiepileptic drugs report impairment when conducting activities of daily living (given the need for cognitive and motor capability within most of these). The study is an important first step in: (i) ensuring there is adequate information on the impact of pharmacological treatment; (ii) identifying measures to determine optimal medication dosage and track change over time; (iii) creating an evidence base that could allow scientific justification of alternative pain treatment options for TN (e.g. the costs/benefits of surgery).

Herbal medicine for the management of idiopathic trigeminal neuralgia: A protocol for a systematic review of controlled trials.

BACKGROUND: Trigeminal neuralgia is an oral facial pain that is limited to one or more parts of the trigeminal nerve. As it becomes chronic, it can seriously affect the quality of life of most patients, and it is expected to increase in incidence in modern aging society. The objective of this systematic review protocol is to provide methods for evaluating the effectiveness and safety of herbal medicines for idiopathic trigeminal neuralgia (ITN). METHODS: A total of 14 databases will be searched for studies uploaded from inception to the present date that investigated the treatment of ITN. These databases are MEDLINE, EMBASE, AMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycARTICLES, four Korean databases, two Chinese databases, and two Japanese databases. We will include randomized controlled trials (RCTs) assessing herbal medicine decoctions used to treat any type of ITN. All RCTs of decoctions or modified decoctions with any type of form of herbal medicine will be eligible for inclusion. The methodological quality of randomized controlled trials will be analyzed using the Cochrane Collaboration tool to assess risk of bias, and the confidence in the cumulative evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument. ETHICS AND DISSEMINATION: The results of this systematic review will be published in a peer-reviewed journal and disseminated electronically and in print. To inform and guide healthcare practices, the review will be updated. TRIAL REGISTRATION NUMBER: PROSPERO CRD42020129667.

Bilateral calcaneal insufficiency fractures due to chronic carbamazepine use for trigeminal neuralgia: A case report.

Stress fractures of calcaneus are uncommon cause of heel pain. Stress fractures could be seen in risc groups such as metabolic diseases/medications causing poor bone quality and exposing repetitive microtrauma. Anti-epileptic drug (AED) use is related with poor bone quality and increased fracture risc. Although carbamazepine-induced stress fracture is a well-known entity and there are case reports in other bones such as the femoral neck, bilateral calcaneal insufficiency fractures is an extraordinary location. To the best of our knowledge, this is the first case reporting an insufficiency fracture involving calcaneus in the relevant literature. Due to the rarity of both conditions, we decided to present and discuss this patient. When patients receiving AED treatment present with heel pain without previous plantar fasciitis history or traumatic event, insufficiency fractures should be kept in mind. This case highlights the importance of screening adverse effect of CBZ on bone metabolism in patients with long CBZ use. We report here a 41-year-old lady suffering from bilateral heel pain without trauma history. Her complaining did not respond to analgesics and stretching exercises of plantar fascia. In her past medical history she reported ongoing carbamazepine (CBZ) use over 8 years for trigeminal neuralgia. She had had low bone mineral density; defined as osteopenia. Both calcaneus MRI revealed bilateral stress fractures of calcaneum. She had been advised immobilization for 6 weeks, vitamin D and calcium supplements. CBZ has been stopped by neurology specialist and she had undergone microvascular decompression surgery for intractable pain of trigeminal neuralgia. She is doing well with full recovery from heel pain and trigeminal neuralgia at the end of one year. CBZ use causes poor bone quality through vitamin D metabolism. Heel pain without traumatic event, objective findings of plantar fasciitis and calcaneal spur syndrome in an CBZ using patient insufficiency fracture of calcaneus should be remembered and evaluated rigorously.

Effects of palmatine on BDNF/TrkB-mediated trigeminal neuralgia.

