Correspondence
Case 21-2006: A Man with Left-Sided Facial Pain
N Engl J Med 2006; 355:2375-2376November 30, 2006
- Article
To the Editor:
The Case Record describing a 61-year-old man with facial pain was a clear presentation of the management of trigeminal neuralgia (July 13 issue).1 Patients who do not have a response to medical therapy or who have intolerable adverse effects are suitable candidates for surgery. Although microvascular decompression is associated with a good outcome, with low overall mortality and complication rates, the procedure remains invasive. Rhizotomy is associated with recurrence in 25 to 50% of patients within 2 to 3 years after treatment and with a higher incidence of facial numbness than is microvascular decompression.2
The authors do not mention stereotactic radiosurgery, a noninvasive, outpatient treatment that is performed without the use of sedation or general anesthesia. Radiosurgery delivers a single high dose of radiation (gamma rays by means of a gamma knife or photon beams by means of a dedicated linear accelerator) with high precision at the proximal trigeminal root, with the patient placed in a stereotactic frame and a target defined on the basis of magnetic resonance imaging. Although the data on radiosurgery for trigeminal neuralgia are predominantly observational and this technique should be studied in a randomized trial, the outcomes with radiosurgery are very similar (83% of patients are pain free) to those achieved with other techniques.3 Until such trials are performed, it seems only fair to inform our patients, and our colleagues, about all the treatment approaches that are available.
3 ReferencesW. Peter Vandertop, M.D., Ph.D.
Frank J. Lagerwaard, M.D., Ph.D.
VU University Medical Center, 1007MB Amsterdam, the Netherlands
wp.vandertop@vumc. nl 1
Case Records of the Massachusetts General Hospital (Case 21-2006). N Engl J Med 2006;355:183-188
Full Text | Web of Science | Medline2
Trigeminal neuralgia. In: Greenberg MS, ed. Handbook of neurosurgery. New York: Thieme Medical, 2006:373-80.
3
Regis J ,Metellus P ,Hayashi M ,Roussel P ,Donnet A ,Bille-Turc F . Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia. J Neurosurg 2006;104:913-924
CrossRef | Web of Science | Medline
To the Editor:
Surprisingly, the authors of the July 13 Case Record did not include oral galvanism as a potential cause of this patient's trigeminal neuralgia.1,2 No mention was made of his dental status or dental procedures he might have undergone before the onset of the facial neuralgia. It would have been informative to know whether he had dissimilar intraoral metals, which may create an intraoral electrical current.2,3 Since a metallic taste — along with electrical facial pain — is the clinical hallmark of such galvanic currents,2 I believe that oral galvanism should be taken into account in the differential diagnosis of trigeminal neuralgia.
3 ReferencesGianpaolo Guzzi, D.D.S.
Italian Association for Metals and Biocompatibility Research, 20122 Milan, Italy
gianpaolo_guzzi@fastwebnet.it 1
Chesire WP Jr . The shocking tooth about trigeminal neuralgia. N Engl J Med 2000;342:2003-2003
Full Text | Web of Science | Medline2
Hugoson A . Results obtained from patients referred for the investigation of complaints related to oral galvanism. Swed Dent J 1986;10:15-28
Web of Science | Medline3
Sutow EJ ,Maillet WA ,Taylor JC ,Hall GC . In vivo galvanic currents of intermittently contacting dental amalgam and other metallic restorations. Dent Mater 2004;20:823-831
CrossRef | Web of Science | Medline
Author/Editor Response
We appreciate the comments of Vandertop and Lagerwaard regarding the potential role of radiosurgery for the treatment of trigeminal neuralgia. Radiosurgery is a relatively new treatment and has not been compared with standard treatments in a formal randomized trial. Moreover, there are fewer data on long-term results of radiosurgery than on those of other treatments. However, it is a reasonable alternative and will probably have a place alongside the standard treatments in the future. In our practice, we include a discussion of radiosurgery when counseling patients about the different options for therapy.
With regard to the comments of Guzzi, oral galvanism is a rare and somewhat controversial cause of severe facial pain. Patients with pain centered over particular teeth should be thoroughly evaluated by a dentist or oral surgeon to rule out oral galvanism and other dental abnormalities that could be mistaken for trigeminal neuralgia.
Emad Eskandar, M.D.
James Rabinov, M.D.
Frederick G. Barker, II, M.D.
Massachusetts General Hospital, Boston, MA 02114- Citing Articles (1)
Citing Articles
1
Young Seok Park, Joo Pyung Kim, Won Seok Chang, Hae Yoo Kim, Yong Gou Park, Jin Woo Chang. (2011) Gamma knife radiosurgery for idiopathic trigeminal neuralgia as primary vs. secondary treatment option. Clinical Neurology and Neurosurgery 113:6, 447-452
CrossRef
