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Harold A. Wilkinson

✓ The published literature suggests that the technique of epidural “blood patch” injection is both safe and effective for the treatment and prevention of headache after spinal puncture. However, a case is reported in which the complications following a “blood patch” outweighed the disability and discomfort produced by the headache itself. The etiology is believed to have been inadvertent injection of blood into the subarachnoid space.

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Harold A. Wilkinson

Object. Trigeminal neuralgia or tic douloureux is a disease affecting older individuals, and thus, office-based “minimally invasive” therapy is inherently attractive. The author sought to determine whether injection of peripheral trigeminal branches with neurolytic solutions offers a simple, less invasive therapy, with low risk for patients with one- or two-division trigeminal neuralgia that is unresponsive to pharmacotherapy.

Methods. This retrospective study focused on a review of case charts from 18 patients treated for tic douloureux. Sixty injections of 10% phenol in glycerol were given to the 18 patients, six of whom had undergone other neurosurgical procedures. The median patient age was 74 years, ranging from 36 to 94 years. There were nine women and nine men. Forty-six injections were administered into the infraorbital nerve in its canal in the midface, 11 percutaneous injections were administered into the mandibular nerve just proximal to the mandibular canal in the ramus of the jaw, and three injections were administered into supraorbital nerves. Eighty-seven percent of injections brought marked or total relief initially. Of those injections that provided initial relief, 37% still provided relief after 1 year and 30% after 2 years, with relief lasting for a median of 9 months after each injection. Most patients whose pain recurred after months of relief requested a repeated procedure, rather than undergo a ganglion nerve block procedure or open surgery. There were no serious complications or dysesthetic pain. Facial sensory loss generally recovered within 6 months and was well tolerated.

Conclusions. Office-based injection of trigeminal branches is a useful technique for neurosurgeons who treat trigeminal neuralgia. It is easily repeated and can provide immediate pain relief of intermediate duration.

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Letter to the Editor

Meralgia paresthetica

Harold A. Wilkinson

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Harold A. Wilkinson

✓ A vascular malformation (“cirsoid aneurysm”) of the frontal scalp was excised from an 8-year-old girl. Eighteen years later, during her second pregnancy, the malformation recurred. Despite the presence of an underlying bone defect, arteriography excluded an intracranial extension. The frequency of association of vascular malformations of the scalp with cerebral vascular malformations is reviewed, and the need for careful arteriography reiterated.

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Harold A. Wilkinson and Andy S. Chan

Object. Sensory ganglionectomy offers theoretical advantages over rhizotomy but remains controversial because reported success rates vary widely. The authors sought to add to the available data on this subject and to review technical aspects of the surgery.

Methods. This retrospective chart review included 19 patients, in whom 22 operations were performed and 35 sensory ganglia were resected between May 1995 and May 1999. The eight women and 11 men ranged in age from 27 to 75 years (median age 40 years, average age 42.3 years). All patients had undergone extensive therapy and a mean of 2.4 previous operations (median three, range zero—eight operations) for their pain, all without long-term pain relief. Duration of symptoms varied, from 1 month (for the cancer patient) to 15 years (mean 5.9, median 4 years). Preoperatively, all patients underwent diagnostic selective nerve root blocks, which temporarily relieved their targeted pain. The duration of follow up averaged 22 months (median 13, range 1.5 [to death of the cancer patient]—58 months). Before undergoing the first ganglionectomy, nearly all patients rated their targeted pain as 8 to 10 (average 9.6, median 10) on an analog (0–10) pain scale.

At 6 months all patients rated their ganglionectomy-specific pain as an average of 4.5 (median 4, range 0–8), and pain reduction of 50% or more was achieved in 74%. At 1 year or more the 13 patients available for study rated their pain as an average of 4.3 (median 4.5, range 0–9). There were no severe complications, residual pain was never worse than presurgical pain, and no patient experienced significant or lasting new motor deficits.

Conclusions. Dorsal root ganglionectomy has a useful role in the treatment of a variety of refractory pain states, especially those involving radicular pain.