Trigeminal neuralgia
“Trigeminal neuralgia is the worst pain in the world,” wrote Peter J. Jannetta in his monograph “Striking back!”, a layman's guide for facial pain patients. Trigeminal neuralgia is the most common form of facial pain in people over 50 years of age. Trigeminal neuralgia is more prevalent in women than men.
Symptoms
Trigeminal neuralgia ir recognized by unilateral, sharp, shooting pain, involving one or more branches of trigeminal nerve. The pain can be triggered by ordinary stimuli, like eating, washing, shaving, teeth brushing, cold, warmth and draught. Patients’ description of the pain is very important: it must be sharp, shooting, lancinating, similar to electric shock.
Treatment
The medication of choice is carbamazepine, which can reduce pain in about 70% of the cases. Other medications can be tried, such as pregabalin, gabapentin and baclofen. If the medical treatment is unsuccessful and has pronounced adverse events, invasive treatment can be considered.
1. Surgical microvascular compression. During this operation, the artery is separated from the root of trigeminal nerve. A small pad of inert material is being inserted between the artery and the nerve.
2. Percutaneous radiofrequency treatment of the trigeminal ganglion. During this procedure, a special needle with an electrode is inserted into the trigeminal ganglion and the ganglion is treated with a high-frequency current. The temperature at the tip of the needle is as high as 60-80 degrees Celsius, thus part of the ganglion is being destroyed.
Recommendations
Radiofrequency treatment of trigeminal ganglion should be considered in elderly patients with comorbidities, as the procedure rarely causes severe adverse events. Younger patients can be recommended surgical treatment.
Symptoms
6 important questions to be asked:
Does the pain occur in attacks?
Are most of the pain attacks of short duration (seconds to minutes)?
Are some of the attacks of extremely short duration?
Are the attacks unilateral?
Do the attacks occur in the region of trigeminal nerve?
Are there unilateral autonomic symptoms?
Getting these questions answered, the diagnostics seems pretty easy.
Cervical radicular pain
Cervical radicular pain is pain in the neck and upper limb caused by irritation or damage to the cervical spinal nerve. The pain can be acute, akin to an electric shock. The pain is often accompanied by impaired sensitivity along the nerve and/or decreased muscle strength in the innervation zone of the affected nerve.
The most often causes of cervical nerves compression are protrusion or hernia of the intervertebral discs and narrowing of the intervertebral openings. This disease is most common at the age of 50-55 years.
Diagnostics
Involves medical history, physical examination of the patient, testing of sensitivity and muscle strength, as well as of tendon reflexes.
Additional examinations, like CT and MRI, are usually tried to exclude the primary pathology, or the so-called “red flags” (tumors, infection processes and fractures). MRI is most commonly used, as it provides for better visualization of changes in soft tissues. It is important to understand that there may not be a direct association between the anatomical changes found during imaging procedure and the pain syndrome. Abnormal MRI scans are found in 20-30% of patients who never experienced neck radicular pain in their lives.
Electrophysiological tests
Electromyography, electroneurography, and quantitative sensory examination render more information about the location and duration of damage. Selective diagnostic blockade of the cervical root
In patients with chronic pain in general, and with cervical radicular pain in particular, it is sometimes very difficult to determine which intervertebral disc or nerve root is the source of pain. Diagnostic blockade is used to identify the root that generates pain. The essence of the procedure is that a small volume (~ 0.5 ml) of local anesthetic is injected around the nerve root under X-ray control. If the intensity of pain decreases by 50% or more within 30 to 60 minutes, further treatment should be directed to this level of lesion.
Differential diagnosis
The main goal of diagnosis is to exclude the so-called “red flags” such as infection, vascular diseases and tumors. The most common tumor requiring exclusion, the so-called “Pancoast tumor”, is a tumor of the apex of the lung that can compress the subclavian artery, phrenic nerve and cervical plexus. In cases of radicular pain, accompanied by symptoms of compression of the spinal cord (unstable gait, decreased muscle strength in the legs, urination disorder), a primary spinal tumor or metastasis should be suspected. Lesions in shoulder joints and/or cervical intervertebral joints can also produce pain, similar to radicular pain, the so-called "pseudoradicular pain syndromes".
Treatment options
1. Conservative treatment
Nonsteroidal anti-inflammatory drugs are recommended as first-line drugs for a short period. Anticonvulsants (pregabalin, gabapentin) are often prescribed for the treatment of neuropathic pain.