Trigeminal neuralgia (TN), a sudden, needle-like pain in the distribution area of the trigeminal nerve, can seriously affect the physical and mental health of patients. In chronic pain conditions including TN, increased levels of brain-derived neurotrophic factor (BDNF) may enhance pain transmission. This study compares the effect of palmatine administration on the expression of BDNF and its receptor TrkB (tropomyosin receptor kinase B) in trigeminal ganglion cells of Sprague-Dawley rats in a sham versus TN model group. Within 14 days of surgery, the mechanical allodynia threshold of the TN group was significantly lower than that of the sham group, while the TN + palmatine group had a higher mechanical pain sensitivity threshold than the TN group (p < 0.05). Real-time quantitative PCR, immunohistochemistry, and immunofluorescence showed that BDNF and TrkB expression in the TN group was higher than that in the sham group, while palmatine treatment could reverse these changes. Western blotting showed that palmatine treatment could reduce the elevated phosphorylation of extracellular signal-regulated kinases 1/2 (ERK1/2) in TN rats. Thus, the BDNF/TrkB pathway may be involved in the pain transmission process of TN, and palmatine treatment may reduce pain transmission by inhibiting the BDNF/TrkB pathway and suppressing ERK1/2 phosphorylation.

A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) can have a significant impact on wellbeing and quality of life. Limited data exist for treatments that improve TN pain acutely, within 24 h of administration. This systematic review aims to identify effective treatments that acutely relieve TN exacerbations. METHODS: We searched Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English language publications. The reference list for all articles was searched for other relevant publications. All studies that satisfied the following PICO criteria were included: (i) Population-adults with acute exacerbation of primary TN symptoms; (ii) Intervention-any medication or intervention with the primary goal of pain relief within 24 h; (iii) Comparator-usual medical care, placebo, sham or active treatment; (iv) Outcome-more than 50% reduction in pain intensity within 24 h of administration. RESULTS: Of 431 studies, 17 studies were identified that reported immediate results of acute treatment in TN. The evidence suggests that the following interventions may be beneficial: local anaesthetic, mainly lidocaine (ophthalmic, nasal or oral mucosa, trigger point injection, i.v. infusion, nerve block); anticonvulsant, phenytoin or fosphenytoin (i.v. infusion); serotonin agonist, sumatriptan (s.c. injection, nasal). Other referenced interventions with very limited evidence include N-methyl-d-aspartate receptor antagonist (magnesium sulphate infusion) and botulinum toxin (trigger point injection). CONCLUSIONS: Several treatment options exist that may provide fast and safe relief of TN. Future studies should report on outcomes within 24 h to improve knowledge of the acute analgesic TN treatments.

Effect of coenzyme Q10 on mitochondrial respiratory proteins in trigeminal neuralgia.

Trigeminal neuralgia (TN) is the neuropathic pain. Mitochondrial dysfunction, increased oxidative stress, and inflammation demonstrated in chronic pain. Carbamazepine (CBZ) is the first-line drug for TN, however, it is still insufficient. Coenzyme Q10 (CoQ10) has been used as the additional supplement for pain therapy. Nonetheless, mitochondrial respiratory proteins, oxidative stress, and inflammation in TN, and the add-on effects of CoQ10 on those defects have never been investigated. CBZ-treated TN-patients, naïve TN-patients, and control subjects were included. CBZ-treated TN-patients were randomised into two subgroups, received either CoQ10 or placebo for 2 months. Pain levels were evaluated, and peripheral blood mononuclear cells were isolated to determine the oxidative stress, mitochondrial oxidative phosphorylation (OXPHOS), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), and cytokines including TNF-α, IL-1ß and IL-18 mRNA expression. Pain scales, oxidative stress, and OXPHOS levels were greater in naïve TN-patients than control, whereas the cytokine profiles were unchanged. Although pain scales were lower in CBZ-treated TN-patients than in naïve TN-patients, oxidative stress, OXPHOS, and cytokine expression profiles were not different. PGC-1α levels found to be increased in CBZ-treated TN patients when compared with the naïve group. CoQ10 supplement in CBZ-treated TN patients reduced pain scale and oxidative stress and increased antioxidants levels when compared with placebo group. However, OXPHOS, PGC-1α, and cytokines were not different between groups. These findings suggest that increased oxidative stress could be potentially involved in the pathogenesis of TN. CoQ10 supplements can reduce oxidative stress, leading to more effective pain reduction in TN patients being treated with CBZ.

