April 2019

A 36 year old Male with right facial pain


An otherwise healthy 36 year old man presents to clinic with a 1 year history of progressively disabling right sided facial pain. He describes the pain as sudden and electrical in nature, occurring either without warning or in response to benign stimuli including light touch, wind, eating and facial expressions such as smiling. These symptoms occur exclusively in the right side of his face, under his eye and along his jaw line and affect his ability to eat as well as to perform at his job. He was treated with carbamazepine by another doctor and this initially helped greatly, but his symptoms have now returned despite high doses of this medication that are now causing him dizziness and cognitive dysfunction.

PMH/PSH: none

Medications: carbamazepine 400 mg twice daily


Neurologically intact, patient winces to light touch on the right face in V2 and V3 distributions but denies numbness to any sensory modality. Otherwise unremarkable.

Follow Up:

The patient is discharged on postoperative day 2 with complete resolution of his symptoms.  By his 4 week postoperative visit he is thrilled to report that he has weaned off carbamazepine with continued pain relief. He denies any facial numbness or other neurologic symptoms.

MRI of the brain, FIESTA (Fast Imaging Employing Steady-state Acquisition) sequence

The patient undergoes a successful right sided retrosigmoid craniotomy for microvascular decompression of the trigeminal nerve.

Intraoperative images are shown before and after decompression.

he returns to your clinic 8 months later with recurrence of his initial symptoms despite resuming carbamazepine. His pain now has the same intensity and severity as before his craniotomy and remains in the right sided V2 and V3 distributions. Repeat MRI (

After discussing treatment options, he chooses to undergo radiofrequency lesioning of the trigeminal (gasserian) ganglion. Since undergoing this procedure he has reported long lasting pain relief for > 1 year and anticipated right sided anesthesia in the


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