Rest is recommended, as well as wearing a soft immobilizing neck collar. All movements that trigger or intensify pain should be avoided.
2. Interventional treatment
1. Epidural administration of steroids. Should therapy fail to provide the desired effect or is accompanied by severe side effects, epidural steroid administration can be used.
The essence of the procedure is that medications with a very strong anti-inflammatory effect are injected directly near the affected nerve root. The procedure should be performed under X-ray control to prevent accidental steroid injection into the vessel.
2. For patients with chronic pain, pulse radiofrequency (PRF) stimulation may also be recommended. The essence of the procedure is that a special needle is brought to the nerve root, which is a source of pain, and the root is treated with high-frequency electric current pulses. The procedure is easy to tolerate and is not associated with any potential serious complications.
Surgical treatment
Surgical treatment is indicated when all other methods have been ineffective. Surgical treatment is relevant in cases of cervical radiculopathy with spinal cord compression, since this condition presents a high risk of developing irreversible neurological disorders.
Conclusion
1. There is no so-called “gold standard” in the diagnosis of cervical radicular pain.
2. The history of the disease, as well as clinical examination findings are the main ones in the diagnostic process.
3. Imaging methods (MRI, CT) are popular in cases where a specific pathological process is suspected.
4. In cases of unsuccessful conservative therapy:
a. In acute cervical radicular pain, epidural steroid administration is recommended.
b. In chronic cervical radicular pain, PRF of the spinal ganglion should be considered.
Lumbosacral radiculitis.
Lumbosacral radiculitis can be recognized by pain in the back with radiation to the leg. Such pain, described by patients as lumbar pain combined with leg pain extending below the knee, is the most common form of neuropathic pain.
The most important risk factors are: male gender, obesity, smoking, anxiety and depression, hard manual labor, vibration.
In 60% of cases it completely or partially subsides within 3 months after the onset. Women suffering from lumbosacral radicular pain are 3 times less likely to recover than men.
In patients under the age of 50, the most common cause of lumbar sacral pain is herniated disc.
After 50 years, such pain is more often caused by degenerative changes in the spine (e.g., stenosis of the intervertebral foramen).
Diagnosis
The nature of radiating pain in different patients may be of a different nature. Pain can be described as acute, dull, stitching, throbbing, burning. In the case of the intervertebral disc hernia, the pain usually intensifies when leaning forward, coughing, sneezing. Pain caused by stenosis of the spinal canal worsens when walking and quickly disappears when stopping and leaning forward. In addition to pain, patients often experience paresthesia (tingling sensation, skin crawling, burning sensation) in the area of innervation of the affected root.
Sometimes there is a decrease in sensitivity (numbness) or a decrease in muscle strength in the affected limb. Given that the natural course of lumbosacral radiculopathy is favorable in 60-80% of cases, and pain within ~ 12 weeks significantly subsides or completely disappears, additional examinations are not of relevancy in the acute stage. MRI can detect a hernia of the intervertebral disc, stenosis of the intervertebral foramen, stenosis of the spinal canal. It should be noted that the specificity of this imaging method is rather low - when examining healthy people who never complained of back or leg pain, herniated discs were found in almost 40% of cases.
The size of the hernia may not correspond to the severity of the pain syndrome. Often, as a result of conservative treatment, symptoms subside, while the size of the hernia can remain unchanged. In 60% of cases, hernias spontaneously resolve within a year.
Differential diagnosis
In case of acute or chronic pain in the back and/or leg, it is important to remember the so-called “red flags”. “Red flags” are conditions and symptoms that require immediate examination.
“Red flags” for back pain are fever, intravenous drug use, spine surgery during the last year, immunosuppressive state, prolonged use of corticosteroids, age below 20 or over 50 years, history of malignant tumors, severe progressive sensory disorders or muscle weakness, dysfunction of the urinary bladder or bowels.
Also, one should remember cauda equina syndrome (CES). This syndrome is usually caused by large disc herniation. When lower lumbar and sacral roots are compressed by herniation, urination disorders and fecal incontinence may develop, as well as muscle weakness in the legs. Such a patient needs immediate surgical treatment.
Treatment
The treatment in most cases is conservative: non-steroidal anti-inflammatory drugs, anticonvulsants, tricyclic antidepressants or opioids in case of severe pain. Conservative treatment combined with physiotherapy is more effective than just conservative treatment.
