Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128

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Journal of Cranio-Maxillo-Facial Surgery

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Treatment of trigeminal neuralgia with bupivacaine HCL using a temporary

epidural catheter and pain pump: Preliminary study
Guhan Dergin*, Gokhan Gocmen, B. Cem Sener
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Marmara, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Trigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterised by severe
Paper received 23 August 2010 paroxysmal pain in the face. The treatment for trigeminal neuropathic pain disorder continues to be
Accepted 31 March 2011 a major therapeutic challenge, as relief provided by medical therapy generally decreases over time. When
medical therapy fails either due to poor or diminishing responses to drugs or to unacceptable side effects,
Keywords: peripheral intervention or surgical management of TN should be considered.
Trigeminal neuralgia
Study design: Fourteen patients (eight men and six women) who were not responsive to further medical
Pain pump
treatment and who were diagnosed with TN previously at other health centres were selected for
Epidural catheter
treatment. For this purpose, the affected nerve was infused with 60 mL (1 mL h
1) of 0.5% bupivacaine
HCl with a pain pump via an temporary epidural catheter. Patient’s visual analogue scores (VAS) were
recorded on the fifth preoperative day and on postoperative day 5, 2 weeks, 1, 3, 6 and 9 months.
Results: There was a significant difference between mean preoperative and postoperative VAS value at
day 5, 2 weeks, 1, 3, 6 and at the end of 9 months ((68.85  1.43) (13.57  6.68) (11.43  6.70)
(14.29  6.52) (20.71  6.41) (20.71  6.41) and (21.43  6.10) respectively; *P < 0.05). Two of 14 patients
did not show any pain relief.
Conclusions: Continuous administration of 60 mL of 0.5% bupivacaine HCl at 1 mL h
1 with a pain pump
and epidural catheter can be used as a transition treatment for patients with side effects from high-dose
antiepileptic drugs and for patients awaiting neurosurgery or individuals who refuse cranial surgery. It
should not be considered as an alternative treatment of neurosurgical approaches, such as MVD, which
has a definite long-lasting results.
Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction significantly reduce the pain in approximately 75% of patients and

The International Association for the Study of Pain defines
trigeminal neuralgia (TN) as sudden, usually unilateral, severe,
brief, stabbing or lancinating, recurrent episodes of pain in one or
more branches of the fifth cranial (trigeminal) nerve (Merskey and
Bogduk, 1994). Current treatments are mainly divided into medical
treatments and surgery, and medication is often the first-line
treatment. Traditionally, patients are offered surgical options only
when medications fail or severe side effects develop (Nurmikko
and Eldridge, 2001; Spatz et al., 2007). Medical management with
anticonvulsant (antiepileptic) drugs has debilitating side effects
and the drugs eventually lose effectiveness (Taylor, 1981). The
medical treatments (anticonvulsant medications) eliminate or
* Corresponding author. Department of Oral and Maxillofacial Surgery Marmara
Universitesi Nisantası Kampusu, Büyük Ciftlik Sk. No:6 34365 Nisantası/Sisli/
Istanbul, Turkey. Tel.: þ90 5323054894.
E-mail address: guhandergin@yahoo.com (G. Dergin).
are considered the treatment of choice for incident cases of TN
(Fields, 1996).
Unfortunately, the relief provided by medical therapy generally
decreases over time. When medical therapy becomes ineffective, an
alcohol block may be used for long-lasting pain relief, even though
almost half of all patients complain of sequelae, such as hypaes-
thesia, paraesthesia, dysaesthesia and ocular complications (Oturai
et al., 1996; Radwan et al., 2001). There have been few reports
regarding the decision process for the treatment of TN, and
management with antiepileptic drugs or surgical procedures
carries risks of side effects, recurrence and complications (Fields,
1996; Oturai et al., 1996; Radwan et al., 2001). When medications
fail to relieve TN pain attacks, it is important to reduce the risk of
severe side effects of surgery and surgical sequelae seen in cranial
surgery considering the mean age of TN patients. In this study we
used a pain pump with a long-lasting local anaesthetic for treating
TN as a minor intervention to decrease the risk of intracranial
neurosurgery complications, eliminate the disadvantages of other

