REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
SCIENTIFIC
ARTICLE
Sphenopalatine
ganglion
pulsed
radiofrequency
treatment
in
patients
suffering
from
chronic
face
and
head
pain
Mert
Akbas
a,∗,
Emel
Gunduz
b,
Suat
Sanli
b,
Arif
Yegin
aaDepartmentofAnaesthesiology,DivisionofAlgology,MedicalFaculty,AkdenizUniversity,Antalya,Turkey bDepartmentofAnaesthesiology,MedicalFaculty,AkdenizUniversity,Antalya,Turkey
Received18April2014;accepted2June2014 Availableonline16September2014
KEYWORDS
Sphenopalatine ganglion; Pulsed
radiofrequency; Chronicfaceand headpain
Abstract
Purpose:There arevarious facialpain syndromesincludingtrigeminal neuralgia, trigeminal neuropathicpainandatypicalfacialpainsyndromes.Effectivenessofthepulsedradiofrequency inmanagingvariouspainsyndromeshasbeenclearlydemonstrated.Therearealimited num-berofstudiesonthepulsedradiofrequencytreatmentforsphenopalatineganglioninpatients sufferingfromfaceandheadpain.Thepurposeofthisstudyistoevaluatethesatisfactionof pulsedradiofrequencytreatmentatourpatientsretrospectively.
Methods:Infrazygomaticapproachwasusedforthepulsedradiofrequencyofthe sphenopala-tineganglionunderfluoroscopicguidance.Afterthetipoftheneedlereachedthetargetpoint, 0.25---0.5mspulsewidthwasappliedforsensorystimulationatfrequenciesfrom50Hzto1V. Paraesthesiaswereexposedattheroofofthenoseat0.5---0.7V.Toruleouttrigeminalcontact thatledto rhythmicmandibular contraction, motorstimulation atafrequencyof2Hz was applied.Then,fourcyclesofpulsedradiofrequencylesioning wereperformedfor120s ata temperatureof42◦C.
Results:Pain relief could notbe achieved in 23% ofthe patients (unacceptable), whereas pain wascompletely relieved in35%ofthepatients (excellent) andmildtomoderate pain reliefcouldbeachievedin42%ofthepatients(good)throughsphenopalatineganglion-pulsed radiofrequencytreatment.
Conclusion:Pulsedradiofrequencyofthesphenopalatineganglioniseffectiveintreatingthe patientssufferingfromintractablechronicfacialandheadpainasshownbyourfindings.There isaneedforprospective,randomized,controlledtrials inordertoconfirmtheefficacyand safetyofthisnewtreatmentmodalityinchronicheadandfacepain.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:akbasmert@akdeniz.edu.tr(M.Akbas).
http://dx.doi.org/10.1016/j.bjane.2014.06.001
PALAVRAS-CHAVE
Gânglio esfenopalatino; Radiofrequência pulsada;
Dorcrônicafaciale decabec¸a
Tratamentocomradiofrequênciapulsadaparagânglioesfenopalatinoempacientes
comdorcrônicadefaceecabec¸a
Resumo
Objetivo: Existem várias síndromes de dor facial, incluindo neuralgia trigeminal, dor neu-ropáticatrigeminalesíndromesatípicasdedorfacial.Aeficáciadaradiofrequênciapulsada (RFP)paraomanejodeváriassíndromesdedorfoiclaramentedemonstrada.Háumnúmero lim-itadodeestudossobreotratamentocomRFPparagânglioesfenopalatino(GEP)empacientes que sofrem de dorfacial ede cabec¸a.O objetivo deste estudofoi avaliar asatisfac¸ãodo tratamentocomPRFemnossospacientes,retrospectivamente..
