1. Peripheral Nerve Stimulation in Trigeminal Neuralgia Department of Neurosurgery, Massachusetts General Hospital Grand Rounds Nikhil Agrawal MD Candidate

2. HPI: 56y M with history of HTN, depression/anxiety, right sided refractory facial pain (V1 distribution) for 8 years s/p microvascular decompression, RF rhizotomy, supraorbital alcohol injection, and left motor cortex stimulator PMH: Anxiety, Depression, HTN, Trigeminal Neuropathic Pain Exam: Intact Pre-op Diagnosis: Severe medically intractable right-sided facial pain. Operation: Placement of right-sided cranial stimulators. Post Operative Course: Patient feels significant relief from pain Brief Case Presentation

3. Burchiel Classification of Facial Pain Spontaneous Onset TN Type 1 (Classic TN)TN Type 1 (Classic TN) –> 50% episodic pain TN Type 2 (Atypical TN)TN Type 2 (Atypical TN) –> 50% constant pain Trigeminal Injury Symptomatic TN (Multiple sclerosis)Symptomatic TN (Multiple sclerosis) Trigeminal neuropathic pain (post-traumatic)Trigeminal neuropathic pain (post-traumatic) Trigeminal deafferentation pain (RF lesion, GKR, etc.)Trigeminal deafferentation pain (RF lesion, GKR, etc.) Post-herpetic facial painPost-herpetic facial pain Secondary TNSecondary TN –Tumors, aneurysm, AVM, etc. Atypical facial pain (somatiform pain disorder)Atypical facial pain (somatiform pain disorder)

4. Trigeminal Neuralgia Etiology Exact cause unknownExact cause unknown Maxillary and mandibular sensory branches affectedMaxillary and mandibular sensory branches affected Four TheoriesFour Theories -Constant pressure causing irritation from the -Constant pressure causing irritation from the superior cerebellar artery superior cerebellar artery - infections from herpes virus, teeth, or brainstem infarct -Multiple Sclerosis -Multiple Sclerosis -Tumor causing pressure and irritation

5. Surgical Treatment of TN Microvascular decompression (MVD)Microvascular decompression (MVD) Percutaneous ablative proceduresPercutaneous ablative procedures –Radiofrequency gangliolysis –Glycerol rhizolysis –Balloon compression Stereotactic radiosurgeryStereotactic radiosurgery –Gamma knife –Linac-based Peripheral ablative procedures (V1 and V2 pain)Peripheral ablative procedures (V1 and V2 pain) –Peripheral branch neurectomy –Alcohol neurolysis Open destructive proceduresOpen destructive procedures –Partial sensory rhizotomy –Subtemporal ganglionectomy (Frazier-Spiller procedure) Peripheral Nerve stimulationPeripheral Nerve stimulation

6. © Slavin et al., 2007

7. MVD vs. Percutaneous Procedures INITIAL PAIN RELIEF MVD98%MVD98% RF rhizotomy98%RF rhizotomy98% Balloon 93%Balloon 93% Glycerol 91%Glycerol 91% RECURRENCE RATES Glycerol54% (4 years)Glycerol54% (4 years) RF rhizotomy23% (9 years)RF rhizotomy23% (9 years) Radiosurgery25% (3 years)Radiosurgery25% (3 years) Balloon21% (2 years)Balloon21% (2 years) MVD15% (5 years)MVD15% (5 years) Taha J, Tew J: Neurosurgery 38:865—871, 1996

8. MICROVASCULAR DECOMPRESSION SURGERY IN THE UNITED STATES, 1996 TO 2000: MORTALITY RATES,MORBIDITY RATES, AND THE EFFECTS OF HOSPITAL AND SURGEON VOLUMES The authors demonstrate that the mortality associated with MVD is significantly lower when performed by high volume surgeons and that morbidity is lower for high-volume surgeons and high-volume hospitals.The authors demonstrate that the mortality associated with MVD is significantly lower when performed by high volume surgeons and that morbidity is lower for high-volume surgeons and high-volume hospitals. Overall mortality was low (0.3%)Overall mortality was low (0.3%) Kalkanis SN, Eskandar EN, Carter BS, Barker FG 2nd.Neurosurgery 52:1251- 1262, 2003

9. Peripheral Stimulation: Facial pain Most Common technique: Most Common technique: ◦ Occipital Nerve Stimulation  Occipital stimulation  “BOTH” stimulation Other techniques: Other techniques: ◦ Trigeminal branch stimulation  Supraorbital  Supratrochlear  Auriculotemporal