1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
doi:10.1016/j.jcms.2011.03.022
 G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128 125

peripheral interventions and presenting a temporary solution for
patients awaiting neurosurgery or individuals who refuse cranial
surgery.
2. Materials and methods
2.1. Patient criteria
The study involved fourteen patients (eight men and six women)
with essential TN. Only patients suffering from paroxysmal pain
were included in order to standardize and focus the study. With this
aim an observational and prospective study was planned and the
patients were followed up at weekly and monthly intervals. The
diagnosis of idiopathic TN was based on paroxysmal attacks of pain
in one or several branches of the trigeminal nerve with pain-free
intervals trigger areas, pain-triggering stimuli and absence of
signs of a trigeminal nerve organic lesion. All patients complained of
strong TN pain attacks, although they were using a maximal dose of
carbamazepine (about 1,400 mg day
1). Patients were offered pain
pump intervention only when medications failed.
Patients diagnosed with TN at other health centres and who
fulfilled the following inclusive criteria were selected. Unilateral
neuralgia in the distribution of the second and/or third branches of
the trigeminal nerve, no prior surgical management of TN, unilateral
pain in the trigeminal nerve region at any one time, abrupt onset
and paroxysmal pain with a pain-free period between attacks, pain
character described as shooting, electric shock-like, lightning and
sharp usually with intensity defined as severe, and each episode of
pain lasting no more than 2 min (mostly a few seconds). Magnetic
resonance imaging (MRI) was performed to exclude organic factors,
such as tumours or other brain lesions (for example multiple scle-
rosis). Pain provoking factors were always present, such as eating,
talking, washing of the face and brushing the teeth. Atypical facial
pain, which has symptoms similar to TN, was excluded. The most
characteristic feature of atypical facial pain is continuous pain,
although it showed paroxysmal pain similar to TN.
All patients were confirmed to be suffering exclusively from
primary TN. Patients were offered our non-invasive option versus
surgery. The patients who preferred non-invasive technique were
included to our study.
pump; Daiken Medical, Osaka, Japan), and 60 mL of 0.5% bupiva-
caine HCl (Marcaine; AstraZeneca, Stockholm, Sweden) was
administered at a rate of 1 mL h
1. The pain pump was hung on the
patient’s neck (Fig. 3). Spiramycin (3 MIU twice per day;
RovamycineÒ; Eczacibasi, Istanbul, Turkey) was prescribed post-
operatively to prevent infection via the catheter. The next day, the
pain pump was checked to ensure that it was working. After 60 h
the catheter was removed
Five days after the procedure, the patients were asked to record
their pain scores every 3 h. These recordings were repeated at 2
weeks, 1, 3, 6 and 9 months and mean values were evaluated.
2.4. Measurements and statistical methods
Patients were stratified by gender and affected branch. Clinical
characteristics of the samples, and preoperative and postoperative
VAS scores were evaluated by the two-sample paired t test. The
data were analysed using SPSS 11.0 (SPSS Inc., Chicago, IL, USA).
3. Results
The mean age of the patients was 55.1 11.69 years (Table 1). In
our study group, eight of the patients suffered from mandibular TN
pain, and six suffered from maxillary trigeminal neuralgia (Table 1)
and had been taking carbamazepine for an average of (10  3
years). There were no significant differences in gender, age or
affected nerve branch. Nine patients complained of a lack of
concentration, dizziness or drowsiness before the operation, but
there were no such complaints after the intervention. Five patients
experienced slight oedema postoperatively around the site of the
block. There was a significant difference between mean preopera-
tive and postoperative VAS value at day 5, 2 weeks, 1, 3, 6 and at the
end of 9 months ((68.85  1.43) (13.57  6.68) (11.43  6.70)
(14.29  6.52) (20.71  6.41) (20.71  6.41) and (21.43  6.10)
respectively; *P < 0.05) (Table 2, Graph. 1). Two (n ¼ 2) (14.28%) of
the 14 patients did not show any pain relief. None of the patients
complained about sensory disturbances such as paraesthesia or any
sensorial disturbance after this procedure.

2.2. Evaluation

The preoperative degree of the pain attacks was recorded 5 days

before the intervention using the visual analogue scale (VAS; 100-
mm line with 0 signifying no pain and 100 mm signifying worst
pain imaginable). Success was defined as complete pain relief or
mild pain without medication. Patients continued taking their
antiepileptic drugs during preoperative pain recording. Before the
pain pump and catheter intervention, test blocks were performed
using 2% lidocaine (JetocaineÒ amp, Adeka, Turkey) with an injec-
tion volume of 0.2 mL to localise the affected nerve branch and
trigger points.

