title: Trigeminal and sphenopalatine ganglion stimulation for intractable craniofacial pain--case series and literature review.
abstract: BACKGROUND
  Facial pain is often debilitating and can be characterized by a sharp, stabbing, burning, aching, and dysesthetic sensation. Specifically, trigeminal neuropathic pain (TNP), anesthesia dolorosa, and persistent idiopathic facial pain (PIFP) are difficult diseases to treat, can be quite debilitating and an effective, enduring treatment remains elusive.
  
  
  METHODS
  We retrospectively reviewed our early experience with stimulation involving the trigeminal and sphenopalatine ganglion stimulation for TNP, anesthesia dolorosa, and PIFP between 2010-2014 to assess the feasibility of implanting at these ganglionic sites. Seven patients received either trigeminal and/or sphenopalatine ganglion stimulation with or without peripheral nerve stimulation, having failed multiple alternative modalities of treatment. The treatments were tailored on the physical location of pain to ensure regional coverage with the stimulation.
  
  
  RESULTS
  Fluoroscopy or frameless stereotaxy was utilized to place the sphenopalatine and/or trigeminal ganglion stimulator. All patients were initially trialed before implantation. Trial leads implanted in the pterygopalatine fossa near the sphenopalatine ganglion were implanted via transpterygoid (lateral-medial, infrazygomatic) approach. Trial leads were implanted in the trigeminal ganglion via percutaneous Hartel approach, all of which resulted in masseter contraction. Patients who developed clinically significant pain improvement underwent implantation. The trigeminal ganglion stimulation permanent implants involved placing a grid electrode over Meckel's cave via subtemporal craniotomy, which offered a greater ability to stimulate subdivisions of the trigeminal nerve, without muscular (V3) side effects. Two of the seven overall patients did not respond well to the trial and were not implanted. Five patients reported pain relief with up to 24-month follow-up. Several of the sphenopalatine ganglion stimulation patients had pain relief without any paresthesias. There were no electrode migrations or post-surgical complications.
  
  
  CONCLUSIONS
  Refractory facial pain may respond positively to ganglionic forms of stimulation. It appears safe and durable to implant electrodes in the pterygopalatine fossa via a lateral transpterygoid approach. Also, implantation of an electrode grid overlying Meckel's cave appears to be a feasible alternative to the Hartel approach. Further investigation is needed to evaluate the usefulness of these approaches for various facial pain conditions.
authors.affiliation: Medical School, Harvard University, Cambridge, MA, USA.
authors.forename: Arsani
authors.initials: A
authors.lastname: William
authors.affiliation: Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Tej Deepak
authors.initials: TD
authors.lastname: Azad
authors.affiliation: Medical School, Harvard University, Cambridge, MA, USA.
authors.forename: Eliezer
authors.initials: E
authors.lastname: Brecher
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Taissa
authors.initials: T
authors.lastname: Cherry
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Ivan
authors.initials: I
authors.lastname: Bernstein
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Diana M
authors.initials: DM
authors.lastname: Bruce
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Stacey
authors.initials: S
authors.lastname: Rohrer
authors.affiliation: Department of Neurosurgery, Northwestern University, Evanston, IL, USA.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Smith
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: William
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Sabelman
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: Heit
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA.
authors.forename: Patrick
authors.initials: P
authors.lastname: Pezeshkian
authors.affiliation: Department of Neurosurgery, Kaiser Permanente-The Permanente Medical Group (TPMG), 1150 Veterans Blvd., 3rd Floor Tower, Redwood City, 94063, CA, USA. msedrak@gmail.com.
authors.forename: Mark
authors.initials: M
authors.lastname: Sedrak
mesh_terms: D000328:Adult; D000368:Aged; D004599:Electric Stimulation Therapy / Q000379:methods*; D004567:Electrodes, Implanted; D005157:Facial Pain / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D005260:Female; D005726:Ganglia, Parasympathetic / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009437:Neuralgia / Q000209:etiology / Q000628:therapy; D010148:Intractable Pain / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D012852:Sinusitis / Q000150:complications; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D012668:Trigeminal Ganglion / Q000601:surgery
keywords: Anesthesia dolorosa; Persistent idiopathic facial pain; Sphenopalatine ganglion; Trigeminal neuralgia