Acupuncture treatment for idiopathic trigeminal neuralgia: A longitudinal case-control double blinded study.

OBJECTIVE: To evaluate the treatment effect of acupuncture on patients with idiopathic trigeminal neuralgia (ITN) by case-control longitudinal blinded study. METHODS: Sixty ITN patients and 30 healthy subjects were included. The ITN patients were randomly assigned to acupuncture group (15 cases), sham-acupuncture group (15 cases) and carbamazepine group (30 cases), respectively. Clinical orofacial evaluation (including pain intensity and medication doses), research diagnostic criteria for temporomandibular disorders (RDC/TMD) and Helkimo indexes (for functional evaluation of the masticatory system), and quantitative sensory testing for sensory thresholds (gustative, olfactory, cold, warm, touch, vibration and superficial and deep pain) were evaluated before treatment, immediately after treatment, and 6 months after treatment. RESULTS: The mean pain intensity by the Visual Analogue Scale only decreased in the acupuncture group at the last evaluation (P=0.012). Patients in the sham-acupuncture group had an increase in carbamazepine doses according to the prescriptions (P<0.01). There was a reduction in secondary myofascial pain and mandibular limitations at the acupuncture and sham-acupuncture groups, however only the acupuncture group kept the changes after 6 months (P<0.01, P=0.023). There was a decrease in mechanical thresholds in the acupuncture group (tactile, P<0.01; vibration, P=0.027) and an increase in deep pain thresholds in both acupuncture and sham-acupuncture groups (P=0.013). CONCLUSIONS: Acupuncture can be an option in the treatment of ITN due to its analgesic effect in both ITN and secondary myofascial pain associated with it.

Hypericum perforatum (St. John's Wort) as a possible therapeutic alternative for the management of trigeminal neuralgia (TN) - A case report.

Hypericum perforatum (St. John's Wort) is an alternative remedy used primarily for depression but also is used for rheumatism, gastroenteritis, headache and neuralgias. The mechanism of action of Hypericum perforatum comprehends a neurotransmitter inhibitory profile, and potential anti-inflammatory and anti-oxidant effects suggesting a role for pain management. In this case report, we describe a 53-year-old Hispanic female patient who came to our orofacial pain clinical service presenting with a history of trigeminal neuralgia (TN). The patient was not able to get an appointment soon enough and decided to take an over the counter homeopathic preparation of Hypericum perforatum since she found on the internet that it was effective for nerve pain. The patient responded dramatically to the Hypericum perforatum preparation. The use of this homeopathic preparation relieved completely the TN pain. The management of TN is often a challenge. Hypericum perforatum may be a promising therapeutic option for TN that deserves to be explored further to solidly support its use in the clinical setting.

[Efficacy of Go-rei-san for Pain Management in Four Patients with Intractable Trigeminal Neuralgia].

Go-rei-san is a Japanese traditional medicine that is used to treat motion sickness, nausea, and vomiting. We report here four patients for whom Go-rei-san was effective in treating pain associated with intractable trigeminal neuralgia. Three patients could not continue carbamazepine due to drug-induced rash, liver damage, and gastrointestinal injury, and suffered from pain. One patient experienced severe dizziness upon combination treatment with pregabalin and carbamazepine. All patients exhibited symptoms of water poisoning on their tongues. All patients experienced significant pain relief without major complications after daily adminis- tration of 7.5 g Go-rei-san. Our findings suggest that Go-rei-san can effectively alleviate pain associated with intractable trigeminal neuralgia without major compli- cations.

