Download
1 / 41
420 likes | 572 Views
In The Name God. Hossein Ashrafian neurologist Iran Gamma knife center. Invasive Treatment Of Craniofacial Pain. Invasive Procedures for Cluster Headache Treatment.
E N D
The majority of CH patients will achieve satisfactory results with pharmacologic treatment. For those who remain refractory to medical treatment, a number of invasive procedures are available. These include peripheral nerve blocks, peripheral or central neurostimulation and ablative surgery. Peripheral nerve block, mostly targeting the greater occipital nerve (GON), may also be used in less refractory patients, as an adjunct to pharmacologic therapy.
Interventional and surgical treatment of cluster H If all drug treatment procedures are ineffective and a secondary cluster headache has been excluded, surgical treatment can be discussed with the patient. Surgical procedures should be considered with great caution because no reliable long-term data are available and because they can induce trigeminal neuralgia or anaesthesiadolorosa : 1-application of glycerol or local anaesthetics into the cisternatrigeminalis of the Gasserianganglion 2-radiofrequency rhizotomy of the Gasserianganglion 3-microvascular decompression 4-resection or blockade of the N petrosussuperficialis
Hypothalamic deep-brain stimulation (hDBS) acts rapidly and has lasting efficacy, but is not without risk
Demographics, clinical features and outcome of enrolled patients
Nerve Blocks for Cluster Headacheresult of 2 studies • 1- Patients received lidocaine 2% (0.5 mL) with either betamethasone or saline. CH attacks disappeared within 72 hours for 4 weeks in 61% of the lidocaine + betamethasone group compared with none of those in the lidocaine + saline group. Injections were well tolerated • 2- Nerve blockade was achieved using 3 mL of lidocaine 1% with triamcinolone 40 mg. 64% of the patients had a good or moderate response
In general, it has to be said that any surgical procedure on peripheral trigeminal structures in episodic cluster headache has to be judged with great caution, as the natural course of the disease includes remission. On the other hand, in chronic cluster headache, there is strong evidence that even a complete trigeminal denervation is not effective in preventing headache attacks or autonomic symptoms .
Gamma knife treatment for refractory cluster headache • The cisternal segment of the nerve was targeted with a single 4 mm collimator (80–85 Gy max • Robert G Ford in 1988
Trigeminal neuralgia • Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain signals from getting through to the brain. In trained hands, surgery has been reported to have an initial success rate approaching 90 percent
TN • Microvascular decompression, also known as the Jannetta procedure,is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a 25-millimetre (1 in) hole behind the ear. The nerve is then explored for an offending blood vessel, and when one is found, the vessel and nerve are separated or "decompressed" with a small pad, usually made from an inert surgical material such as Teflon. When successful, MVD procedures can give permanent pain relief with little to no facial numbness.
TN • Other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions. Some have excellent success rates using a cost-effective percutaneous surgical procedure known as balloon compression have been reported.This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression.
TRIGEMINAL (GASSERIAN) GANGLION BLOCK • The trigeminal ganglion is located intracranially and measures approximately 1 × 2 cm. In its intracranial location, it lies lateral to the internal carotid artery and cavernous sinus and slightly posterior and superior to the foramen ovale, through which the mandibular nerve leaves the cranium
Patients are placed in a supine position and asked to fix their gaze straight ahead, as if they were looking off into the distance. The anesthesiologist should be positioned at the patient’s side, slightly below the level of the shoulder, so that by looking toward the patient’s face . A skin wheal is raised immediately medial to the masseter muscle, which can be located by asking the patient to clench the teeth . (It most often occurs approximately 3 cm lateral to the corner of the mouth.
A 22-gauge, 10-cm needle is inserted through this site. The plane of insertion should be in line with the pupil. This allows the needle tip to contact the infratemporal surface of the greater wing of the sphenoid bone, immediately anterior to the foramen ovale. This occurs at a depth of 4.5 to 6 cm. Once the needle is firmly positioned against this infratemporal region, it is withdrawn and redirected in a stepwise manner until it enters the foramen ovale at a depth of approximately 6 to 7 cm, or 1 to 1.5 cm past the needle length required to contact the bone initially
Stereotactic radiation therapy in TN • The nerve can also be damaged to prevent pain signal transmission using Gamma Knife or a linear accelerator-based radiation therapy
Gamma knife &TN • No incisions are involved in this procedure. It uses very precisely targeted radiation to bombard the nerve. This option is used especially for those people who are medically unfit for a long general anaesthetic, or who are taking medications for prevention of blood clotting (e.g., warfarin, heparin, aspirin). It also may be used for those who may need to have a less invasive procedure. • A prospective Phase I trial performed at Marseille, France, showed that 83% of patients were pain-free at 12 months, with 58% pain-free and off all medications. Side effects were mild, with 6% experiencing mild tingling and 4% experiencing mild numbness. • However, there is no guarantee for a permanent success
Surgical treatment for migraine • This surgery has only recently been initiated in the US and involves removing the corrugator muscle found above the eyebrows. The theory is that the surgery eliminates migraines by eliminating the muscle, responsible for negative interaction with nerves around the area creating the migraines.
