Surgical Treatment of Neuropathic Facial Pain – an Algorithmic Approach Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional Neurosurgery Department of Neurosurgery University of Illinois at Chicago 2011

Facial pain treatment algorithm 10/15/10

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Facial pain classification

Facial pain classification

Facial pain classification Trigeminal neuralgia (classic) - Burchiel TN1 Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

History of trigeminal neuralgia

History of trigeminal neuralgia

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) – Burchiel TN 2 Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain 2011

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain A.D.

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Natural history of trigeminal neuralgia

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery Sindou et al. MVD for TN Acta Neurochir, 2006

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities

Treatment modalities

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery Sheehan, JNS, 2005

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

Treatment modalities No surgery Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

How to choose the right procedure? Trigeminal neuralgia – MVD? Multiple sclerosis – RF PTG? Elderly patients – SRS? Anesthesia dolorosa – MCS? Atypical facial pain – no surgery?

Rationale for algorithm Facilitates decision making Aimed at maximal improvement / minimal side effects Individually tailored approach Standardization Eliminates uncertainty Patient and physician education

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Trigeminal Other cranial nerve Non-anatomic

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Sharp / shooting Constant / dull Combination

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Yes No

Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Yes No

Facial pain treatment algorithm

Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location

Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Yes No

Treatment questions Healthy? Young? Willingness to have surgery Yes Distribution of pain Severity of numbness Exact pain location Yes No

Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location V2, V3, V2-3 V1, V1-2, V1-3, V 1-2-3

Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Partial Complete

Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Supraorbital Infraorbital Mandibular

CNS 2011

Facial pain treatment algorithm

Current Algorithm of Facial Pain Treatment ~ 100 new patients with facial pain/year ~ 65% - trigeminal neuralgia ~35% - typical idiopathic TN ~15% - atypical idiopathic TN ~15% - secondary TN (MS, neoplasms, etc.) ~ 15% - trigeminal neuropathic pain ~ 5% - other cranial neuralgias / syndromes ~ 15% - atypical facial pain

Current Algorithm of Facial Pain Treatment ~ 70 surgeries for facial pain /year ~20-30 microvascular decompressions ~15-25 percutaneous RF gangliolysis ~2-3 balloon compressions ~5-15 GK radiosurgery ~1-3 trigeminal peripheral nerve stimulation ~0-1 motor cortex stimulation

Current Algorithm of Facial Pain Treatment 96% pain relief (at the time of discharge) 23% overall recurrence rate ~15% need another procedure 98% patient satisfaction

Current Algorithm of Facial Pain Treatment The proposed treatment algorithm for intractable facial pain that includes open and percutaneous procedures, radiosurgery and neuromodulation, appears to be effective for patients with a wide variety of painful conditions and may be recommended for use in other institutions.

Thank you!