Surgical intervention in acute radicular pain gives a faster pain relief, however, after 1-2 years the results in the groups of those who underwent surgery and those treated conservatively were approximately the same.
In patients with lumbar spine stenosis, neurological disorders after surgical treatment can either remain for life or regress for a long time. More than half of patients have neurological disorders after surgical decompression.
In chronic (> 3 months) radicular lumbosacral pain, medication treatment is recommended as the primary option. The drugs of choice are anticonvulsants (e.g. gabapentin) and tricyclic antidepressants. In practice, the use of these drugs is limited by their adverse effects and occasionaly low effectiveness. Significant improvement due to drug treatment is seen in less than 30% of patients.
Invasive treatment
In patients with subacute radicular pain epidural administration of corticosteroids is indicated.
In chronic radicular pain, epidural steroid administration is much less effective. In chronic radicular pain, the method of choice is the treatment of the spinal ganglion with radiofrequency pulses, the so-called pulse neurostimulation. This treatment modality for chronic radicular pain is not associated with side effects.
The number of epidural injections is also an important issue. At the moment, there are no studies proving any advantage of 3 consecutive injections.
Given the possible side effects, the interval between injections should be at least 2 weeks.
SIJ
Causes of pain in the lower back in about 20% of patients may be damage to the SIJ (Sacroiliac Joint). Pain in the sacroiliac joint is defined as pain in the SIJ region, triggered by provocative stresses and subsiding after infiltrating SIJ with a local anesthetic.
Specific signs
- Appears when changing position (pain when standing up)
- Usually localized below the spinous process of the 5th lumbar vertebra.
- Usually unilateral
- May radiate to the buttock, groin, abdomen, lower limb, down to the foot
Diagnostics
Imaging methods (X-ray, CT, MRI) are non-diagnostic and can only be used to exclude the so-called “red flags”.
3 or more positive provocative tests (Patrick test, Gaenslen test, distraction test, etc.) in 75% of cases are indicative of SIJ pathology.
To confirm the diagnosis, infiltrating SIJ with a local anesthetic should be considered.
The use of X-ray to locate the needle in the joint cavity is highly recommended.
Treatment
Conservative treatment - drug therapy, manual therapy, physiotherapy.
Interventional therapy
Intra-articular injection of corticosteroids can give a significant pain reduction in the SIJ for a fairly long period, up to 1 year. In case the results of intraarticular blockade are unsatisfactory, SIJ denervation is indicated.
Symptoms
Trigeminal neuralgia ir recognized by unilateral, sharp, shooting pain, involving one or more branches of trigeminal nerve. The pain can be triggered by ordinary stimuli, like eating, washing, shaving, teeth brushing, cold, warmth and draught. Patients’ description of the pain is very important: it must be sharp, shooting, lancinating, similar to electric shock.
Treatment
The medication of choice is carbamazepine, which can reduce pain in about 70% of the cases. Other medications can be tried, such as pregabalin, gabapentin and baclofen. If the medical treatment is unsuccessful and has pronounced adverse events, invasive treatment can be considered.
1. Surgical microvascular compression. During this operation, the artery is separated from the root of trigeminal nerve. A small pad of inert material is being inserted between the artery and the nerve.
2. Percutaneous radiofrequency treatment of the trigeminal ganglion. During this procedure, a special needle with an electrode is inserted into the trigeminal ganglion and the ganglion is treated with a high-frequency current. The temperature at the tip of the needle is as high as 60-80 degrees Celsius, thus part of the ganglion is being destroyed.
Recommendations
Radiofrequency treatment of trigeminal ganglion should be considered in elderly patients with comorbidities, as the procedure rarely causes severe adverse events. Younger patients can be recommended surgical treatment.
Symptoms
6 important questions to be asked:
Does the pain occur in attacks?
Are most of the pain attacks of short duration (seconds to minutes)?
Are some of the attacks of extremely short duration?
Are the attacks unilateral?
Do the attacks occur in the region of trigeminal nerve?
Are there unilateral autonomic symptoms?
Getting these questions answered, the diagnostics seems pretty easy.
Cervical radicular pain
Cervical radicular pain is pain in the neck and upper limb caused by irritation or damage to the cervical spinal nerve. The pain can be acute, akin to an electric shock. The pain is often accompanied by impaired sensitivity along the nerve and/or decreased muscle strength in the innervation zone of the affected nerve.
The most often causes of cervical nerves compression are protrusion or hernia of the intervertebral discs and narrowing of the intervertebral openings. This disease is most common at the age of 50-55 years.
