MCS and Trigeminal Neuropathic Pain

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Trigeminal neuropathic facial pain is a syndrome of severe, constant facial pain related to disease of, or injury to, the trigeminal nerve or ganglion. Causes of trigeminal neuropathic pain can include injury from sinus or dental surgery, skull and/or facial trauma, or intentional destruction for therapeutic reasons (deafferentation), as well as intrinsic pathology of any part of the trigeminal system (Burchiel, 2003). Despite extensive studies, no significant advances have occurred in its pharmacological treatment and it continues to be treated with anticonvulsant and antidepressant therapies. Many patients who fail surgical treatment for trigeminal neuralgia will develop trigeminal neuropathic pain (also called trigeminal deafferentation pain (Burchiel, 2003)), for which there are few, if any, effective treatments. Many treatments that are effective for trigeminal neuralgia can, in fact, worsen trigeminal neuropathic pain. Deep brain stimulation of well-defined targets in the sensory thalamus and periaqueductal or periventricular gray matter with stereotactic placement of electrodes has not proven efficacious (Burchiel, 2001; Coffey, 2001). MCS has shown some promise in the treatment of trigeminal neuropathic pain.

Despite the encouraging reports of MCS for neuropathic pain in the literature, there is still some question as to its true efficacy. The effect of MCS can wane over time, requiring reprogramming (Henderson et al., 2004). Even in patients who undergo intensive reprogramming, pain relief cannot always be achieved. There is a risk of seizures during stimulator programming (Meyerson et al., 1993; Ebel et al., 1996; Rainov et al., 1997; Henderson et al., 2004), although the development of epilepsy has not been reported. There thus exists clinical equipoise regarding the true risk/benefit ratio of MCS for the treatment of trigeminal neuropathic pain. In addition, programming parameters vary from investigator to investigator, with some groups achieving pain relief from parameters that other groups find ineffective.

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