The surgery targets the trigger point where migraine headaches usually begin. On eliminating the muscle, the point at which it interacts with surrounding nerves, which creates the debilitating pain and pressure is removed. This procedure does not help all migraines. It will only work for corrugator muscle triggered migraines and the specific nerve group in the head. A screening test must be done to determine if this trigger is the cause and if the patient is a suitable candidate for the surgery.
Occipital Nerve Block for Migraine Headaches • Occipital nerve block is a procedure where anesthetic agents (lidocaine and bupivacaine) are injected near the occipital nerve on the back of the head near the base of the skull on the side of the migraine headache. Within five minutes after the nerve block, 60% of patients had mild or no headache and 75% of patients had mild or no light sensitivity (photophobia). The investigators of the study concluded that greater occipital nerve blocks are safe and easy procedures that can be performed in the office and show results more quickly than oral triptan medications.
a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
TCD in GON finding The greater occipital artery, which serves as the most reliable landmark, is palpated. TCD ultrasonography can be used to easily and precisely detect pulsation of the greater occipital artery. The patient was placed in the prone position, and the 8-MHz probe was manipulated along the superior nuchal ridge until the blood flow in the occipital artery was audible and visible. After the pulsating vessel was identified, a 25- gauge 1.5-inch needle was inserted just medial to the point of pulsation, and a local anesthetic was injected around the artery.
The use of botulinum neurotoxin type A for headaches • The mechanism of Botox is complex. When botulinum neurotoxin is injected into a target tissue, a series of events occur, blocking the release of acetylcholine which result in flaccid paralysis . • Botulinum toxin has been found to have no direct effects on the central nervous system . • On the spinal level, botulinum toxin is capable of producing reflex inhibition of the muscle spindle organ. • On the supraspinal level, studies have shown that botulinum toxin can normalize altered intracortical inhibition and altered somatosensory evoked potentials
Botox treatment for painful conditions such as headaches: Chronic daily headaches pertain to a group of headache disorders that are defined by the presence of headaches greater than 15 days per month for more than three months . These can include both tension-type headaches, cervicogenic headaches and migraine headaches,
Chronic Paroxysmal Hemicrania • Anesthetic blockade of the occipital nerves and supraorbital nerve have not provided significant relief. Occipital nerve blockade helps in distinguishing CPH and HC from cervicogenic headache. Supraorbital nerve blockade may help in distinguishing HC and supraorbital nerve neuralgia (in which nerve block is markedly effective). • Reliable evidence of efficacy of chiropractic manipulation, acupuncture, or surgical management in the treatment of CPH does not exist.
Cervicogenic headache • Neck pain and cervical muscle tenderness are common and prominent symptoms of primary headache disorders. Conversely, it is plausible that head pain can be referred from bony structures or soft tissues of the neck, a condition called cervicogenic headache
The anatomic locus for cervicogenic headache is the trigeminocervical nucleus in the upper cervical spinal cord, where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory fibers from the upper cervical roots. • The first three cervical spinal nerves and their rami are the primary peripheral nerve structures that can refer pain to the head
Panel 1: Clinical criteria for the diagnosis of cervicogenic • headache • 1 Unilateral headache without side-shift • 2 Symptoms and signs of neck involvement: pain triggered • by neck movement or sustained awkward posture and/or • external pressure of the posterior neck or occipital region; • ipsilateral neck, shoulder, and arm pain; reduced range of • motion • 3 Pain episodes of varying duration or flactuating • continuous pain • 4 Moderate, non-excruciating pain, usually of a • non-throbbing nature • 5 Pain starting in the neck, spreading to • oculo-fronto-temporal areas • 6 Anaesthetic blockades abolish the pain transiently • provided complete anaesthesia is obtained, or occurrence • of sustained neck trauma shortly before onset • 7 Various attack-related events: autonomic symptoms and • signs, nausea, vomiting, ipsilateraloedema and fl ushing • in the peri-ocular area, dizziness, photophobia, • phonophobia, or blurred vision in the ipsilateral eye
