Anesthesia & Analgesia:
Analgesia: Brief Report
The Long-Term Outcome of Mandibular Nerve Block with Alcohol for the Treatment of Trigeminal Neuralgia
Han, Kyung Ream MD, PhD; Kim, Chan MD, PhD
From the Department of Anesthesia and Pain Medicine, Pain Clinic, Ajou University Hospital, Suwon, Korea.
Disclosure: The authors report no conflicts of interest.
Address correspondence and reprint requests to Chan Kim, MD, PhD, Department of Anesthesia and Pain Medicine, Ajou University Hospital, San 5 Won-Cheon Dong Pal-Dal Gu, Suwon, Korea 442-721. Address e-mail to email@example.com.
Accepted April 12, 2010
Published ahead of print June 28, 2010
Ninety-eight patients received 160 mandibular nerve (V3) blocks with alcohol for the treatment of trigeminal neuralgia in this prospective study. According to the Kaplan-Meier analysis, the probabilities of remaining pain free for 1, 2, 3, and 7 years after the procedures were 90.4%, 69%, 53.5%, and 33%, respectively. There was no significant difference in the probability of pain-free duration and complications between patients with repeat versus single V3 block with alcohol. We conclude that single and repeat V3 alcohol block for trigeminal neuralgia can provide long-lasting pain relief.
Trigeminal nerve block with alcohol is an accepted treatment for trigeminal neuralgia (TN),1,2 but is not as widely used as other percutaneous procedures or microvascular decompression.3–12 The main reason for this reluctance to perform an alcohol block of the trigeminal nerve for the management of TN is the concern that it provides limited pain relief and that repeated blocks have a lower success rate and a higher morbidity rate including neuritis.13 However, this concern has not been well validated1,14,15; therefore, we evaluated the efficacy and related complications of an alcohol block of the mandibular division (V3) of the trigeminal nerve for the treatment of TN. We also examined whether a previous alcohol block affected procedure outcomes.
All patients that received a V3 alcohol block for TN between March 2000 and February 2007 were allocated for the study. This prospective study was approved by the IRB at Ajou University Hospital in Korea. Three hundred fifty-two patients were diagnosed with TN, and of these, 142 patients had pain in the V3 division. Ninety-eight patients with V3 TN participated in the study and informed consents were obtained (Fig. 1).
All 98 patients fulfilled the diagnostic criteria for TN as detailed in the international classification of headache disorders.16 Magnetic resonance imaging was performed to exclude tumors and other brain lesions, such as those caused by multiple sclerosis. All study patients had previously been treated with carbamazepine and/or other anticonvulsants to which they had become immune or could not tolerate the side effects of the drugs (Table 1).
The V3 block was performed with fluoroscopic guidance. One milliliter 1% lidocaine was used for skin anesthesia. An 8-cm, 21-gauge needle (Hakko Medical, Nagano-Ken, Japan) was introduced below the zygomatic arch 1.5 to 2 cm anterior to the tragus and directed medially across the infratemporal fossa until it impinged on the lateral pterygoid plate, and was then “walked off” posteriorly until it passed just posterior to the lateral pterygoid plate in the anteroposterior oblique view (Fig. 2, A and B). At this point, needle placement was confirmed to be in proper position per the submentomandibular view (Fig. 2, C and D), and then 0.7 mL 1% lidocaine was injected. After obtaining a sensory loss in the V3 distribution area, 0.7 mL absolute alcohol (Dehydrated Alcohol Injection, USP; Tera Pharmaceuticals, Buena Park, CA) was administered.
Success was defined as the achievement of a pain-free state without medication. Recurrence was defined as the return of any pain, regardless of whether it was controlled by medication or required another procedure. Patients were contacted for periodic follow-up examinations bimonthly by one of our residents who was not otherwise involved in this study. The total follow-up duration was 44.1 ± 24.0 months (range, 2–86 months).
Kaplan-Meier analysis was used to construct pain-free survival curves for censored survival data, and the log-rank test was used to compare the survival curves. The relationships between independent preoperative variables and treatment outcomes were determined by Cox multivariate proportional hazards analysis. Statistical significance was accepted for P values of <0.05.
Ninety-eight patients received 160 V3 blocks during the study period. The clinical characteristics of the study subjects are summarized in Table 1. Seven of the 98 patients (7.1%) died of unrelated causes during the follow-up period, and 21 (21%) were lost to follow-up. Thirty-five of the study subjects (36%) had no further treatment after the first alcohol V3 block over the study period. However, 45 patients (45.9%) experienced recurring pain after the first block and 2 subjects chose medication for pain control when pain recurred (Fig. 1).
Ninety-seven of the 98 study subjects (99%) experienced complete and immediate pain relief without any medication after the first block. According to Kaplan-Meier analysis conducted at 7 years after the first study procedure, mean and median pain-free durations were 46 and 39 months, respectively. The probabilities of remaining pain free at 1, 2, 3, and 7 years after a successful alcohol block were 90.4%, 69%, 53.5%, and 33%, respectively. No significant difference in pain-free durations was found between patients with and without previous alcohol blocks (Fig. 3). Mean (median ± SE, 95% confidence interval) pain-free durations for first and repeated blocks were 47 months (41.0 ± 5.8 months, 30.0–52.4) and 41 months (29.0 ± 10.7 months, 8.1–50.0), respectively.