Métodos: A abordagem infrazigomática foi usada para a RFP do GEP sob orientac¸ão fluo-roscópica. Depoisdeapontadaagulha atingiropontoalvo, pulsosde0,25a0,5msforam aplicadosparaaestimulac¸ãosensorialemfrequênciasde50Hza1V.Parestesiasforamexpostas notetodonarizem0,5a0,7V.Paraexcluirocontatotrigeminalquelevouàcontrac¸ão mandibu-larrítmica,aestimulac¸ãomotorafoiaplicadanafrequênciade2Hz.Emseguida,quatrociclos deRFPforamrealizadosdurante120segundosaumatemperaturade42◦C.
Resultados: Oalíviodadornãofoiobtidoem23%dospacientes(inaceitável);enquantoador foitotalmentealiviadaem35%dospacientes(excelente)eoalíviodeleveamoderadodador foiobtidoem42%dospacientes(bom),comotratamentoRFP-GEP.
Conclusão:RFP para GEP é eficaz no tratamento de pacientes que sofrem de dor crónica intratável,facialedecabec¸a,comomostradopornossasdescobertas.Estudosprospectivos, randômicos econtrolados sãonecessáriosparaconfirmaraeficácia eseguranc¸adessa nova modalidadedetratamentoparadorcrônicafacialedecabec¸a.
©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
The etiologies of sphenopalatine ganglion (SPG) neuralgia includeirritationoftheganglioncausedbyintranasal defor-mitiessuchasdeviatedseptum,septalspurs,andprominent turbinates.1TherearestudiesreportingtheuseofSPGblock
to relieve various pain syndromes such as post-traumatic headache,postherpetic neuralgia, myofascial pain involv-ingthehead-neck-shoulders,2painduetotonguecancerand
cancerofthefloorofthemouth,atypicalodontalgia, post-temporomandibularjoint(TMJ)surgery,angina,backpain, sciaticaanddysmenorrhea;however,manyofthesereports areanectodal.Therefore,thereisaneedforwell-controlled studies on the above-mentioned indications. SPG neural-gia,trigeminalneuralgia(TN),migraineheadaches,cluster headaches,postherpeticneuralgiaandatypicalfacialpain arecurrentlythemostcommonindicationsforSPGblock.3
Treatment protocols generally begin with oral med-ications, such as anticonvulsants, nonsteroidal anti-inflammatory drugs, antidepressantsand may progress to invasiveproceduressuchaspercutaneousor opensurgical procedures.Carbamazepinehasbeenmainlyusedsofaras an anticonvulsant for thetreatment ofchronic facial and headpain1 althoughitsefficacydecreases intime.2Other
pharmacotherapies such as pregabalin, baclofen, oxcar-bazepine, andlamotriginehave been used;however,they donotseem tobeaseffectiveascarbamazepine.3
There-fore,invasivetreatmentssuchasneurosurgicalablationand microvasculardecompressionareneeded.Thesuccessrate ofthesurgicalproceduresisinitiallyashighas98%,whereas
thatitfallsdownto80%inthefirst1---2yearsandto64%in 8---10yearsasshownbymanystudies.4 Otherlessinvasive
optionsincludechemical neurolysis(such asglycerol gan-gliolysis) andablative or radiofrequency (RF)treatments. Radiofrequency thermocoagulation (RFTC) is a minimally invasiveoptiontotreatchronicfacialandheadpain. Follow-ingthesensorystimulationofnervesinawakepatientsunder fluoroscopicguidance,thermallesionisperformedincycles of45---90s attemperatures of60---90◦C.The reports show
thatthesuccessrateofRFTCis83%,whiletherecurrence rateis49%in72months.Dysesthesiahasbeenobservedin 25%ofthecasesundergoingthistreatmentmodality.5
Pulsedradiofrequency(PRF)hasbeenincreasingly draw-ingattentionbecauseitisdeliveredinpulses;thusitgives timeforheatandenergydissipation.Asaresult, surround-ing structures are less damaged.6 Animal studies showed
histomorphological changes in PRF treated sciatic nerves at temperaturesof 40---80◦Cunder continuous RF. Studies
foundthatchangessuchasedema,cellandmyelin patho-logicalchangesdidnotdiffersignificantlybetweenthesham and PRF groups, whereas such changes were significantly differentinthecontinuousRFtreatment group.Moreover, morepathologicalchangeswereobservedundercontinuous RFtreatment at 80◦C in contrastto40◦C.7 Although PRF
hasbeen successful,multipleinterventional therapies are neededforasuccessfultreatmentthatfocusesonthelives ofpatients.