2.3. Pain pump intervention

First, 1.8 cc of 2% lidocaine was injected into the related nerve

target to confirm the correct location and anaesthetic effect, and
then the introducing needle of the epidural catheter (PortexÒ
epidural catheters; Portex, Kent, UK) was inserted until it reached
the related nerve foramen (infraorbital, mental or mandibular)
(Fig. 1). The catheter was inserted into the target nerve through the
introducing needle and stabilised with 3.0 sutures. The introducing
needle was removed and the catheter was connected to a dispos- Fig. 1. The catheter was inserted and located close target nerve foramen through the
able infusion pump (Fig. 2) (CoopdechÒ Syrinjector 60 mL-infusion introducing needle and stabilised with 3.0 sutures.
126 G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128

4. Discussion as visual disturbance (1.0%), hearing loss (6.3%), severe dysaesthesia

When medical treatment for TN fails either due to poor or
diminishing response to drugs or to unacceptable side effects, it is
necessary to consider peripheral intervention or surgical manage-
ment (Spatz et al., 2007).
Surgery for TN is either destructive (ablative), in which the
trigeminal nerve sensory function is intentionally destroyed, or
nondestructive, in which the trigeminal nerve is decompressed,
with normal function usually preserved. Surgeries at the level of
the Gasserian ganglion are all destructive and include radio-
frequency thermocoagulation, balloon compression (BC) and
percutaneous glycerol rhizolysis. Microvascular decompression is
a major neurosurgical procedure requiring full anaesthesia and a
5-day hospital stay (Ashkan and Marsh, 2004). Some of these
invasive surgical treatments are not recommended for the elderly
or patients with associated comorbidities (Laghmari et al., 2007).
All surgical procedures carry risks of complications either in the
immediate perioperative period or in the long-term after BC, such
(5.2%), subjective taste loss (3.1%), tearing and visual disturbance
(3.1%), subjective smell and hearing loss (1.0%) and ear itching
(1.0%) (Kanpolat et al., 2001).
Reported rates of anaesthesia dolorosa after thermocoagulation
range from 0.7% to 9.6 % (Burchiel et al., 1981). Many of the reports
on ablative surgery omitted data on postoperative numbness,
sensorial abnormalities and severe dysaesthesia (Ischia et al., 1990).
Microvascular decompression (MVD) is a safe and effective treat-
ment for trigeminal neuralgia (TN), providing a high rate of long-
term success (Barker et al., 1996) with recently reported mortality
and morbidity rates of 0.3% and 3.8%, respectively, in the USA
(Barker et al., 1996; Kalkanis et al., 2003; Keyoumars and Henry,
2004). MVD has become a generally accepted procedure among
most neurosurgeons. Nevertheless, reported success rates and
complication frequencies related to MVD vary widely (Barker et al.,
1996; Fields, 1996). Peripheral surgical techniques are a less inva-
sive technique and eliminate risks of surgery at the level of the
Gasserian ganglion. Patients unable to tolerate medical treatment,
considering mean age and comorbidities, may not be suitable for
neurosurgical intervention. Thus, peripheral surgical treatment
may become their sole form of management, and repeatability
becomes another important issue in such patients (Radwan et al.,
2001).
A number of peripheral surgical techniques have been suggested
for managing TN to eliminate the risks of cranial surgical interven-
tions, all of which broadly interfere with pathways from the trigger
zone to prevent stimulation of aberrant conduction pathways.
Peripheral surgical options for TN are neurectomy, alcohol injection,
glycerol injection, cryotherapy and jawbone cavity removal.
Peripheral neurectomy is one of the simplest surgical procedure
among them. After neurectomy recurrence is common between 12

Table 1
Distribution of patients age, gender and effected branch of trigeminal nerve.
Fig. 2. The catheter was connected to a disposable infusion pump and 60 mL of 0.5%
bupivacaine HCl was administered at a rate of 1 mL h
1. Patient Age Gender Affected nerve Time of
name disease
H.A. 52 Female Maxillary 11
M.A. 49 Male Mandibular 8
A.B. 55 Male Mandibular 12
Ö.Ş. 37 Male Mandibular 7
Z.E. 50 Male Maxillary 9
K.T. 41 Male Mandibular 11
K.D 43 Male Maxillary 7
K.S. 62 Female Mandibular 11
A.Ö. 71 Male Maxillary 13
B.B. 46 Female Mandibular 8
M.Y. 78 Female Mandibular 12
S.D. 57 Male Maxillary 13
C.K. 61 Female Maxillary 10
M.U. 70 Female Mandibular 8

Table 2
Comparison of preoperative VAS scores with postoperative 5 days, 2 week, 1, 3, 6, 9
months VAS score means.

