Management of trigeminal neuralgia during COVID-19 pandemic

Sir,

Ever since the COVID-19 pandemic began, the outpatient pain management clinics across the world have been forced to shut down due to a significant increase in burden upon the healthcare system and a need to protect patients as well as healthcare workers (HCWs) from unnecessary exposure.[[1]] Trigeminal neuralgia (TN) is an episodic chronic pain condition that has an incidence of approximately 4.5 per 100,000 and is typically seen in middle-aged or elderly patients. This condition causes excruciating neuropathic facial pain triggered by normal activities, such as talking, chewing, or swallowing. It has been shown to cause interference with activities of daily living and considerable mental distress, causing depression, anxiety, and suicidal ideation, hence, also known as “Suicide disease.”[[2]] These patients with chronic pain are more likely to experience disruption to their care due to diversion of resources during the pandemic, and their management poses a unique challenge. They may also be more susceptible to COVID-19 than others, due to their increased age and multiple comorbidities, and hence, minimizing their exposure as much as possible is vital.

To manage this disease during the COVID-19 pandemic, telemedicine consultations may be used to conduct a basic assessment of the patient's condition, and mild cases may be managed using medications such as analgesics or anticonvulsant drugs.[[3]] Telemedicine may also be used to assess the impact of the disease on the psychological state and quality of life, and measures such as telepsychiatry, guided physical therapy, and training for cognitive behavior therapy may be offered to patients. Those who remain refractory to medical management and remain in significant pain should be encouraged to stay in touch with their pain physicians throughout the period of this pandemic.

If an invasive procedure is deemed to be absolutely necessary, patients may be asked to visit the hospital. The management options for TN include procedures such as blockade of individual nerves, ganglion blockade, rhizotomy, radiofrequency ablation, balloon microcompression of trigeminal ganglion, and surgical interventions such as microvascular decompression of the aberrant vascular loops [[Figure 1]]. Neural blockade procedures require a physician to be in proximity to the patient's face and may be considered high-risk procedures for the transmission of respiratory droplets, necessitating the use of appropriate personal protective equipment (PPE). Procedures such as isolated nerve blocks and radiofrequency ablation require monitored anesthesia care. If the patient tests positive for COVID-19 or if their status is unknown, full PPE should be donned before performing any interventional pain procedure by the HCWs.

Figure 1: Management strategy for trigeminal neuralgia during COVID-19 pandemic

Balloon decompression as well as microvascular decompression is performed under general anesthesia, and appropriate testing may be undertaken to establish risk of disease transmission before these procedures. Such procedures may be deferred till the patient tests negative for COVID-19, and the alternative procedures may be considered to alleviate pain during this period. All patients requiring interventional pain procedures require close monitoring postprocedure, and appropriate measures to maintain social distancing should be instituted.

Conflict of Interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

• References

• 1 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382:1708-20.
• 2 Wu TH, Hu LY, Lu T, Chen PM, Chen HJ, Shen CC, et al. Risk of psychiatric disorders following trigeminal neuralgia: A nationwide population-based retrospective cohort study. J Headache Pain 2015;16:64.
• 3 Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020;382:1679-81.

Publication History

Received: 01 June 2020

Accepted: 24 July 2020

Article published online:
16 August 2022