Resultados sobre la aplicación cráneo-facial del parche de capsaicina 8 % en una serie de 5 casos / Results of the capsaicin 8% patch in craniofacial application in five clinical cases

Los parches de capsaicina al 8 % son una alternativa de segunda línea para el tratamiento del dolor neuropático periférico. Aunque tiene pocos efectos secundarios, no tiene indicación para el tratamiento cráneo-facial debido a la posible irritación de mucosas por la capsaicina. Sólo hemos encontrado tres publicaciones que refieren la aplicación del parche en estas localizaciones, describiendo 7 casos clínicos. Hemos recogido 4 casos en los que se realizan 5 aplicaciones en total, 3 mujeres (repitiendo aplicación en una de ellas) y 1 hombre, entre 58 y 84 años, con los siguientes diagnósticos: necrosis cáustica en labio inferior tras limpieza dental, neuralgia del trigémino y neuropatía postherpética. Tras comprobar ineficacia de otros tratamientos, se propuso el parche de capsaicina al 8 %, con firma previa de los consentimientos informados de la aplicación de parche en régimen de hospital de día y de tratamiento fuera de ficha técnica. Previamente a la aplicación del parche en la zona cutánea dolorosa, se procedió a realizar protección ocular de ambos ojos con parche oftálmico quirúrgico, y de mucosas oral y nasal con mascarilla facial quirúrgica sellada. La protección se mantuvo durante toda la aplicación del parche y se quitó una vez retirado éste y limpiada la zona de aplicación. Únicamente se reportaron 3 efectos secundarios leves del total de las 5 aplicaciones: un paciente presentó piel eritematosa que cedió espontáneamente, otra paciente refirió sensación de quemazón y dolor que cedió con analgesia endovenosa, y otra paciente explicó dolor leve bien tolerado, que cedió de manera espontánea. En ninguno de los casos se apreciaron efectos secundarios a nivel de mucosas. En cuanto a resultados, dos pacientes notaron mejoría durante uno y dos meses, colocando nuevamente el parche en una de ellas, sin lograr esta segunda vez alivio. Las otras dos pacientes no notaron ningún cambio. El tratamiento con parches de capsaicina 8 % en superficies cráneo-faciales parece tener similar eficacia a su aplicación en otras áreas de la piel. Los efectos secundarios en su aplicación en estas superficies son escasos, al igual que en otras aplicaciones corporales. Creemos que con las medidas de precaución adecuadas en las regiones cráneo-faciales, la utilidad clínica observada del parche de capsaicina 8 % lo sitúa como otra opción de tratamiento para dolor neuropático, sin complicaciones añadidas. No obstante, estudios clínicos con mayor número de pacientes deberían llevarse a cabo para confirmar estos hallazgos (AU)

The capsaicin 8 % patch is a secondary line alternative to neuropathic peripheral pain treatment. Although it has few secondary effects, is not indicated in head and facial treatment due to the possibility of the irritation of mucosa. We have only found three publications related with the patch application in those locations, describing 7 clinical cases. We have analyzed 4 cases in which we have applied 5 patches in total. There were 3 women (repeating the application in one of them) and 1 man, between 58 and 84 years old, with the following diagnosis: caustic necrosis in the inferior lip after dental cleaning, trigeminal neuralgia and post-herpetic neuropathy. Inefficacy of other treatments was confirmed, and after that, the capsaicin 8 % patch was proposed. Informed consent of the application of the patch at day clinic and treatment out of technical data sheet were previously signed. Before the patch was applied to the painful cutaneous area, we proceed with ocular protection of both eyes with surgical ophthalmic patch and oral and nasal mucosa protection with surgical mask hermetically seal. That protection was maintained during the whole application of the patch, and was removed once the capsaicin patch was taken off and the application area was cleaned. There were only 3 mild secondary effects of the total 5 applications: one patient showed erythematic skin that was resolved spontaneously, another patient related burn and pain sensation which was solved with endovenous analgesia. Finally, another patient explained mild pain well tolerated, that was resolved also spontaneously. In no cases there were secondary effects in mucosa. Related with the results, 2 patients felt improvement between one and two months, applying again the patch in one of them, not reaching this time relief in the pain. The other 2 patients did not notice any change. The capsaicin 8 % patch treatment in head and facial areas seems to have similar efficacy as the application in other skin areas. Secondary effects in these surfaces are very low, the same as in other corporal locations. We believe that with the adequate preventive measures in head and facial areas, clinical utility observed with capsaicin 8 % patch places it as another treatment option for neuropathic pain, with no complications added. However, clinical studies with a higher number of patients should carry on to confirm these findings (AU)

