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Surgical Treatment of Neuropathic Facial Pain – an Algorithmic Approach Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional.

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Presentation on theme: "Surgical Treatment of Neuropathic Facial Pain – an Algorithmic Approach Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional."— Presentation transcript:

1 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

2 Facial pain treatment algorithm
10/15/10

3 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

4 Facial pain classification

5 Facial pain classification

6 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

7 History of trigeminal neuralgia

8 History of trigeminal neuralgia

9 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

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

11 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.

12 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

13 Natural history of trigeminal neuralgia

14 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

15 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

16 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

17 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

18 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

19 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

20 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

21 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

22 Treatment modalities

23 Treatment modalities

24 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

25 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

26 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

27 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

28 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

29 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

30 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

31 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

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

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

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

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

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

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

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

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

40 Facial pain treatment algorithm

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

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

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

44 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

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

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

47 CNS 2011

48 Facial pain treatment algorithm

49 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

50 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

51 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

52 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.

53 Thank you!

54

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