When intra-operative exploration is the only option, severe medically refractory trigeminal neuralgia

Introduction: Patients with trigeminal neuralgia (TN) are usually treated on an outpatient basis, and symptoms can be controlled using various medical therapeutic options. We present a case of severe TN with an acute on chronic flare, which was now refractory to a wide variety of medical options, had a prolonged inpatient hospitalization, and ultimately required surgery with excellent results.Case: A 54-year-old Hispanic male was admitted with severe left-sided TN. His symptoms gradually became more pronounced and frequent to a point where he was unable to have a meaningful quality of life. A trial of gabapentin, phenytoin, opioids, and NSAIDs had also been unsuccessful before this hospitalization. He had three ER visits before he was finally hospitalized with intractable pain and unfortunately had begun to have suicidal thoughts. Various therapeutic interventions were tried, including escalating doses of opioids and local nerve blocks, but all non-surgical options failed to provide relief. Neurosurgical route was eventually approached, and patient underwent left retro mastoid suboccipital craniectomy. Intraoperatively, the left superior cerebellar artery was found to adhere to the inferior ventral aspect of the left trigeminal nerve root entry zone. Upon decompression patient’s symptoms resolved dramatically. Interestingly this vascular compression was not seen on multiple prior brain imaging.Conclusion: TN can severely affect someone’s quality of life. It often leads to severe anxiety and depression. Our case represents the importance of proceeding towards surgical options sooner rather than later. An early multi-disciplinary approach is warranted.