Open Journal of Anesthesiology, 2013, 3, 375-378
Published Online November 2013 (
Open Access OJAnes
Continuous Inferior Alveolar Nerve Block Using an
Indwelling Catheter and Inferior Maxillary Artery
Embolization for the Management of Atypical
Trigeminal Neuralgia
Samer Abdel-Aziz, Ahmed Ghaleb
Department of Anesthesiology and Pain Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
Received July 5th, 2103; revised August 6th, 2013; accepted September 1st, 2013
Copyright © 2013 Samer Abdel-Aziz, Ahmed Ghaleb. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
A 40-years-old female patient with severe right facial pain with a throbbing component along the mandibular division
of the trigeminal nerve resistant to medical management. Continuous inferior alveolar nerve block with local anesthetics
using an indwelling catheter provided a complete p ain resolution for the patient for 2 weeks, after which the catheter got
infected and was removed. A trial of balloon occlusion of the right internal maxillary artery provided complete resolu-
tion of the throbbing component of the patient’s pain. This was followed by permanent embolization with multiple
Keywords: Trigeminal Neuralgia; Inferior Alveolar Nerve Block; Inferior Maxilary Artery Embolization
1. Introduction
Trigeminal neuralgia (TN) can cause severe pain resis-
tant to medical management. Several interventional pain
and surgical procedures are available and individualized
based on the patient’s condition. We report a case with
severe trigeminal neuralgia pain resistant to medical ma-
nagement in which we used two uncommon treatment
modalities that provided excellent pain relief for our pa-
tient; continuous inferior alveolar nerve block with local
anesthetics using an indwelling catheter and internal
maxillary artery embolization.
2. Case Report
A 40-year-old female referred to our pain clinic com-
plaining of right facial pain along the mandibular divi-
sion of the trigeminal nerve for 4 years. She describes her
pain as constant throbbing burning pain with occasional
electric-like sensation. The pain is 8/10 in severity. It
occasionally goes up to 10/10 and gets severe enough for
her to think about killing herself. It affects her daily ac-
tivities, occasionally keeping her in bed all day. It gets
worse in the ev ening and gets better wh en she app lies ice
on her face and after she takes her atenolol pill which she
takes twice a day for h ypertension. Th e pain was initially
thought to be of dental cause which resulted in her hav-
ing multiple dental procedures without improvement.
Over the past 4 years, she tried multiple medications in-
cluding Ibuprofen, gabapentin, carbamazepine, cyclo-
benzaprine with minimal relief. She had and MRI and
MRA of her face and neck to exclude any mass effect or
vascular compression of the nerve, all were reported nor-
mal. We initially started her on topiramate and amitrip-
tyline with oxycodone-acetaminophen pills for break-
through, this improved her pain to 5/10. However it was
still severe, affecting her ability to perform her daily ac-
tivities. As medical management failed to provide suffi-
cient pain relief, decision was made to proceed with a
nerve block. Right inferior alveolar and lingual nerve
blocks were performed by injecting 5 ml of lidocaine 1%,
1 ml of triamcinolone (40 mg/ml) and 5 ml of bupiva-
caine 0.5%. The patient reported complete resolution of
pain for 2 days only, so decision was made to proceed
with placement of an indwelling catheter that the patient
Continuos Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery
Embolization for the Management of Atypical Trigeminal Neuralgia
can dose herself with a local anesthetic like bupivacaine
0.5%. The catheter was placed close to the right inferior
alveolar nerve using an epidural needle set and was se-
cured in place with Nylon sutures. The catheter place-
ment was successful and provided excellent pain relief
for the patient however, one month later the catheter dis-
lodged from its placed and had to be replaced. Two
weeks after the catheter replacement it got infected and
had to be removed. After the catheter removal the patient
experienced severe pain again, at this point we decided to
refer her for interventional radiology for an angiogram
and temporary occlusion of her right internal maxillary
artery as this might help with her throbbing pain. A bal-
lon catheter was advanced into the right internal maxil-
lary artery and was kept inflated for 10 minutes, the pa-
tient reported complete resolution of her throbbing pain.
Since the patient passed the ballon test, embolization of
the artery with multiple detachable and push coils was
performed. After the artery embolization the patient re-
ported complete resolution of her throbbing pain. She
still reports having some burning pain which is well con-
trolled with the topiramate and amitriptyline. On her last
clinic visit she reported a pain score of 0/10.
3. Discussion
Trigeminal neuralgia (TN) is a sudden, unilateral, severe,
brief, recurrent episodes of pain in the distribution of one
or more branches of the trigeminal nerve [1]. It is the
most common form of cranial neuralgia [2,3], with an
incidence of 4.3 per 100,000 persons per year, with a
slightly higher incidence for women (5.9 per 100,000)
compared with men (3.4 per 100,000) [4]. The gender
ratio of prevalence in women to men is approximately
2:1 [5].
