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“Anesthesia dolorosa” is Latin for “painful numbness.” When we perform a radio frequency lesion, we deliberately make the painful part of the face numb. It’s exactly the same feeling as a novocaine injection. The vast majority of patients find the numbness to be vastly preferable to the pain of trigeminal neuralgia. Usually they rapidly adjust to the numb feeling. A small number of patients, however, find the numbness to be very painful. They describe the feeling as “woody, thick, burning, crawling.” In fact, this is what novocaine feels like. Once the nerve is numb there is no reliable surgical treatment for anesthesia dolorosa. In about half the cases, the numbness gradually fades, the anesthesia dolorosa goes away, but the trigeminal neuralgia recurs.
If you have had novocaine for dental procedures and remember that feeling as particularly uncomfortable, you may not want to have a radio frequency lesion for trigeminal neuralgia. Painful numbness can also follow microvascular decompression or radiosurgery, although less frequently.
I have found the patients with anesthesia dolorosa often feel better after taking an older antidepressant medication called Elavil. This medication works directly on the pain and also on the depression which frequently accompanies chronic pain.
Facial pain is a debilitating, life-altering experience. Many patients who would benefit from surgery spend years getting dental work and medical treatment. At the University of Florida, we are willing to see any and all patients with intractable facial pain. We will evaluate you promptly and, hopefully, help find a medical or surgical solution.
Herpes zoster is a virus that causes chicken pox in childhood. In adult life, if it recurs, it causes “shingles”, an outbreak of small lesions on the skin. They usually occur in the distribution of a nerve root. If the nerve root is the trigeminal nerve, the outbreak will occur on the face, usually in V1, the forehead and eye. The outbreak is painful. If you have this you should seek immediate medical attention, since early drug treatment can prevent chronic pain.
About 10% of people with a zoster infection develop chronic pain in that distribution. It’s called “postherpetic neuralgia.” The best medical treatments involve topical application of capsaicin cream. It burns, a lot. But if you use it for 2-3 weeks the postherpetic pain often diminishes.
If your pain is totally incapacitating, you may be a candidate for an operation called the “nucleus caudalis dorsal root entry zone lesion (DREZL) procedure. This involves surgery, under general anesthesia, where a needle is placed into the pain center of the brainstem and lesions are made. At UF, we have performed many of these procedures.
Radiosurgery is an outpatient treatment that focuses hundreds of very small beams of radiation on an intracranial lesion. It has revolutionized the treatment of small brain tumors (including metastatic tumors, meningiomas, schwannomas, and others) as well as brain blood vessel malformations. It has also been used for some time to treat trigeminal neuralgia.
If you are considering radio surgery, make sure that you are dealing with a very experienced radiosurgery team. The trigeminal nerve target is very small, so absolute accuracy is required and this is not available on every commercial radiosurgery system. I would recommend systems that use a head ring and have a proven mechanical accuracy of less than .5mm.
I have used radiosurgery to treat over 4500 patients since we first started in 1988. We have extensively published our results (over 150 papers and chapters) and spoken at over a 100 international and national meetings. I was president of the International Stereotactic Radiosurgery Society. And yet I am not very enthusiastic about radiosurgery for trigeminal neuralgia. Why?
- It takes 6-8 weeks for radiosurgery to produce pain relief. Many of my patients can’t wait that long.
- Many patients still need to take medication after radiosurgery to control their pain. Why is that a problem. Well, side effects of medical treatment are what bring most patients to surgical treatment. If you have to continue meds, disabling side effects may also continue.
- Radiosurgery has a poorer long term pain control record than microvascular decompression. That is, your pain relief is more likely to be temporary than with other surgical approaches.
That said, the advantage of radiosurgery is that it virtually eliminates the rare but occasionally very serious risks of open surgery. If radiosurgery fails, it will not preclude you from pursuing other options.
So, think about it!