Thirty-two (20%) of the 160 blocks were associated with complications. Eighteen patients (11.3%) complained of paresthesia, dysesthesia, or deep sensory loss, although all study patients had varying degrees of sensory deficit on the V3 area. However, all sensory discomforts gradually decreased, patients adapted without medication, and the majority of complications resolved within 6 months. Other complications included 7 cases of masseter muscle weakness, 3 of heavy salivation, 3 of tinnitus, and 1 hematoma in the upper cheek. No significant difference in the incidence of complications was found between patients with and without previous alcohol blocks (P < 0.076).
Patient age, gender, onset duration, lateralization of the lesion, and history of surgical procedures were not found to be related to the procedure outcome. However, patients with a complication achieved a significantly longer pain-free duration than patients without a complication (Fig. 4).
Pain relief duration observed in this study is comparable with that reported for alternative techniques such as radiofrequency thermocoagulation; rates of complete pain relief at 1, 2, and 5 years after the procedure were 70%–90%, 62%–65%, and 51%–56%, respectively.3,4 This study failed to find a significant degradation in pain relief duration between first and repeat blocks. This is consistent with a previous study that observed continued efficacy of repeated trigeminal nerve alcohol blocks, even after 14 blocks had been administered in 1 individual over several years.15,17 Our patients with complications had a significantly longer pain-free duration (60 months) than patients without complications (41 months), which is similar to earlier studies.18–20 However, complications of V3 alcohol block were not as serious as other authors have reported.15,21
1. Grant FC. Alcohol injection in the treatment of major trigeminal neuralgia. J Am Med Assoc 1936;107:771–4
2. Ruge D, Brochner SR, Davis L. A study of the treatment of 637 patients with trigeminal neuralgia. J Neurosurg 1958;15:528–36
3. Kanpolat Y, Savas A, Bekar A, Berk C. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25 year experience with 1,600 patients. Neurosurgery 2001;48:524–34
4. Oturai AB, Jensen K, Eriksen J, Madsen F. Neurosurgery for trigeminal neuralgia: comparison of alcohol block, neurectomy, and radiofrequency coagulation. Clin J Pain 1996; 12:311–5
5. North RB, Kidd DH, Piantadosi S, Carson BS. Percutaneous retrogasserian glycerol rhizotomy: predictors of success and failure in treatment of trigeminal neuralgia. J Neurosurg 1990;72:851–6
6. Slettebo H, Hirschberg H, Lindegaard KF. Long-term results after percutaneous retrogasserian glycerol rhizotomy in patients with trigeminal neuralgia. Acta Neurochir (Wien) 1993;122:231–5
7. Lichtor T, Mullan JF. A 10-year follow-up review of percutaneous microcompression of the trigeminal ganglion. J Neurosurg 1990;72:49–54
8. Brown JA, McDaniel MD, Weaver MT. Percutaneous trigeminal nerve compression for treatment of trigeminal neuralgia: results in 50 patients. Neurosurgery 1993;32:570–3
9. Maesawa S, Salame C, Flickinger JC, Pirris S, Kondziolka D, Lunsford LD. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 2001;94:14–20
10. Pollock BE, Phuong LK, Foote RL, Stafford SL, Gorman DA. High-dose trigeminal neuralgia radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 2002;97:347–53
11. Barker FG, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996;334:1077–83
12. Sindou M, Leston J, Howeidy T, Decullier E, Chapuis F. Micro-vascular decompression for primary trigeminal neuralgia (typical or atypical): long-term effectiveness on pain—prospective study with survival analysis in a consecutive series of 362 patients. Acta Neurochir (Wien) 2006; 148:1235–45
13. Loeser JD. Cranial neuralgias. In: Loeser JD, Butler SH, Chapman CR, Turk DC eds. Bonica's Management of Pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001:855–60
14. Fardy MJ, Zakrzewska JM, Patton DW. Peripheral surgical techniques for the management of trigeminal neuralgia: alcohol and glycerol injections. Acta Neurochir 1994;129:181–5
15. McLeod NMH, Patton DW. Peripheral alcohol injections in the management of trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:12–7
16. Zakrzewska JM. Trigeminal, eye and ear pain. In: Wall PD, Melzack R eds. Textbook of Pain. 4th ed. London: Churchill Livingstone, 2000:739–41
17. Ecker A, Perl T. Precise alcoholic gasserian injection for tic douloureux. J Neurol Neurosurg Psychiatry 1965;28:65–70
18. Taha JM, Tew JM, Buncher CR. A prospective 15-year follow up of 154 consecutive patients with trigeminal neuralgia treated by percutaneous stereotactic radiofrequency thermal rhizotomy. J Neurosurg 1995;83:989–93
19. Jawahar A, Wadhwa R, Berk C, Caldito G, DeLaune A, Ampil F, Willis B, Smith D, Nanda A. Assessment of pain control, quality of life, and predictors of success after gamma knife surgery for the treatment of trigeminal neuralgia. Neurosurg Focus 2005;18:E8
20. Spatz AL, Zakrzewska JM, Kay EJ. Decision analysis of medical and surgical treatments for trigeminal neuralgia: how patient evaluations of benefits and risks affect the utility of treatment decision. Pain 2007;131:302–10
21. Fardy MJ, Patton DWP. Complications associated with peripheral alcohol injections in the management of trigeminal neuralgia. Br J Oral Maxillofac Surg 1994;32:387–91
© 2010 International Anesthesia Research Society
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read