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2011 Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional Neurosurgery Department of Neurosurgery University of Illinois at.

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Presentation on theme: "2011 Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional Neurosurgery Department of Neurosurgery University of Illinois at."— Presentation transcript:

1 2011 Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional Neurosurgery Department of Neurosurgery University of Illinois at Chicago Konstantin Slavin, MD Professor and Head Section of Stereotactic and Functional Neurosurgery Department of Neurosurgery University of Illinois at Chicago Surgical Treatment of Neuropathic Facial Pain – an Algorithmic Approach

2 201110/15/10 Facial pain treatment algorithm

3 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

4 2011 Facial pain classification

5 2011 Facial pain classification

6 2011 Facial pain classification Trigeminal neuralgia (classic) - Burchiel TN1 Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

7 2011 History of trigeminal neuralgia

8 2011 History of trigeminal neuralgia

9 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) – Burchiel TN 2 Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain 2011

10 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

11 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain A.D.

12 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

13 2011 Natural history of trigeminal neuralgia

14 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

15 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

16 2011 Facial pain classification Trigeminal neuralgia (classic) Trigeminal neuralgia (atypical) Symptomatic trigeminal neuralgia Trigeminal deafferentation pain Trigeminal neuropathic pain Cancer facial pain Other cranial neuralgias Atypical facial pain

17 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

18 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

19 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery Sindou et al. MVD for TN Acta Neurochir, 2006

20 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

21 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

22 2011 Treatment modalities

23 2011 Treatment modalities

24 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

25 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery Sheehan, JNS, 2005

26 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

27 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

28 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

29 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

30 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

31 2011 Treatment modalities Microvascular decompression Radiofrequency gangliolysis Balloon compression Stereotactic radiosurgery Peripheral nerve stimulation Neurectomy Motor cortex stimulation Tractotomy Surgery on other cranial nerves No surgery

32 2011 How to choose the right procedure? Trigeminal neuralgia – MVD? Multiple sclerosis – RF PTG? Elderly patients – SRS? Anesthesia dolorosa – MCS? Atypical facial pain – no surgery?

33 2011 Rationale for algorithm Facilitates decision making Aimed at maximal improvement / minimal side effects Individually tailored approach Standardization Eliminates uncertainty Patient and physician education

34 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery

35 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Trigeminal Other cranial nerve Non-anatomic

36 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery

37 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Sharp / shooting Constant / dull Combination

38 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Yes No

39 2011 Initial questions Distribution of pain MRI findings Nature of pain Presence of numbness Previous surgery Yes No

40 2011 Facial pain treatment algorithm

41 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location

42 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Yes No

43 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Yes No

44 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location V2, V3, V2-3 V1, V1-2, V1-3, V 1-2-3

45 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Partial Complete

46 2011 Treatment questions Healthy? Young? Willingness to have surgery Distribution of pain Severity of numbness Exact pain location Supraorbital Mandibular Infraorbital

47 CNS 2011

48 2011 Facial pain treatment algorithm

49 Current Algorithm of Facial Pain Treatment ~ 100 new patients with facial pain/year ~ 65% - trigeminal neuralgia ~35% - typical idiopathic TN ~15% - atypical idiopathic TN ~15% - secondary TN (MS, neoplasms, etc.) ~ 15% - trigeminal neuropathic pain ~ 5% - other cranial neuralgias / syndromes ~ 15% - atypical facial pain

50 Current Algorithm of Facial Pain Treatment ~ 70 surgeries for facial pain /year ~20-30 microvascular decompressions ~15-25 percutaneous RF gangliolysis ~2-3 balloon compressions ~5-15 GK radiosurgery ~1-3 trigeminal peripheral nerve stimulation ~0-1 motor cortex stimulation

51 Current Algorithm of Facial Pain Treatment 96% pain relief (at the time of discharge) 23% overall recurrence rate ~15% need another procedure 98% patient satisfaction

52 Current Algorithm of Facial Pain Treatment The proposed treatment algorithm for intractable facial pain that includes open and percutaneous procedures, radiosurgery and neuromodulation, appears to be effective for patients with a wide variety of painful conditions and may be recommended for use in other institutions.

53 Thank you!

54


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