9;33%
18;67%
Male
Female
Figure1 Patientdemographics(sex)undergoing sphenopala-tineganglionpulsedradiofrequencytreatment.
Patients
and
methods
27patientssufferingfromheadandfacepain(9maleand18 female)wereevaluatedunderwentPRFtreatmentforSPG fromJanuary 2010 to December 2011 (Fig. 1). The study protocolwasapprovedbythemedicalethicscommitteeof ourhospitalanda writteninformedconsentwasobtained fromeach patient.PRF wasperformed forthepatients to managechronicheadandfacepaincausedbyvarious etiolo-giessuchasatypicalfacialpain,SPGneuralgiaduetoZona Zoster,atypicalTNthatdidnotrespondtopriortreatments andunilateralmigraineheadaches.Allpatientsresponded positivelytodiagnosticinfrazygomaticlocalanestheticand steroidblock.Thesamepainmanagementphysician exam-inedallpatients andreviewed theimagingstudies before theinjection.Weusedthepatientrecordsretrospectively andclinicalfollow-upvisitsprospectivelytocollectdataat
0
20-40
Age (year)
Number of patients
40-60 60-80
2 4 6 8 10 12 14
Figure2 Patientdemographics(age)undergoing sphenopala-tineganglionpulsedradiofrequencytreatment.
theUniversityFacultyofMedicine,Departmentof Anesthe-siology,DivisionofAlgology.
Theageofourpatientsrangedfrom27to78years,witha meanageof56(Fig.2).Symptomswerepresentfor3months to30years.InfrazygomaticapproachwasusedforthePRFof theSPGunderfluoroscopicguidance(Fig.3A).Patientswere positionedinthesupinepositiononthefluoroscopytable. Lateralviewwasobtainedatmandibularlevelfollowedby the rotation of the head under continuous fluoroscopyto superimpose the two rami of the mandible. The angle of theC-armwasadjustedtowardtheheadtoseethe ptery-gopalatinefossaintheshapeofan‘‘invertedvase’’.Local anesthesiawasadministeredtotheskinandunderlying tis-sueattheanteriorramusoftheipsilateralmandiblebelow thezygoma. To facilitatethe penetrationofthe 20-gauge PRFneedle,a16-gaugeangiocathwasinsertedthroughthe previouslyestablishedskinentrypoint.Then,advancement of a 10-cmcurved,blunt needle witha 10-mm activetip wasrealizedunderfluoroscopy.AsdescribedbyRajetal.,8
the needlewaspositionedmedially,cephalad and slightly posteriorlytowardthepterygopalatinefossa(Fig.3B).The anterior---posteriorfluoroscopicimagingconfirmedthatthe needle lied adjacent to the lateral nasal mucosa at the superior-medialangleofthemaxillarysinus.8Afterthetip
oftheneedlereached thetargetpoint,0.25---0.5mspulse width wasapplied for sensory stimulation at frequencies
Table1 SatisfactionScaleafter3months.
Unacceptable 7(23%)
Excellent 9(35%)
Good 11(42%)
from50Hzto1V.9 Paraesthesiaswereexposedattheroof
ofthenoseat0.5---0.7V.Toruleouttrigeminalcontactthat ledtorhythmicmandibularcontraction,motorstimulation atafrequencyof2Hzwasapplied.Then,fourcyclesofPRF lesioningwereperformedfor120satatemperatureof42◦C.
Anursewhowasnotinvolvedintheproceduresaskedthe patientstoratetheirpainonVerbalNumericalRatingScale (VNRS,0---10)in3monthsaftertheprocedure.