In the large majority of TN patients, the clinical ex-
amination, imaging studies and laboratory tests are un-
remarkable (classic TN). However, in a smaller group,
the signs and symptoms of TN are secondary to another
disease process affecting the trigeminal system (symp-
tomatic TN) [6,7]. Both dental and medical professionals
often misdiagnose the disorder, potentially resulting in
unnecessary dental extractions or inappropriate prescrip-
tion of drugs.
The cause of trigeminal neuralgia has not been defini-
tively established. However, the most prevalent cause is
mechanical compression, generally by an artery (superior
cerebellar artery or one of its branches) or a tumor, of the
trigeminal root as it exits the brain stem [8]. Also, fol-
lowing trauma, regenerating nerve fibers become rela-
tively depolarized and physiologically more excitable.
Spontaneous action potentials may originate from multi-
ple sites and a single action potential may evoke sus-
tained discharges [6].
Optimal treatment of TN remains challenging, as each
clinical situation can vary significantly. Patients who
suffer from TN have a number of treatment modalities to
consider, and treatments should be tailored to the indi-
vidual situation. Conservative management with drug
therapy is always the first-line treatment. When drugs are
not efficacious or produce intolerable adverse effects,
interventional pain treatment or surgery is considered.
Carbamazepine has been used for many decades in the
treatment of TN, and it is the drug of choice [9,10]. Other
medications with reported efficacy include oxcarbaze-
pine, baclofen, and lamotrigine [11-13]. Topiramate, ga-
bapentin, pregabalin, and levetiracetam have also shown
success in treating TN [11].
Peripheral techniques like cryotherapy, neurectomies,
peripheral acupuncture, peripheral radiofrequency ther-
mocoagulations (RFTs) and a variety of injections, such
as alcohol, phenol and streptomycin have been described
as treatment modalities for TN. Percutaneous procedures
at the level of the Gasserian ganglion which involve the
insertion of a cannula through th e foramen ovale into the
trigeminal ganglion have also been used. The ganglion
can then be lesioned using heat (RFTs), injection of glyc-
erol, or mechanical compression by a balloon.
Microvascular decompression (MVD) and gamma knife
surgery (GKS) are surgical options available to patients
with TN. MVD has been widely used based on the theory
that vascular compression of the trigeminal nerve is re-
sponsible for TN [14,15]. A retrospective review of pa-
tients with TN who had undergone MVD showed that
71% reported complete pain relief 10 years after surgery
[16]. GKS is a noninvasive stereotactic radiosurgical
technique that utilizes a focused beam of radiation to tar-
get the root of the trigeminal nerve. Pain relief obtained
from GKS is delayed and usually occurs about 2 weeks
later. Initial good pain relief can be achieved in 80% of
patients [17,18]. However, there is a risk of recurrence
after 1 year [17].
Continuos mandibular nerve block with local anes-
thetics using an ind welling catheter to control TN pain is
uncommon but has been reported [19]. It allows con-
tinuous or intermitten t injection of lo cal anesthetics when
necessary. It is more convenient than repeated nerve
blocks as it eliminates the use of a needle and can be
dosed by the patient. It is also reversible and safe. It pro-
vided complete resolution of pain and satisfaction for our
patient. However as described in our case it is highly
vulnerable to infection and dislodgment and is difficult to
maintain for a long period of time. For this reason we
recommend its use as a temporary measure to control
pain until a more definitive permanent procedure is un-
Embolization of the internal maxillary artery is used to
Open Access OJAnes
Continuos Inferior Alveolar Nerve Block Using an Indwelling Catheter and Inferior Maxillary Artery
Embolization for the Management of Atypical Trigeminal Neuralgia 377
control epistaxis and life threatening bleeding following
facial trauma [20,21]. However, its use for trigeminal
neuralgia is uncommon. One study reported the use of
maxillary embolization in 76 patients with trigeminal
neuralgia with achievement of absolute improvement
[22]. Since in our case the patient’s pain had a throbbing
component we thought she might benefit from internal
maxillary artery embolization. We first used a balloon
trial to test if artery occlusion will provide pain resolu-
tion, when the patient passed the trial we embolized the
artery, the patient reported complete resolution of the
throbbing pa in. The pro cedure is safe as th e area su pp lied
by the artery has collateral blood supply. We recommend
this procedure for patients with throbbing pain not con-
trolled by medical management with emphasis on a bal-
loon trail before permanent occlusion.
4. Conclusion
Treatment of TN should be tailored to the individual
situation. Several interventional pain and surgical proce-
dures are available to treat pain resistant to medical
management. Continuous mandibular or alveolar nerve
blocks with local anesthetics using an indwelling cath eter
can provide complete pain resolution and patient satis-
faction but with a risk of infection on long term use. In-
ternal maxillary embolization is a permanent treatment
modality to be considered in patients with a throbbing
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Open Access OJAnes
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Embolization for the Management of Atypical Trigeminal Neuralgia
Open Access OJAnes
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