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ANESTHESIA DOLOROSA
Conditions:  Facial Neuralgias

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| Description | Possible Causes | Symptoms | Diagnosis | Treatments |  References

Description
Anesthesia Dolorosa is one of the most dreaded complications of neurosurgery and is considered to be non-reversible.  It occurs when the trigeminal nerve is damaged by surgery or physical trauma in such a way that the feeling sensation in part of the face is reduced or eliminated entirely while the sense of pain remains.  According to Dr. Steven Graff-Radford, director of the Head and Neck Section of Cedars Sinai Medical Center's Pain Center in Los Angeles, there are two forms of anesthesia dolorosa, each of which responds best to different treatments.

Causes
As far as can be seen from the medical literature,  anesthesia dolorosa is caused by injury to the trigeminal nerve or as a complication of surgery to correct a condition such as trigeminal neuralgia  It can occur after glycerol injection, alcohol injection,  partial nerve sections, radiofrequency rhizotomy, gamma knife surgery, balloon compressions  and microvascular decompression.

Symptoms
The two main symptoms of AD are facial numbness (much like the numbness from a dental anesthetic injection) and constant pain.  The pain is usually burning, pulling or stabbing but can also include a sharp, stinging, shooting or electrical component. Pressure and "heaviness" can also be part of the pain symptoms. Often there is eye pain.  Cold increases the feeling of numbness sometimes making the face feel frozen.

Diagnosis
In the past, diagnosis of anesthesia dolorosa was based on symptoms.  More recently, thermograms ( a test that measures minute temperature differences in the painful area) and nerve blocks of the sympathetic nervous system are sometimes used to distinguish between two forms of anesthesia dolorosa.      

Treatments
Unfortunately, there are no easy answers to the pain and discomfort of   anesthesia dolorosa.  No single treatment has been found yet that resolves all of the pain.   However there are a number of treatment options that can help to manage the pain and discomfort. 

Drug Treatments

bullet5.gif (101 bytes)  Capsaicin (topical applications)

bullet5.gif (101 bytes)  Clonidine (topical applications)

Offsite Link  EMLA (an anesthetic which hospitals use to numb the skin before inserting an IV)

bullet5.gif (101 bytes)  Nerve blocks

bullet5.gif (101 bytes)  Nortriptyline (Pamelor)

Offsite Link  Paroxetine ( Paxil).

bullet5.gif (101 bytes)  Carbamazepine (tegretol) - Used if there is an electrical, shooting pain component

bullet5.gif (101 bytes)  Gabapentin (Neurontin) - Used if there is an electrical, shooting pain component

bullet5.gif (101 bytes)  Clonazepam (Klonopin)

bullet5.gif (101 bytes)  Lidocaine (IV treatment)

bullet5.gif (101 bytes)  Ketamine (IV treatment)

bullet5.gif (101 bytes)  Opioids

Other pain relief strategies that can help include:

bullet5.gif (101 bytes) Hot and cold compresses

bullet5.gif (101 bytes) Acupuncture

bullet5.gif (101 bytes)  Biofeedback

bullet5.gif (101 bytes)  TENS Units

Surgical Treatments
Once anesthesia dolorosa is diagnosed, any further surgery on the trigeminal nerve should be avoided as there is little evidence surgery will improve this condition.  In fact, surgery can actually make anesthesia dolorosa worse.  

There are several forms of brain surgery  used to treat anesthesia dolorosa that selectively destroy parts of the pain-transmission area of the brain.  These are extreme procedures and should only be considered as a last resort.

bullet5.gif (101 bytes)  Thalamotomy

bullet5.gif (101 bytes)  Cingulotomy

bullet5.gif (101 bytes)  DREZ - Dorsal Root entry Zone
This procedure developed by Dr. Blain Nashold at Duke University in Georgia includes selectively damaging part of the pain-transmission system at the back to the head with a radiofrequency electrode.  Most medical professionals advise that this procedure should only be used as the "absolute last ditch effort" as the success rate is so low  (reported by some at  50%). Complication rates are as high as  30% and include numbness or loss of coordination in the arms and hands.

References

Epstein JB, et al. "Topical clonidine for orofacial pain: a pilot study. " J Orofac Pain. 1997 Fall;11(4):346-52.

Weigel, George, Trials and Treatments of Anesthesia Dolorosa, TN Alert, Winter 1996/1997


 

 
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