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Prolonged relief of tic douloureux from partial root destruction is associated with localized analgesia.

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Prolonged Relief of
Tic Douloureux from
Partial Root Destruction
Is Associated with
Localized A nalge sia
prolonged relief of tic douloureux ( T D ) are usually achieved. B u t how much of the half-face need be
denervated? Which modalities of sensation must be
impaired, and to what degree? Previous studies have
shown n o correlation between the exact location,
extent, quality, intensity, o r duration of sensory defect and relief of TD [l-3, 6, 81. Among these negative results were two from my own studies [ 2 , 31
which included patients’ awareness of sharpness, but
not actual pain, from superficial pinprick stimulation;
the latter is reported here.
T h e present inquiry sought to determine whether,
after partial root destruction, prolonged relief of TD
is associated with persistent loss of sensation of pain
o n pinprick in the formerly neuralgic area or areas
and, conversely, whether late recurrence of TD is associated with recovery of pain o n pinprick in the
neuralgic areas.
Arthur Ecker, MD, PhD
Fifty-eight patients who had been relieved of tic
douloureux (TD) for at least 3 years after partial destruction of the trigeminal sensory root by injection of
minimal amounts of alcohol were reexamined 3$$ to 21
years after treatment. Of 41 patients still in remission
at a median of 10 years after treatment, 32 had
analgesia; i.e., sensation of pain from pinprick was absent in all 52 originally neuralgic areas. T h e other 9
patients in remission had some pain on pinprick in
their neuralgic areas. I n contrast, of 17 patients with
recurrence of T D 334 to 11 years (median, 6 years) after
treatment, at least 15 had demonstrable pain on pinprick in the neuralgic areas. I t is concluded that continuing absence of pain on pinprick in the affected facial mucocutaneous area (or areas) is associated with
prolonged relief of tic douloureux.
Ecker A: Prolonged relief of tic douloureux from
partial root destruction is associated with localized
analgesia. Ann Neurol 7:181-182, 1980
After partial destruction of the trigeminal sensory
root by any means-surgical,
chemical, o r thermal-partial
denervation of the side of the face and
All patients with classic T D who had been treated by precise minimal alcohol injection of the juxtaganglionic
trigeminal root at least 3 years previously were invited to
return for reexamination without charge. Forty-one patients still in remission returned. At the same time, 17 patients who had been relieved for at least 3 years and were
now suffering recurrent T D were reexamined. This report
is based on study of these 58 patients.
Besides the cornea, 25 areas o n each half-face were
tested: 15 on skin and 10 on oral mucous membrane. The
corresponding area on the healthy half of the face was always tested first as a standard of normal. Tactile sensation
was tested by a light stroke, a few millimeters long, with a
cotton swab 4 mm in diameter. For painful sensation-not
just sharpness-from pinprick, a sharp pin was pressed
firmly twice in each area, but not deeply enough to draw
blood. Semiquantitative responses were recorded [2, 31.
PROLONGED RELIEF FROM TD. Forty-one patients
with 66 neuralgic areas remained free from TD for
3% to 2 1 years (median, 10 years) after injection. Of
the 66 neuralgic areas in these 4 1 patients, 42 were
o n the skin of the cheek and 24 o n the oral mucous
membrane. Among these 41 patients, 32 had absence
of pain o n pinprick in all of their 52 original neuralgic
areas (Table 1). These areas were usually more than 2
cm in diameter. Touch sensation was absent in 28 of
these 52 areas (median, 7 years after injection) and
present in 24 areas (median, 11 years).
N i n e patients (with 14 neuralgic areas) from the 41
still in remission at reexamination had some pain o n
pinprick in o n e or m o r e of their neuralgic areas; 4 of
these patients had absence of pain from pinprick in at
least 1 neuralgic area.
Accepted for publication June 17, 197’9.
Address reprint requests to Dr Ecker, 407 University Ave, Syracuse, N Y 13210.