Paired samples statistics Mean N Std err mean P value

Pair 1 Preop. mean 68.85 14 1.4315 0.000*
After 5 days 13.57 14 6.68
Pair 2 Preop. mean 68.85 14 1.4315 0.000*
After 2 weeks 11.43 14 6.701
Pair 3 Preop. mean 68.85 14 1.4315 0.000*
After 1 month 14.29 14 6.523
Pair 4 Preop. mean 68.85 14 1.4315 0.000*
After 3 months 20.71 14 6.416
Pair 5 Preop. mean 68.85 14 1.4315 0.000*
After 6 months 20.71 14 6.416
Pair 6 Preop. mean 68.85 14 1.4315 0.000*
After 9 months 21.43 14 6.1

Fig. 3. The pain pump was hung on the patient’s neck. * means highly significant.
 G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128
Graph 1. Change of patient VAS means in 9 month period after continous bupivacaine
HCL administration with pain pump.
and 15 months and after a second procedure at between 9 and
12 months. Sensory function disturbance and recurrence were the
main problem in neurectomy (Cerovic et al., 2009).
Peripheral nerve block can alleviate the pain immediately after
injection. Generally, peripheral surgical treatments are easy to
perform but they have limited duration of action, cause tissue
necrosis and some patients have experienced alcohol neuralgia;
patients must be advised that they may require repeated proce-
dures. Furthermore, various complications have been reported
that disrupt daily life activities, including muscle palsy, sensory
disturbances and neuropathic pain (Richardson and Straka, 1973;
Konishi et al., 1997).
It is widely thought that peripheral alcohol injection is
complicated by reduced effectiveness with repeated administration
due to the dense fibrotic tissue around the nerve region, which
reduces penetration of the fluids (Fardy and Patton, 1994). Peet and
Schneider reported that, in 21 cases with repeated injections, there
tended to be a shorter period of relief, but in nine cases there was
a progressively longer period of relief after each injection (Peet and
Schneider, 1952). Neurolytic agents, such as alcohol and glycerol,
are not indicated in patients scheduled to undergo microvascular
decompression (Umino et al., 2002).To alleviate the adverse effects,
alcohol or phenol administration and local anaesthetics have been
used in several cases. Peripheral nerve block using high concen-
trations of local anaesthetics prolongs the analgesic effect in
patients with TN, without adverse effects (Goto et al., 1999; Radwan
et al., 2001). TN block with local anaesthetics is reversible and
nontraumatic, and is appropriate for further surgical interventions,
such as microvascular decompression (Umino et al., 2002). Clinical
and experimental data indicate that changes in the expression of
voltage-gated sodium channels play a key role in the pathogenesis
of neuropathic pain and that drugs that block these channels are
potentially therapeutic (Amir et al., 2006). Clinical and experi-
mental data indicate that changes in the expression of voltage-
gated sodium channels play a key role in the pathogenesis of
neuropathic pain, and drugs that block these channels are poten-
tially therapeutic in TN (Amir et al., 2006). In addition, recent data
show that local anaesthetics may have pain-relieving actions at
targets other than sodium channels; these targets include neuronal
G protein-coupled receptors and binding sites on immune cells.
However, the effects of some of these drugs manifest only with
long-term exposure, as they regulate the sodium channel activity
(Amir et al., 2006; Myers et al., 1986).
Patients with painful peripheral neuropathy sometimes receive
weeks of relief following a single local anaesthetic block of the painful
region (Arner et al., 1990). One postulated mechanism for the long-
term effect of local anaesthetics on the trigeminal nerve is Waller-
ian degeneration. Histologically, the extrafascicular administration of
127
local anaesthetics at clinical concentrations can alter perineural
permeability, causing endoneurial oedema, increased endoneurial
fluid pressure, and Wallerian degeneration with Schwann cell injury
and axonal dystrophy (Myers et al., 1986) which may reduce allody-
nia, hyperalgesia, and trigger point hypersensitivity.
Many patients choose a non-invasive technique for pain relief,
given the higher risk for complications with a surgical intervention
compared with our method. In addition, many patients reason that
a surgical option would be available if the initial non-invasive
intervention were to fail.
In the studies reported to date, the local administration of high
concentrations of anaesthetics was accomplished by intermittent
local injections (Goto et al., 1999; Amir et al., 2006). Seventeen
patients with long-lasting idiopathic trigeminal neuralgia were
treated by Stajcic et al. with weekly peripheral streptomycin/lidocaine
(S/L) or lidocaine alone injections, in a double blind controlled study.
Eight patients responded initially to the treatment in the S/L group
and three patients in the lidocaine group. Pain recurred in four
patients from the S/L group within two weeks and six months
following the last injection. One patient from the lidocaine group
remained pain-free for eight months. At the final assessment, three
