Introduction: Facial anesthesia dolorosa is a known unusual complication of destruction to the trigeminal nerve. The pain source is thought to be “centralized”, as a peripheral component of a given nerve has been destroyed.

Methods: We reviewed a case of an extreme approach to treat life-altering anesthesia dolorosa including the history. The patient underwent initially a Caldwell-Luc procedure. He later developed trigeminal distribution pain and underwent many procedures including: trigeminal nerve ablations (two trans-ovale radiofrequency rhizotomy), trigeminal nerve stimulation, motor-cortex stimulation, deep brain stimulation, high cervical intrathecal pain pump. Clearly by time of presentation the patient had trigeminal anesthesia dolorosa with pain in the deep orbit (V1) and maxillary regions (V2). He underwent a stimulation trial directed at the trigeminal ganglion, the sphenopalatine ganglion, and the supraorbital nerve stimulation.

Results: Patient responded well to combination of trigeminal ganglion stimulation and sphenopalatine stimulation, but not to supraorbital stimulation. The trigeminal ganglion stimulation helped with pain but stimulation was limited by masseter muscle contraction. He later underwent full implantation with a paddle placed on the trigeminal ganglion via subtemporal craniotomy to capture only V1 and V2 components and exclude V3 with a more anterior placement. Frameless stereotaxy was utilized to place the sphenopalatine ganglion stimulator.

Conclusions: Patient reported excellent relief and had a return of ability to function and exercise. This is the first report of the use of both these locations as a target for stimulation in the treatment of facial anesthesia dolorosa. Although anesthesia dolorosa is a “central” version of pain, it may respond positively to peripheral forms of stimulation, and the autonomic nervous system may need to be included in this therapy.

Patient Care: Offers new treatment options for patients. Proposed algorithm of treatment for facial pain problems.

Learning Objectives: Treatment options for Anesthesia Dolorosa

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