Calcitonin as an Additive to Local Anesthetic and Steroid Injection Using a Modified Coronoid Approach in Trigeminal Neuralgia.

BACKGROUND: Pharmacotherapy is the main treatment for management of trigeminal neuralgia. However, many patients become refractory to drugs. OBJECTIVES: The present study aimed to evaluate the effect of adding calcitonin to local anesthetic and methylprednisolone using a modified coronoid approach in management of trigeminal neuralgia pain involving the mandibular and/or maxillary branches. STUDY DESIGN: Randomized double blind clinical trial. SETTING: Hospital outpatient setting. METHODS: Thirty-three patients received maxillary and mandibular blocks by a modified coronoid approach. Patients were allocated into 2 groups. Group 1 received a block with 3 mL of lidocaine 0.5% plus 40 mg of methylprednisolone and another syringe contained 1 mL of 0.9% saline. Group 2 received a block with 3 mL of lidocaine 0.5% plus 40 mg of methylprednisolone and another syringe contained 50 international units of calcitonin. Pain was evaluated by visual analog scale (VAS) before the block (basal), at 2 weeks, one month after the procedure, and monthly for one year. Duration of the effective pain relief of the first block (VAS = 3) was reported. Repeated blockade was allowed for any patient reporting a VAS > 30 mm during one year of follow-up and the number of blocks were reported. Adverse effects were also reported. RESULTS: A significantly longer duration of effective pain relief was noticed in group 2 compared with group 1 (P < 0.0004) while the duration of effective pain relief of the second block in group 1 was 28.5 ± 8.9 weeks. Four patients did not need repeated blocks in group 1 versus 15 in group 2. Six patients received 2 blocks versus 2 patients in each group, respectively. Moreover, 6 patients needed 3 blocks in group1 versus none in group 2. No serious adverse events were reported during or after the interventional procedure. VAS was comparable in both groups (P > 0.05). LIMITATIONS: Small sample size. CONCLUSION: Calcitonin may be a useful additive to local anesthetic and steroid in management of trigeminal neuralgia. Also, a modified coronoid approach for maxillary and mandibular nerve is simple, free of radiation, safe, and may be an effective percutaneous procedure in trigeminal neuralgia. KEY WORDS: Calcitonine, modifed, coronoid approach, trigeminal neuralgia.

Real-time ultrasound-guided infraorbital nerve block to treat trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine.