Asubjective3-pointscalethatwasdesignedspecifically for the culture of each patient wasused tomeasure and understandthesatisfactionofpatientsaboutthepain con-trolprocedure(unacceptable,good,excellent)(Table1).
Results
Theprocedurewasperformedontheleftsideinsixty per-centofthepatientswhereasitwasperformedontheright sidein29%andbilaterallyin11%.
Painreliefcouldnotbeachievedin23%ofthepatients (unacceptable)(VNRS7---10),whereaspainwascompletely relievedin35%ofthepatients(excellent)(VNRS0---2)and mild tomoderate painrelief couldbe achievedin 42%of thepatients(good)(VNRS3---6)throughSPG-PRFtreatment (Fig. 1). Neither infection, epistaxis, hematoma, dyses-thesia, numbness of the palate, maxilla or pharynx nor bradycardiawereobserved.
Mean and standard deviations in anthropometric and demographicdata were given.Friedmen test wasapplied for VNRS comparisons. Wilcoxons signed rank test was performedwithBonferronicorrection.Significancewas con-sideredas0.05.
Discussion
Chronicface-headpainimposeslimitationsforthepatients andaffectsallfamilymembers.Patientspresentwithanger anddespairwhentheyvisitthepainclinic.Therefore,such painshouldbemanagedimmediatelywithoutanydelay.
PercutaneousSPG-PRFtreatmentofheadandfacialpain wasdemonstratedtobesurprisinglylengthyin thisstudy. In Shah study,10 SPG-pulsed radiofrequency lesioning was
performed onthe patients for 19 monthsto relievepain. 3 cycles of PRF was performed in that study while we performed 3 cycles. We had to repeat the procedure on the involved site in only 35% of ourpatients. No adverse effectsincludinginfection,epistaxis,hematoma, dysesthe-sia,numbnessofpalate,maxillaorpharynxorbradycardia wereobservedinourstudy.However,unexpectedadverse effectswerereportedonlyinafewcasesduringRFTCofthe SPGforheadache.11,12
The principle ofradiofrequency(RF)is thatit isin the formofalternatingelectrical currentandtheheatis gen-eratedaroundthetipoftheelectrode.Cellculturestudies haveshownthatexposurecreatesabiologicaleffectdueto
theinductionofearlygeneexpressioninthedorsalhorn.13
RFTChasbeenusedtodestroythetissueinTN,ablatetumor metastasis,performlateralcordotomyinunilateral malig-nantpain,destroy dorsal rootganglion in spinal painand treatdiscogenicbackpain.ButRFhasasignaloutputwhich istypicallyacontinuouswaveofRFvoltage,whereasPRFhas aRFwavethatisbrokenintoshortburstsofsignaloutput. Betweensuchbursts,therearesometimeperiodswithno signal.Thereisoftennoneedtoincreasetheaveragetarget tissuetemperatureabove42◦CforthePRFtobeeffective.14
Trigeminalradiosurgeryhasbeenrecentlyclaimedtobe an alternative surgical procedure totreat chronic cluster headache.15,16 However,itdoes nothelprelievingthepain
ina long-term and hasan association with ahigh rate of toxicity.17,18
Combinationofsphenopalatineandtrigeminalneurolytic blockwasreportedtobesuccessfulinacasestudytorelieve facialpaindue toa tumor thatcaused a large mid-facial defect.19Sphenopalatineblockshavebeensuccessfullyused
totreatclusterheadachesthattypicallyoccurinthe peri-orbitalregionasdescribedbythepatient.20
PRFoftheSPGiseffectiveintreatingthepatients suffer-ingfromintractablechronicfacialandheadpainasshownby ourfindings.Butwemustrememberthatthereisascarcity ofstudiesabout thePRF applicationof theSPGandmore studies need to be performed. The incidence of adverse eventsmaybereducedbecausetheneedleisinserted pre-ciselytothe targetpoint underthe real-time fluoroscopy andelectricalstimulationbeforeradiofrequencylesioning.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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