LATE RECURRENCE. From 31/2 to 11 years after
injection (median, 6.5 years), 17 patients (with 22
0364-5134/80/020181-02s01.25 @ 1978 by Arthur Ecker
Table 1 . Maximal Lerel of Sensation in 66 Neuralgic
Areas of 41 Patiewts during Continued Relief from T D ,
.3 lJ2 t o 21 Years after Alcohol lnjection
Pain on
Normal or almost
Moderately diminished
Markedly diminished
10 4
10 9
78 17
100 41
Table 2. hlaxinial Level of Sen.ratiot2 in 22 Neuralgic
Areas of 17 Patients at Recurrence of T D , 3'12 t o 11
Years after Alcohol 111jectioti
Pain o n
Normal or almost
Moderately diminished
Markedly diminished
"A single region 2 to 3 mm in diameter was tested; in 1 of these
patients light touch was normal, and in the other, almost normal.
neuralgic areas) had recurrence of severe TD in 1 or
more of these areas (Table 2). Of the 22 neuralgic
areas, 15 were in the oral cavity and 7 in the skin of
the half-face. At recurrence, both pain sensation on
pinprick and light tactile sensation were present in
almost all of these areas, which sometimes were less
than 2 cm in diameter. In some cases it was necessary
to test many sites within a small area to find painsensitive points. Unfortunately, this was not done in
the 2 patients in whom pain on pinprick was reported
T o avoid the chance of spontaneous remission, a
minimum of 3 years of freedom from TD after alcohol injection was required for patients to enter this
study. Many patients had died, all due to causes unrelated to TD; this was the case in more than half of
those who had been injected 11 to 2 1 years previously. Most of the rest were unwilling to return for
reexamination because of distance, senility, or other
infirmity. Those with recurrence returned because
they desired further medical treatment. Since the
Annals o f Neurology
No 2 February 1980
numbers of patients are small, they cannot be dealt
with statistically and the results should be viewed
with caution.
At the time of alcohol injection of the trigeminal
sensory root, total loss of both light touch and pain on
pinprick in the neuralgic areas was deliberately produced [4, 51. As patients were reexamined through
the years, it was found that light touch sensation usually returned before pain from pinprick, and often
without recurrence of TD [2, 31. Even though TD is
usually triggered by nonnoxious stimuli (touch or
muscle afferents), there are 24 patients in this report
who had tactile sensation in 1 or more neuralgic areas
and still were free from TD after many years (see
Table 1). Therefore, TD did not recur after return of
tactile stmsation alone, but only after pain from pinprick could be felt in the neuralgic area as well. This
observation is consistent with early results reported
after radiofrequency thermocoagulation of the trigeminal sensory root [7I.
1. Burmeister H : Trigeminusneuralgie. Beobachtungen und Erfahrungen an Hand von 730 chirurgisch behandelten Kranken.
Arch Klin Chir 295:175-185, 1960
2. Ecker A: Tic douloureux. Eight years after alcoholic gasserian
injection. N Y State J Med 74:1586-1592, 1974
3. Ecker A: Sensory loss and prolonged remission of tic
douloureux after selective alcoholic gasserian injection, in
Bonica JJ, Albe-Fessard D (eds): Advances in Pain Research
and Therapy. New York, Raven, 1976
4. Ecker A: Precise selective alcoholic gasserian injection for tic
douloureux. Recent advances in technic and results. Acta
Neurochir 34:241-243, 1976
5. Ecker A, Per1 T: Selective gasserian injection for tic
douloureux. Acta Radio1 (Stockh) 938-48, 1969
6. Rasmussen P: Facial Pain. Copenhagen, Munksgaard, 1965
7. Sweet WH: Treatment of facial pain by percutaneous differential thermal trigeminal rhizotomy, in Krayenbuhl H (ed):
Progress in Neurological Surgery 7 Primary Afferent Neurons.
Basel, Karger, 1976
8. White JC, Sweet WH: Pain and the Neurosurgeon. Springfield,
IL, Thomas, 1969
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associates, destruction, relief, tic, localized, partial, prolonged, analgesia, roots, douloureux
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