10. Trigeminal Branch Stimulation Stimulation of supraorbital, infraorbital nervesStimulation of supraorbital, infraorbital nerves IndicationsIndications –Trigeminal neuropathic pain –Trigeminal deafferentation pain –Post-herpetic neuralgia –Chronic daily headache

11. Summary of Cases CaseAge/SexPre-op DiagnosisDuration of Sympto ms Trigeminal Branch Pain ReliefFollow Up Duration 171/MTNP :Secondary to enucleation 11 yearsV1 and V2100%27 months 252/MTNP :Secondary to zygomatico- maxillary fracture 18 monthsV1 and V2100%23 months 344/MPostherpetic neuralgia18 monthsV160%6 months Stidd DA, et al. Pain Physician. 2012 Jan-Feb;15(1):27-33

12. Pain Relief Post Operative Medication UsePatient Satisfaction Rating Peripheral Trigeminal Branch Stimulation for Neuropathic Pain Johnson M, Burchiel K, Neurosurgery, 2004

13. Peripheral Trigeminal Branch Stimulation for Neuropathic Pain Effective for trigeminal neuropathic painEffective for trigeminal neuropathic pain Less effective for PHNLess effective for PHN Simple, low morbiditySimple, low morbidity Pain relief seems relatively durablePain relief seems relatively durable Major problem is erosion of connectorMajor problem is erosion of connector

15. Conclusion “Though there are no randomized trials, peripheral neuromodulation has been shown to be an effective means of treating TNP refractory to medical management in a growing number of case series. PNS is a safe procedure that can be performed even on patients that are not optimal surgical candidates and should be considered for patients suffering from TNP that have failed medical management.”-Dr Stidd“Though there are no randomized trials, peripheral neuromodulation has been shown to be an effective means of treating TNP refractory to medical management in a growing number of case series. PNS is a safe procedure that can be performed even on patients that are not optimal surgical candidates and should be considered for patients suffering from TNP that have failed medical management.”-Dr Stidd

16. References 1.Loeser, J.D. Tic douloureux and atypical facial pain, In: Wall PD, Melzack R, eds. Textbook of Pain. 3rd edition. Edinburgh: Churchill/Livingstone, 1994: p 699- 710. 2. David A. Stidd, MD1, Adam Wuollet, MD1, Kirk Bowden, DO1, Theodore Price PhD1, Amol Patwardhan, MD, PhD1 Pain Physician 2012; 15:27-33 3.Madland G. and C. Feinmann, Chronic facial pain: a multidisciplinary problem. J Neurol Neurosurg Psychiatry, 2001;71:p. 716-719. 4. Osenbach, R., Neurostimulation for the Treatment of Intractable Facial Pain. Pain Medicine. 7(s1). 5. Johnson, M. and K. Burchiel, Peripheral Stimulation for Treatment of Trigeminal Postherpetic Neuralgia and Trigeminal Posttraumatic Neuropathic Pain: A Pilot Study, 2004: 55(1): p. 135-142. 5. Johnson, M. and K. Burchiel, Peripheral Stimulation for Treatment of Trigeminal Postherpetic Neuralgia and Trigeminal Posttraumatic Neuropathic Pain: A Pilot Study, 2004: 55(1): p. 135-142. 6. Broggi G, Ferroli P, Franzini A, Servello D, Dones I: Microvascular decompression for trigeminal neuralgia: Comments on a series of 250 cases, including 10 patients with multiple sclerosis. J Neurol Neurosurg Psychiatry68:59–64, 2000. 7.. Burchiel KJ, Clarke H, Haglund M, Loeser JD: Long-term efficacy of microvascular decompression in trigeminal neuralgia. J Neurosurg 69:35– 38,1988.

17. Special Thanks To: Dr. Emad N. EskandarDr. Emad N. Eskandar Dr. Daniel Cahill M.D. Ph.D.Dr. Daniel Cahill M.D. Ph.D. Dr. William Curry, M.D.Dr. William Curry, M.D. Dr. Jean-Valéry Coumans, M.D.Dr. Jean-Valéry Coumans, M.D. Dr Pankaj K. Agarwalla, M.D.Dr Pankaj K. Agarwalla, M.D. Dr. Matthew Mian, M.DDr. Matthew Mian, M.D