Continuous Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery Embolization for the Management of Atypical Trigeminal Neuralgia

doi:10.4236/ojanes.2013.39079

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Open Journal of Anesthesiology, 2013, 3, 375-378

Published Online November 2013 (http://www.scirp.org/journal/ojanes)

http://dx.doi.org/10.4236/ojanes.2013.39079

Open Access OJAnes

375

Continuous Inferior Alveolar Nerve Block Using an

Indwelling Catheter and Inferior Maxillary Artery

Embolization for the Management of Atypical

Trigeminal Neuralgia

Samer Abdel-Aziz, Ahmed Ghaleb

Department of Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.

Email: [email protected]

Received July 5th, 2103; revised August 6th, 2013; accepted September 1st, 2013

bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

ABSTRACT

A 40-years-old female patient with severe right facial pain with a throbbing component along the mandibular division

of the trigeminal nerve resistant to medical management. Continuous inferior alveolar nerve block with local anesthetics

using an indwelling catheter provided a complete p ain resolution for the patient for 2 weeks, after which the catheter got

infected and was removed. A trial of balloon occlusion of the right internal maxillary artery provided complete resolu-

tion of the throbbing component of the patient’s pain. This was followed by permanent embolization with multiple

coils.

Keywords: Trigeminal Neuralgia; Inferior Alveolar Nerve Block; Inferior Maxilary Artery Embolization

1. Introduction

Trigeminal neuralgia (TN) can cause severe pain resis-

tant to medical management. Several interventional pain

and surgical procedures are available and individualized

based on the patient’s condition. We report a case with

severe trigeminal neuralgia pain resistant to medical ma-

nagement in which we used two uncommon treatment

modalities that provided excellent pain relief for our pa-

tient; continuous inferior alveolar nerve block with local

anesthetics using an indwelling catheter and internal

maxillary artery embolization.

2. Case Report

A 40-year-old female referred to our pain clinic com-

plaining of right facial pain along the mandibular divi-

sion of the trigeminal nerve for 4 years. She describes her

pain as constant throbbing burning pain with occasional

electric-like sensation. The pain is 8/10 in severity. It

occasionally goes up to 10/10 and gets severe enough for

her to think about killing herself. It affects her daily ac-

tivities, occasionally keeping her in bed all day. It gets

worse in the ev ening and gets better wh en she app lies ice

on her face and after she takes her atenolol pill which she

takes twice a day for h ypertension. Th e pain was initially

thought to be of dental cause which resulted in her hav-

ing multiple dental procedures without improvement.

Over the past 4 years, she tried multiple medications in-

cluding Ibuprofen, gabapentin, carbamazepine, cyclo-

benzaprine with minimal relief. She had and MRI and

MRA of her face and neck to exclude any mass effect or

vascular compression of the nerve, all were reported nor-

mal. We initially started her on topiramate and amitrip-

tyline with oxycodone-acetaminophen pills for break-

through, this improved her pain to 5/10. However it was

still severe, affecting her ability to perform her daily ac-

tivities. As medical management failed to provide suffi-

cient pain relief, decision was made to proceed with a

nerve block. Right inferior alveolar and lingual nerve

blocks were performed by injecting 5 ml of lidocaine 1%,

1 ml of triamcinolone (40 mg/ml) and 5 ml of bupiva-

caine 0.5%. The patient reported complete resolution of

pain for 2 days only, so decision was made to proceed

with placement of an indwelling catheter that the patient

Continuos Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery

Embolization for the Management of Atypical Trigeminal Neuralgia

376

can dose herself with a local anesthetic like bupivacaine

0.5%. The catheter was placed close to the right inferior

alveolar nerve using an epidural needle set and was se-

cured in place with Nylon sutures. The catheter place-

ment was successful and provided excellent pain relief

for the patient however, one month later the catheter dis-

lodged from its placed and had to be replaced. Two

weeks after the catheter replacement it got infected and

had to be removed. After the catheter removal the patient

experienced severe pain again, at this point we decided to

refer her for interventional radiology for an angiogram

and temporary occlusion of her right internal maxillary

artery as this might help with her throbbing pain. A bal-

lon catheter was advanced into the right internal maxil-

lary artery and was kept inflated for 10 minutes, the pa-

tient reported complete resolution of her throbbing pain.

Since the patient passed the ballon test, embolization of

the artery with multiple detachable and push coils was

performed. After the artery embolization the patient re-

ported complete resolution of her throbbing pain. She

still reports having some burning pain which is well con-

trolled with the topiramate and amitriptyline. On her last

clinic visit she reported a pain score of 0/10.

3. Discussion

Trigeminal neuralgia (TN) is a sudden, unilateral, severe,

brief, recurrent episodes of pain in the distribution of one

or more branches of the trigeminal nerve [1]. It is the

most common form of cranial neuralgia [2,3], with an

incidence of 4.3 per 100,000 persons per year, with a

slightly higher incidence for women (5.9 per 100,000)

compared with men (3.4 per 100,000) [4]. The gender

ratio of prevalence in women to men is approximately

2:1 [5].