Diagnostics
Involves medical history, physical examination of the patient, testing of sensitivity and muscle strength, as well as of tendon reflexes.
Additional examinations, like CT and MRI, are usually tried to exclude the primary pathology, or the so-called “red flags” (tumors, infection processes and fractures). MRI is most commonly used, as it provides for better visualization of changes in soft tissues. It is important to understand that there may not be a direct association between the anatomical changes found during imaging procedure and the pain syndrome. Abnormal MRI scans are found in 20-30% of patients who never experienced neck radicular pain in their lives.
Electrophysiological tests
Electromyography, electroneurography, and quantitative sensory examination render more information about the location and duration of damage. Selective diagnostic blockade of the cervical root
In patients with chronic pain in general, and with cervical radicular pain in particular, it is sometimes very difficult to determine which intervertebral disc or nerve root is the source of pain. Diagnostic blockade is used to identify the root that generates pain. The essence of the procedure is that a small volume (~ 0.5 ml) of local anesthetic is injected around the nerve root under X-ray control. If the intensity of pain decreases by 50% or more within 30 to 60 minutes, further treatment should be directed to this level of lesion.
Differential diagnosis
The main goal of diagnosis is to exclude the so-called “red flags” such as infection, vascular diseases and tumors. The most common tumor requiring exclusion, the so-called “Pancoast tumor”, is a tumor of the apex of the lung that can compress the subclavian artery, phrenic nerve and cervical plexus. In cases of radicular pain, accompanied by symptoms of compression of the spinal cord (unstable gait, decreased muscle strength in the legs, urination disorder), a primary spinal tumor or metastasis should be suspected. Lesions in shoulder joints and/or cervical intervertebral joints can also produce pain, similar to radicular pain, the so-called "pseudoradicular pain syndromes".
Treatment options
1. Conservative treatment
Nonsteroidal anti-inflammatory drugs are recommended as first-line drugs for a short period. Anticonvulsants (pregabalin, gabapentin) are often prescribed for the treatment of neuropathic pain.
Rest is recommended, as well as wearing a soft immobilizing neck collar. All movements that trigger or intensify pain should be avoided.
2. Interventional treatment
1. Epidural administration of steroids. Should therapy fail to provide the desired effect or is accompanied by severe side effects, epidural steroid administration can be used.
The essence of the procedure is that medications with a very strong anti-inflammatory effect are injected directly near the affected nerve root. The procedure should be performed under X-ray control to prevent accidental steroid injection into the vessel.
2. For patients with chronic pain, pulse radiofrequency (PRF) stimulation may also be recommended. The essence of the procedure is that a special needle is brought to the nerve root, which is a source of pain, and the root is treated with high-frequency electric current pulses. The procedure is easy to tolerate and is not associated with any potential serious complications.
Surgical treatment
Surgical treatment is indicated when all other methods have been ineffective. Surgical treatment is relevant in cases of cervical radiculopathy with spinal cord compression, since this condition presents a high risk of developing irreversible neurological disorders.
Conclusion
1. There is no so-called “gold standard” in the diagnosis of cervical radicular pain.
2. The history of the disease, as well as clinical examination findings are the main ones in the diagnostic process.
3. Imaging methods (MRI, CT) are popular in cases where a specific pathological process is suspected.
4. In cases of unsuccessful conservative therapy:
a. In acute cervical radicular pain, epidural steroid administration is recommended.
b. In chronic cervical radicular pain, PRF of the spinal ganglion should be considered.
Lumbosacral radiculitis.
Lumbosacral radiculitis can be recognized by pain in the back with radiation to the leg. Such pain, described by patients as lumbar pain combined with leg pain extending below the knee, is the most common form of neuropathic pain.
The most important risk factors are: male gender, obesity, smoking, anxiety and depression, hard manual labor, vibration.
In 60% of cases it completely or partially subsides within 3 months after the onset. Women suffering from lumbosacral radicular pain are 3 times less likely to recover than men.
In patients under the age of 50, the most common cause of lumbar sacral pain is herniated disc.
After 50 years, such pain is more often caused by degenerative changes in the spine (e.g., stenosis of the intervertebral foramen).
