gms | German Medical Science

Objective: Persistent trigeminal neuralgia remains a challenge for any pain physician. Medical treatment options often do not provide sufficient pain relief. Operative and interventional as well as neuromodulative procedures are well able to control the pain. However, when these measures fail to provide long-term pain control treatment the becomes extremely difficult.

Method: We report a case of a 72 years old female, who initially presented with a sphenoid ridge meningioma, which extended into Meckel´s cave and caused a severe trigeminal neuralgia V1,2 on the right side. The patient was operated on this tumor 4 times (2x 1990, 1997 and 2010). A Linac radiation had already been performed on 1997. The trigeminal neuralgia persited despite extensive medical treatment. A trigeminal thermocoagulation was performed twice with only short-term success (3 months of pain relief). Subsequently, a caudalis DREZ lesion from C2 up to the obex was performed in 2010. However, the trigeminal neuralgia did not subside.

Finally in 2012, a Rickham reservoir with a ventricular catheter was placed into the left lateral ventricle. Several intraventricular test injections with 0,2 mg and 0,4 mg of morphin each were performed in an intensive care set up. Afterwards, the trigeminal neuralgia subsided remarkably. We finally implanted a permanent drug delivery pump in the abdominal region.

Results: Since then, the frequency of the attacks of the trigeminal neuralgia has been reduced by 50%. The severity of the pain has dropped on VAS from 9–10/10 to about 6/10.

Currently, the daily dose of morphin is 2,5 mg. However, the previous pain medication consisting of Lamotrigen, Gabapentin and Neurocil has still to be continued.

Conclusions: In desperate situations of trigeminal neuralgia not responsive to any treatment, intraventricular application of morphin may still be a valuable option of therapy