Background Trigeminal neuralgia is a neuropathic disorder characterized by episodes of intense pain in the face. Drug therapy is the first choice of treatment. However, in cases where drug therapy are contraindicated due to side effects, patients can get pain relief from lengthy neurosurgical procedures. Alternatively, a peripheral trigeminal nerve block can be easily performed in an outpatient setting. Therefore it is a useful treatment option for the acute paroxysmal period of TN in patients who cannot use drug therapy. We performed real-time ultrasound guidance for infraorbital nerve blocks in TN patients using a high concentration of tetracaine dissolved in bupivacaine. In this report, we examine the efficacy of our methods. Patients As approved by the Institutional Review Board, the medical records in our hospital were queried retrospectively. Six patients with TN at the V2 area matched the study criteria. All patients could not continue drug therapy with carbamazepine due to side effects and they received an ultrasound-guided infraorbital nerve block with a high concentration of tetracaine dissolved in bupivacaine. Methods The patient was placed in the supine position and the patient's face was sterilized and draped. An ultrasound system with a 6-13 MHz linear probe was used with a sterile cover. The probe was inserted into the horizontal plane of the cheek just beside the nose and was slid in the cranial direction to find the dimple of the infraorbital foramen. The 25G 25 mm needle was inserted from the caudal side just across from the probe using an out-of-plane approach. To lead the needle tip to the foramen, needle direction was corrected with real-time ultrasound guidance. After the test block with lidocaine (2%, 0.5 ml), a solution of tetracaine (20 mg) dissolved in bupivacaine (0.5%, 0.5 ml) was injected. During each injection, the spread of the agent around the nerve was confirmed using ultrasound images. Results Ten blocks were performed for six patients. Immediately after the procedure, all 10 blocks produced analgesia and relieved the pain. In the three blocks, pain was experienced in a new trigger point outside of the infraorbital nerve region (around the back teeth) within a week after the block and pain were relieved using other treatment. Two patients developed small hematomas in the cheek but they disappeared in a week. All patients did not complain about other side effects including paraesthesia, hyperpathia, dysaesthesia, or double vision. Hypoaesthesia to touch and pain in the infraorbital region were observed in all blocks after 2 weeks. Conclusions We performed real-time ultrasound-guided infraorbital nerve block for TN with a high concentration of tetracaine dissolved in bupivacaine. Our method achieved a high success rate and there were only minor and transient side effects. Implications Real-time ultrasound-guided infraorbital nerve block is one of the useful options to treat the acute paroxysmal period of TN at the infraorbital nerve area. Ultrasound-guided injections may become the standard practice for injecting peripheral trigeminal nerves. Using this high concentration of tetracaine as a neurolytic agent is effective and appears to have only minor side effects.

[Topical pharmacologic approach with 5% lidocaine medicated plaster in the treatment of localized neuropathic pain]. / Approccio farmacologico topico con lidocaina cerotto 5% nel trattamento del dolore neuropatico localizzato.

The treatment of neuropathic pain is a medical challenge. The responsiveness to the different classes of drugs is often unsatisfactory and frequently associated to a wide range of side effects. International guidelines suggest for the "localized" neuropathic pain the topical treatment with 5% lidocaine medicated plaster, alone or associated to systemic drugs, as the first choice since its favorable efficacy and tolerability profile. Many clinical experiences support the rationale for using 5% lidocaine medicated plaster in different kinds of localized neuropathic pain, such as postherpetic and trigeminal neuralgia, compressive syndromes, painful diabetic polyneuropathy and pain secondary to trauma or surgical interventions. This paper reports a series of clinical cases whose heterogeneity suggests the wide burden of applicability of the topical 5% lidocaine, either alone and associated to systemic drugs. All the described conditions were characterized by a highly intense pain, not adequately controlled by actual medications, which improved after the use of topical lidocaine. The good response to lidocaine allowed the reduction, of even the withdrawal, of concurrent drugs and improved the patients' quality of life.

[Odontogenic pain syndrome: integrated approach in analgesia].

The article deals with the study of 96 patients (69 women and 27 men) with odontogenic facial pain syndrome. All patients received complex neurodentist examination with radiological assessment of maxillofacial area and additional functional methods. Patients were divided into two groups, 48 patients in each group. All patients received usual therapy; mouth cavity sanitation, selective grinding of teeth, drug therapy (anticonvulsants, B vitamins) and physiotherapy. Patients in group 2 received corporeal acupuncture. Efficacy of the therapy was assessed by changes of basic subjective and objective significatives on 10th, 30th and 60th day of treatment. Reflective anaesthesia techniques using allowed to stop the pain faster and decreased the dosage of drugs in patients of group 2.