patients from the S/L group and two patients from the lidocaine group
remained pain-free up to 30 months (Stajcic et al. 1990). They also
reported that sensory functions of the injected nerves were not
affected after repeated injections as in our study. Continuous nerve
block with bupivacaine HCl using an indwelling catheter has not been
studied for orofacial pain control, although this catheter technique
has been used frequently and successfully in the epidural space to
safely manage limb, chest, and abdominal pain (Symreng et al.,1989).
There has been only one previously published case report describing
a long-term continuous trigeminal nerve block with local anaes-
thetics using a pain pump and a temporary indwelling catheter
(Umino et al., 2002). In that case, patient-controlled analgesia via
a pump injection was used with no side effects during local anaes-
thetic infusion, as in our study. In a few case reports on the clinical
application of high-concentration local anaesthetics for the treatment
of TN, pain relief lasted for 2.2 weeks to 14 months (Radwan et al.,
2001; Goto et al., 1999; Arner et al., 1990).
Maximum doses of bupivacaine are 150e225 mg every 3 h or
400 mg every 24 h (Laghmari et al., 2007). Symreng et al. reported
that serum levels of bupivacaine reached 0.44e1.5 mg mL
1 after
a bolus dose of 20 mL of 0.25% bupivacaine. This is far below the
toxic level of 2e4 mg mL
1 (Symreng et al., 1989). In our study, local
administration of bupivacaine HCl (24 mL per 24 h ¼ 120 mg
bupivacaine HCl) was significantly less than the daily maximal dose
suggested for postoperative pain control after surgery, which was
why we did not see any dose-related side effects.
Umino et al. concluded that the blockade of mandibular nerve
pain with local anaesthetics administered via a pain pump was
beneficial for pain control in patients with TN (Umino et al., 2002).
Goto et al. used an infraorbital nerve block with 4% tetracaine
dissolved in 0.5% bupivacaine to treat older TN patients who did not
wish to have a neurolytic block or surgical treatment, and reported
that the analgesic effects continued for more than 3 months (Goto
et al., 1999). In our cases, the duration of effective pain relief with
high concentrations of analgesic was much shorter than that in
previous reports in which an infraorbital nerve block was used for
TN. Sato et al. reported two cases of idiopathic superior laryngeal
neuralgia treated with a superior laryngeal nerve block using a high
concentration of lidocaine; the pain was alleviated for 1 year
without the need to continue block therapy after 10 treatments
using 1 mL of 10% lidocaine over 12 days (Takahashi et al., 2007).
They postulated that the effective period in previous cases was
shorter because the injected local anaesthetic remained in the
trigger zone for a shorter time (Takahashi et al., 2007). The ideal
128 G. Dergin et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 124e128
goal of managing TN is to achieve long-term total analgesia, while
preserving the sensory functions of the trigeminal nerve. We were
able to provide pain relief to 11 of 14 patients (Graph 1) for up to 9
months without jeopardising sensory function. In addition, this
method allows patients to continue their daily social activities
without antiepileptic drugs, which can cause a lack of concentra-
tion, drowsiness, and dizziness. This long-term effect may be
attributable to the continuous administration through a pain pump
and epidural catheter, which delivered a continuous high concen-
tration of local anaesthetic to the trigger zone.
5. Conclusion
The continuous administration of 60 mL of 0.25% bupivacaine
HCl at 1 mL h
1 with a pain pump and temporary epidural catheter
can be a useful alternative treatment for patients who are unsuit-
able for neurosurgical intervention due to comorbidities or age and
for patients who are unable to tolerate high doses of antiepileptic
drugs. We observed a significant improvement in pain relief with
this method without surgery. Our intervention has minimal risk for
complications in comparison with cranial neurosurgery. Peripheral
surgical treatments such as alcohol injection minimize such risks,
but repeatability, fibrous tissue formation, tissue necrosis, and
neuropathic pain related to alcohol injection are concerns. This
procedure reduces allodynia, hyperalgesia, and trigger point
hypersensitivity without sensorial loss.
Although peripheral surgical methods can be used as a transi-
tion treatment for patients experiencing side effects from
high-dose antiepileptic drugs, patients awaiting neurosurgery, or
individuals who refuse surgery, it should not be considered as an
alternative treatment to neurosurgical approaches such as MVD,
which has definite long-lasting results with relative few post-
operative complications compared with other surgical methods.
However, the repeatability of our method is an important issue that
must be addressed. Further studies are required to evaluate the
outcomes of our treatment over longer time periods.
Funding source
None.
Conflict of interest
None.
Acknowledgements
None.
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