P051: TREATMENT OF SEVERE COMBINED HEAD AND FACIAL PAIN VIA CERVICOMEDULLARY JUNCTION RETROGRADE SPINAL CORD STIMULATION LEAD PLACEMENT
Juan Mora, MD, James Ashford, MD, Ivan Samcam, MD, Ajay Antony, MD, Rene Przkora, MD, PhD; University of Florida
Background: Chronic neuropathic facial pain is well known to be extremely difficult to treat with conservative medical management. However, chronic neuralgias involving the head and neck have been confirmed to respond well to neuromodulation via peripheral nerve stimulation (PNS).
Like PNS, spinal cord stimulation (SCS) has been shown to be an effective therapy in conditions such as failed back surgery syndrome, radiculopathy, peripheral neuropathy, and CPRS. The use of high cervical SCS at the cervicomedullary junction can provide significant pain reduction in neuralgias located above the neck such as occipital neuralgia and supraorbital neuralgia. Due to the significant anatomical overlap between afferent nerve fibers of the trigeminal nerve and C2-3 nerve roots. This overlap forms the trigeminocervical complex (TCC) which projects from the trigeminal nucleus caudalis at the level of C3.
Case Description: A 54-year-old female with history of chronic migraines and cervicalgia caused by an MVC whiplash injury who subsequently developed severe unrelenting right frontotemporal and supraorbital pain unresponsive to appropriate medical management. Interventional head and neck denervation modalities such as Botulinum toxin, cervical epidural steroid injections, and radiofrequency denervation of her cervical facet joints all failed to provide adequate pain relief. Patient experienced unilateral allodynia, alopecia in the right frontotemporal area and due to the supraorbital pain exacerbation, she was unable to lie flat which greatly decreased her ability to sleep. Work up to determine the etiology of her pain including temporal artery biopsy and head and cervical spine MRI did not show any structural lesions that would contribute to her symptoms.
Patient underwent a successful cervicomedullary spinal cord stimulation trial with a percutaneous epidural paddle lead. The single lead was placed with contacts between C1-C5. Her supraorbital and frontotemporal pain was most responsive using the paresthesia free amplitudes of BurstDR™ stimulation at the C2-C3 level. Pain intensity preoperatively was 8/10. This intervention completely resolved her pain during the subsequent 7-day SCS trial period. On the basis of her excellent response, a permanent Penta™ 5-column epidural paddle lead was placed via a retrograde approach at C1 to overlay the C2-3 levels. There were no procedural complications. At the first follow-up visit, the SCS therapy was initiated, and the patient experienced significant pain reduction (>90%) over both her cervical and supraorbital pain foci.
At 5-months follow–up, she continued to report an excellent reduction of her pain as well as overall functional improvement.
Discussion: We present a case report of a patient with severely debilitating, unrelenting right supraorbital and frontotemporal pain (atypical facial pain) that was refractory to conservative therapy. However, since her pain was responsive to cervical SCS, particularly “burst mode” during the trial, she underwent a retrograde permanent paddle-type lead placement with complete resolution of pain and significant improvement of daily function and quality of life as well as a reduction in her requirement of pain medications. This also supports previous studies which conclude that cervical SCS to be both safe and efficacious and the new paresthesia-free modalities may show promise in treating headache and facial pain.