The Clinical journal of pain
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The efficacy of the anticonvulsant drug carbamazepine in the management of trigeminal neuralgia is evidenced in several controlled trials, and the numbers needed to treat to obtain one patient with at least 50% pain relief (NNT) is 1.7. Single small trials have shown that baclofen alone provides pain relief (NNT = 1.4) and that lamotrigine has an additional effect in patients with insufficient relief using carbamazepine or phenytoin (NNT = 2.1). Uncontrolled observations and clinical practice indicate that phenytoin, clonazepam, sodium valproate, gabapentin, and lidocaine will also relieve trigeminal neuralgia. ⋯ Acute exacerbation has successfully been treated with intravenous loading with phenytoin or lidocaine, but again these procedures have not been tested in controlled trials. In conclusion, carbamazepine is the mainstay of pharmacotherapy of trigeminal neuralgia, and secondary drug choices are baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin, and sodium valproate. Controlled trials testing the effect of some of these drugs, new drugs, and drug combinations are needed.
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The assumption that individuals are capable of accurately recalling past painful experiences has been a fundamental tenet of a number of cognitive-behavioral theories of pain, including the gate control theory. However, there has been very little research on the topic in the past, and the results have often been contradictory. A general conclusion that can be drawn is that memory for pain is variable, and there is need to identify what factors contribute to this variability in memory for pain. The current study examined the relation of catastrophizing to the recall of persistent pain associated with rheumatoid arthritis. ⋯ Participants who scored higher on catastrophizing demonstrated better accuracy in the recall of general pain intensity and pattern over a 30-day diary period. The results of the study are discussed in terms of future studies as well as their potential clinical importance.
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Microvascular decompression (MVD) remains the only treatment of trigeminal neuralgia that directly addresses the presumed pathogenesis. It is a proven therapy, associated with the longest duration of pain relief while preserving facial sensation. ⋯ In an effort to more successfully select candidates for MVD, the authors have incorporated high-resolution magnetic resonance imaging into our preoperative algorithm, since it has proven extremely accurate in defining the neurovascular relations at the trigminal nerve complex. Microvascular decompression can only be recommended when it is performed with low rates of morbidity.
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Extradural cortical stimulation is a recent addition to the armamentarium of functional neurosurgery. This article reviews results of treatment of chronic central and neuropathic pain. ⋯ It is concluded that extradural cortical stimulation may be effective in several refractory cases.
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Review
Peripheral and gasserian ganglion-level procedures for the treatment of trigeminal neuralgia.
This review discusses the various peripheral and ganglion-level procedures available for treating trigeminal neuralgia and summarizes specific success and complication rates for each technique. ⋯ Each patient should receive an informed and impartial account of the available surgical options. There is a need for prospective randomized controlled studies in procedure-naïve subjects to determine the optimal surgical management of trigeminal neuralgia.