Diagnosis
The nature of radiating pain in different patients may be of a different nature. Pain can be described as acute, dull, stitching, throbbing, burning. In the case of the intervertebral disc hernia, the pain usually intensifies when leaning forward, coughing, sneezing. Pain caused by stenosis of the spinal canal worsens when walking and quickly disappears when stopping and leaning forward. In addition to pain, patients often experience paresthesia (tingling sensation, skin crawling, burning sensation) in the area of innervation of the affected root.
Sometimes there is a decrease in sensitivity (numbness) or a decrease in muscle strength in the affected limb. Given that the natural course of lumbosacral radiculopathy is favorable in 60-80% of cases, and pain within ~ 12 weeks significantly subsides or completely disappears, additional examinations are not of relevancy in the acute stage. MRI can detect a hernia of the intervertebral disc, stenosis of the intervertebral foramen, stenosis of the spinal canal. It should be noted that the specificity of this imaging method is rather low - when examining healthy people who never complained of back or leg pain, herniated discs were found in almost 40% of cases.
The size of the hernia may not correspond to the severity of the pain syndrome. Often, as a result of conservative treatment, symptoms subside, while the size of the hernia can remain unchanged. In 60% of cases, hernias spontaneously resolve within a year.
Differential diagnosis
In case of acute or chronic pain in the back and/or leg, it is important to remember the so-called “red flags”. “Red flags” are conditions and symptoms that require immediate examination.
“Red flags” for back pain are fever, intravenous drug use, spine surgery during the last year, immunosuppressive state, prolonged use of corticosteroids, age below 20 or over 50 years, history of malignant tumors, severe progressive sensory disorders or muscle weakness, dysfunction of the urinary bladder or bowels.
Also, one should remember cauda equina syndrome (CES). This syndrome is usually caused by large disc herniation. When lower lumbar and sacral roots are compressed by herniation, urination disorders and fecal incontinence may develop, as well as muscle weakness in the legs. Such a patient needs immediate surgical treatment.
Treatment
The treatment in most cases is conservative: non-steroidal anti-inflammatory drugs, anticonvulsants, tricyclic antidepressants or opioids in case of severe pain. Conservative treatment combined with physiotherapy is more effective than just conservative treatment.
Surgical intervention in acute radicular pain gives a faster pain relief, however, after 1-2 years the results in the groups of those who underwent surgery and those treated conservatively were approximately the same.
In patients with lumbar spine stenosis, neurological disorders after surgical treatment can either remain for life or regress for a long time. More than half of patients have neurological disorders after surgical decompression.
In chronic (> 3 months) radicular lumbosacral pain, medication treatment is recommended as the primary option. The drugs of choice are anticonvulsants (e.g. gabapentin) and tricyclic antidepressants. In practice, the use of these drugs is limited by their adverse effects and occasionaly low effectiveness. Significant improvement due to drug treatment is seen in less than 30% of patients.
Invasive treatment
In patients with subacute radicular pain epidural administration of corticosteroids is indicated.
In chronic radicular pain, epidural steroid administration is much less effective. In chronic radicular pain, the method of choice is the treatment of the spinal ganglion with radiofrequency pulses, the so-called pulse neurostimulation. This treatment modality for chronic radicular pain is not associated with side effects.
The number of epidural injections is also an important issue. At the moment, there are no studies proving any advantage of 3 consecutive injections.
Given the possible side effects, the interval between injections should be at least 2 weeks.
SIJ
Causes of pain in the lower back in about 20% of patients may be damage to the SIJ (Sacroiliac Joint). Pain in the sacroiliac joint is defined as pain in the SIJ region, triggered by provocative stresses and subsiding after infiltrating SIJ with a local anesthetic.
Specific signs
- Appears when changing position (pain when standing up)
- Usually localized below the spinous process of the 5th lumbar vertebra.
- Usually unilateral
- May radiate to the buttock, groin, abdomen, lower limb, down to the foot
Diagnostics
Imaging methods (X-ray, CT, MRI) are non-diagnostic and can only be used to exclude the so-called “red flags”.
3 or more positive provocative tests (Patrick test, Gaenslen test, distraction test, etc.) in 75% of cases are indicative of SIJ pathology.
To confirm the diagnosis, infiltrating SIJ with a local anesthetic should be considered.
The use of X-ray to locate the needle in the joint cavity is highly recommended.
Treatment
Conservative treatment - drug therapy, manual therapy, physiotherapy.
Interventional therapy
Intra-articular injection of corticosteroids can give a significant pain reduction in the SIJ for a fairly long period, up to 1 year. In case the results of intraarticular blockade are unsatisfactory, SIJ denervation is indicated.