PainHistologic analysis of a human trigeminal nerve after failed stereotactic radiosurgery: case report
Introduction
Stereotactic radiosurgery is now an accepted surgery for patients with medically refractory trigeminal neuralgia. Radiosurgery appeals to patients and physicians because of the ease of the procedure compared with other surgical options. Despite the increased use of this procedure to manage patients with trigeminal neuralgia, the mechanism of pain relief remains poorly understood. It has been speculated that SRS selectively injures fibers involved in the transmission of painful stimuli from the face [2], [7]. However, recent experimental studies using animal models have suggested that radiosurgery diffusely damages all axons of the trigeminal nerve in a nonselective manner [1]. Moreover, most studies on trigeminal neuralgia radiosurgery have noted a clear association between the development of new trigeminal deficits and improved facial pain outcomes [3], [5], [6], [8], [10].
In this case report, we describe the clinical course and histologic findings in a patient who underwent partial sectioning of the trigeminal nerve after 2 previous radiosurgical procedures failed to relieve her facial pain.
Section snippets
History
A 74-year-old woman presented with an 8-year history of right-sided episodic, shock-like facial pain in a V2 and V3 distribution. The pain was triggered by cool breezes, brushing of teeth, and touching of face. Her symptoms were consistent with trigeminal neuralgia; there were no atypical features. Magnetic resonance imaging showed no evidence of tumors, stroke, or demyelinating disease. Previous surgeries included an MVD 6 years earlier. The patient had complete relief from her symptoms after
Discussion
Despite the routine and increasing use of radiosurgery for patients with medically refractory trigeminal neuralgia, the mechanism of pain relief is unknown. Similar to other destructive procedures for trigeminal neuralgia [4], [9], there appears to be a strong correlation between the development of facial numbness and long-term pain relief after trigeminal neuralgia radiosurgery [3], [5], [6], [8], [10]. In this report, we describe a patient who was initially pain-free after radiosurgery but
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