Trigeminal Neuralgia

A 52-year-old hypertensive female presented with a lancinating pain in right side of face for 15 years, frequently affecting her daily life activity. Chewing food or brushing teeth would precipitate into severe facial pain, which radiated towards forehead and ears. Her sleep was also severely affected due to facial pain. She was initially treated with carbamazepine 100 mg/day that was later increased up to 400 mg/day. Her pain was controlled inadequately despite the additional administration of gabapentin at 450 mg/day. As a result of difficulty in taking food, she had lost a lot of weight in the past 1 year. The pain was distributed in all the three zones of trigeminal nerve. Routine blood tests and MRI of the trigeminal nerve were done. The trigger of pain was found to be confined to zone 2. We planned to perform transcutaneous transovale radiofrequency ablation (RFA) of the trigeminal root entry zone. Patient was counselled for possible complications, and her consent was taken. The whole procedure was done under sedation with propofol, and vitals were constantly monitored. Oxygen was given through a nasal cannula. The position of the patient was supine with head-end raised up to 30°. The procedure was performed in a cathlab under C-Arm. C-Arm was focused on sub-mental view, and ipsilateral foramen ovale was identified. The RFA cannula was then introduced approximately 2 cm lateral to ipsilateral angle of mouth and directed towards the foramen of ovale. Upon penetration of foramen ovale, the patient experienced extreme pain. The RF lesion generator was checked, and ground electrode was attached. RFA electrode was introduced through the cannula, and correct impedance was monitored to ensure its correct placement. Stimulation was given, and the patient experienced pain similar to her facial pain due to trigeminal neuralgia. Three consecutive lesions were made at 60, 70, and 80 centigrade for 60 s each. During lesioning, the corneal reflex was examined by the assistant. Ice pack was placed over the affected side of the face, and prophylactically, a single dose of 1 g of ceftriaxone was administered. In the first follow-up, 15 days after the intervention, the patient reported a reduction in pain and mild heaviness of the face, with no fever, an absence of Kernig’s sign, and an intact corneal reflex. She did not report or notice any complications, for example, an increase in the threshold of pain, corneal anaesthesia, or anaesthesia dolorosa. The dose of the medication was tapered and gradually stabilised at carbamazepine 200 mg/day over a month. On her second follow-up (after 2 months), she was relatively free from facial pain.