"One Shot To Silence The Pain”: Chemical Neurolysis For Trigeminal Neuralgia

Abstract

Objectives: To demonstrate the feasibility, safety, and efficacy of fluoroscopy-guided chemical neurolysis of the trigeminal nerve in a patient with refractory  Trigeminal-Neuralgia.  Methods: A 55-year-old male with right-sided facial pain since 2018, consistent with classical trigeminal neuralgia, reported electric shock-like pain triggered by cold, chewing, or speaking. The pain was resistant to multiple pharmacologic agents, including carbamazepine and pregabalin. MRI revealed a cerebellopontine angle mass without vascular compression. With no vestibular or sensory deficits impacting candidacy, a fluoroscopy-guided chemical neurolysis was planned.  Under local anaesthesia and aseptic conditions, a spinal needle was percutaneously advanced to the foramen ovale using a lateral submental tilt  approach. The needle tip was positioned near the V3 division of the trigeminal nerve under real-time fluoroscopy. After confirming placement, a diagnostic block with 2 mL of 0.5% bupivacaine was administered. Following symptom relief, 3 mL of absolute alcohol was slowly injected into the seated patient seated. The patient was monitored for two hours post-procedure in a neck-flexed sitting position. Results: The patient experienced immediate and significant pain relief, with the Visual Analogue Scale (VAS) score dropping from 9/10 to 2/10. At one-month follow-up, he remained pain-free without medication. Mild infraorbital numbness was reported but did not affect function. Conclusion: This case supports fluoroscopy-guided chemical neurolysis as a safe, effective, and cost-efficient treatment for refractory TN, particularly in patients unresponsive to medications and not suitable for surgical interventions.