Contributed by Andrew W. Grande, MD
Many patients with facial pain have compounding disorders that cause or exacerbate their condition, including trigeminal neuralgia (TN), dental problems, migraines, and depression. In these complex cases, surgery alone for TN might not eliminate all of the patient’s pain. These patients can benefit from a multidisciplinary team approach in which specialists collaborate to help resolve the multiple factors causing pain or enhancing perception of pain.
A 26-year-old female presented at the Neurosurgery Department at University of Minnesota Medical Center seeking treatment for severe, debilitating facial pain. The patient reported using several medications to manage the chronic pain. The patient’s shock-like, intermittent pain on one side of her face led to a diagnosis of TN, and we recommended microvascular decompression (MVD), an in-patient procedure performed under general anesthesia. This procedure is recommended for younger patients because it is far more likely to provide a permanent solution for TN than less-invasive surgical procedures are.1
The patient chose to seek a second opinion at a different medical facility, where she subsequently underwent MVD surgery. This operation did not control her chronic facial pain. In frustration, approximately 5 months after her first consultation, she returned to University of Minnesota Medical Center for further treatment. The physician assistant performing initial patient evaluations for the Department of Neurosurgery guided the patient to the Facial Pain Clinic.
The clinic’s specialists met with the patient to discuss her treatment options, recommending that her condition should be re-explored surgically. The patient agreed and underwent an MVD surgery, in which a vein that had continued to compress the trigeminal nerve, causing pain, was removed. The neurosurgeon also relieved pressure on the trigeminal nerve by drawing away an additional large branch of the artery. The patient recovered without sequelae.
After the successful surgery, the clinic’s team of specialists consulted with the patient to develop a pain management plan that would address the patient’s emotional health and dependence on pain medications. The patient was referred and agreed to receive treatment from a neuropsychologist affiliated with the University of Minnesota School of Dentistry, who treats acute and chronic pain, as well as systemic illnesses exacerbated by stress. The physician team recognized that chronic pain can heighten a patient’s distress and exacerbate depression, which in turn can increase the expression of pain and cause further pain symptoms.
The team also recommended that the patient receive treatment from a University of Minnesota Health pharmacist specialist. The specialist helped the patient wean from numerous pain medications. Throughout the treatment processes and follow-ups, the physician assistant continued to communicate with the patient and track her progress, while updating the Facial Pain Clinic’s primary and consulting specialists.
Chronic pain is also linked to an increase in depression, anxiety, sleeping problems, and social isolation. In recent years, studies have shown that mental health disorders can increase the expression of pain and trigger even more pain. Providers, as a result, should consider not only the biological aspects of chronic pain but also its psychological impacts and its effects on a patient’s social interactions, according to A National Pain Strategy, released in March 2016.2 For patients with severe facial pain or TN, an integrated, multidisciplinary care approach best addresses the complexity of these conditions.
The severe pain of trigeminal neuralgia can disrupt patient lives and trigger depression. New surgical procedures and multidisciplinary approaches that take into account the impact of chronic pain are providing relief.Continue reading