In the large majority of TN patients, the clinical ex-

amination, imaging studies and laboratory tests are un-

remarkable (classic TN). However, in a smaller group,

the signs and symptoms of TN are secondary to another

disease process affecting the trigeminal system (symp-

tomatic TN) [6,7]. Both dental and medical professionals

often misdiagnose the disorder, potentially resulting in

unnecessary dental extractions or inappropriate prescrip-

tion of drugs.

The cause of trigeminal neuralgia has not been defini-

tively established. However, the most prevalent cause is

mechanical compression, generally by an artery (superior

cerebellar artery or one of its branches) or a tumor, of the

trigeminal root as it exits the brain stem [8]. Also, fol-

lowing trauma, regenerating nerve fibers become rela-

tively depolarized and physiologically more excitable.

Spontaneous action potentials may originate from multi-

ple sites and a single action potential may evoke sus-

tained discharges [6].

Optimal treatment of TN remains challenging, as each

clinical situation can vary significantly. Patients who

suffer from TN have a number of treatment modalities to

consider, and treatments should be tailored to the indi-

vidual situation. Conservative management with drug

therapy is always the first-line treatment. When drugs are

not efficacious or produce intolerable adverse effects,

interventional pain treatment or surgery is considered.

Carbamazepine has been used for many decades in the

treatment of TN, and it is the drug of choice [9,10]. Other

medications with reported efficacy include oxcarbaze-

pine, baclofen, and lamotrigine [11-13]. Topiramate, ga-

bapentin, pregabalin, and levetiracetam have also shown

success in treating TN [11].

Peripheral techniques like cryotherapy, neurectomies,

peripheral acupuncture, peripheral radiofrequency ther-

mocoagulations (RFTs) and a variety of injections, such

as alcohol, phenol and streptomycin have been described

as treatment modalities for TN. Percutaneous procedures

at the level of the Gasserian ganglion which involve the

insertion of a cannula through th e foramen ovale into the

trigeminal ganglion have also been used. The ganglion

can then be lesioned using heat (RFTs), injection of glyc-

erol, or mechanical compression by a balloon.

Microvascular decompression (MVD) and gamma knife

surgery (GKS) are surgical options available to patients

with TN. MVD has been widely used based on the theory

that vascular compression of the trigeminal nerve is re-

sponsible for TN [14,15]. A retrospective review of pa-

tients with TN who had undergone MVD showed that

71% reported complete pain relief 10 years after surgery

[16]. GKS is a noninvasive stereotactic radiosurgical

technique that utilizes a focused beam of radiation to tar-

get the root of the trigeminal nerve. Pain relief obtained

from GKS is delayed and usually occurs about 2 weeks

later. Initial good pain relief can be achieved in 80% of

patients [17,18]. However, there is a risk of recurrence

after 1 year [17].

Continuos mandibular nerve block with local anes-

thetics using an ind welling catheter to control TN pain is

uncommon but has been reported [19]. It allows con-

tinuous or intermitten t injection of lo cal anesthetics when

necessary. It is more convenient than repeated nerve

blocks as it eliminates the use of a needle and can be

dosed by the patient. It is also reversible and safe. It pro-

vided complete resolution of pain and satisfaction for our

patient. However as described in our case it is highly

vulnerable to infection and dislodgment and is difficult to

maintain for a long period of time. For this reason we

recommend its use as a temporary measure to control

pain until a more definitive permanent procedure is un-

dertaken.

Embolization of the internal maxillary artery is used to

Open Access OJAnes

Continuos Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery

Embolization for the Management of Atypical Trigeminal Neuralgia 377

control epistaxis and life threatening bleeding following

facial trauma [20,21]. However, its use for trigeminal

neuralgia is uncommon. One study reported the use of

maxillary embolization in 76 patients with trigeminal

neuralgia with achievement of absolute improvement

[22]. Since in our case the patient’s pain had a throbbing

component we thought she might benefit from internal

maxillary artery embolization. We first used a balloon

trial to test if artery occlusion will provide pain resolu-

tion, when the patient passed the trial we embolized the

artery, the patient reported complete resolution of the

throbbing pa in. The pro cedure is safe as th e area su pp lied

by the artery has collateral blood supply. We recommend

this procedure for patients with throbbing pain not con-

trolled by medical management with emphasis on a bal-

loon trail before permanent occlusion.

4. Conclusion

Treatment of TN should be tailored to the individual

situation. Several interventional pain and surgical proce-

dures are available to treat pain resistant to medical

management. Continuous mandibular or alveolar nerve

blocks with local anesthetics using an indwelling cath eter

can provide complete pain resolution and patient satis-

faction but with a risk of infection on long term use. In-

ternal maxillary embolization is a permanent treatment

modality to be considered in patients with a throbbing

pain.

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Continuos Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery

Embolization for the Management of Atypical Trigeminal Neuralgia

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