J Neurosurg. 2019 Jan 11;131(6):1805-1811. doi: 10.3171/2018.8.JNS1893. Print 2019 Dec 1.
First-line treatment for trigeminal neuralgia (TN) is pharmacological management using antiepileptic drugs (AEDs), e.g., carbamazepine (CBZ) and oxcarbazepine (OCBZ). Surgical intervention has been shown to be an effective and durable treatment for TN that is refractory to medical therapy. Despite the lack of evidence for efficacy in patients with TN, the authors hypothesized that patients with neuropathic facial pain are prescribed opioids at high rates, and that neurosurgical intervention may lead to a reduction in opioid use.
This is a retrospective study of patients with facial pain seen by a single neurosurgeon. All patients completed a survey on pain medications, medical comorbidities, prior interventions for facial pain, and a validated pain outcome tool (the Penn Facial Pain Scale). Patients subsequently undergoing neurosurgical intervention completed a survey at the 1-month follow-up in the office, in addition to telephone interviews using a standardized script between 1 and 6 years after intervention. Univariate and multivariate logistic regression were used to predict opioid use.
The study cohort consisted of 309 patients (70% Burchiel type 1 TN [TN1], 18% Burchiel type 2 [TN2], 6% atypical facial pain [AFP], and 6% TN secondary to multiple sclerosis [TN-MS]). At initial presentation, 20% of patients were taking opioids. Of these patients, 55% were receiving concurrent opioid therapy with CBZ/OCBZ, and 84% were receiving concurrent therapy with at least one type of AED. Facial pain diagnosis (for diagnoses other than TN1, odds ratio [OR] 2.5, p = 0.01) and facial pain intensity at its worst (for each unit increase, OR 1.4, p = 0.005) were predictors of opioid use at baseline. Neurosurgical intervention led to a reduction in opioid use to 8% at long-term follow-up (p < 0.01, Fisher's exact test; n = 154). Diagnosis (for diagnoses other than TN1, OR 4.7, p = 0.002) and postintervention reduction in pain at its worst (for each unit reduction, OR 0.8, p < 10-3) were predictors of opioid use at long-term follow-up. On subgroup analysis, patients with TN1 demonstrated a decrease in opioid use to 5% at long-term follow-up (p < 0.05, Fisher's exact test), whereas patients with non-TN1 facial pain did not. In the nonsurgical group, there was no statistically significant decrease in opioid use at long-term follow-up (n = 81).
In spite of its high potential for abuse, opioid use, mostly as an adjunct to AEDs, is prevalent in patients with facial pain. Opportunities to curb opioid use in TN1 include earlier neurosurgical intervention.
三叉神经痛（TN）的一线治疗是使用抗癫痫药物（AED）进行药物治疗，例如卡马西平（CBZ）和奥卡西平（OCBZ）。手术干预已被证明是一种有效且持久的治疗方法，适用于对药物治疗无反应的 TN。尽管缺乏对 TN 患者疗效的证据，但作者假设患有神经性面部疼痛的患者开阿片类药物的比率很高，神经外科干预可能会导致阿片类药物使用减少。
这是一项对一位神经外科医生诊治的面部疼痛患者的回顾性研究。所有患者均完成了关于疼痛药物、合并症、先前治疗面部疼痛的干预措施以及经过验证的疼痛结局工具（宾夕法尼亚面部疼痛量表）的问卷调查。随后接受神经外科干预的患者在术后 1 个月的办公室随访中完成了问卷调查，并在干预后 1 至 6 年内使用标准化脚本进行了电话访谈。采用单变量和多变量逻辑回归预测阿片类药物的使用情况。
研究队列包括 309 名患者（70%为 Burchiel 1 型 TN [TN1]，18%为 Burchiel 2 型 [TN2]，6%为非典型面部疼痛 [AFP]，6%为多发性硬化症继发 TN [TN-MS]）。初次就诊时，20%的患者正在服用阿片类药物。在这些患者中，55%同时接受 CBZ/OCBZ 阿片类药物治疗，84%同时接受至少一种 AED 治疗。面部疼痛诊断（TN1 以外的诊断，比值比 [OR] 2.5，p = 0.01）和疼痛最严重时的疼痛强度（每增加一个单位，OR 1.4，p = 0.005）是基线时阿片类药物使用的预测因素。神经外科干预可将长期随访时的阿片类药物使用率降低至 8%（p < 0.01，Fisher 精确检验；n = 154）。诊断（TN1 以外的诊断，OR 4.7，p = 0.002）和术后疼痛最严重时的疼痛缓解（每降低一个单位，OR 0.8，p < 10-3）是长期随访时阿片类药物使用的预测因素。亚组分析显示，TN1 患者的阿片类药物使用率在长期随访时降至 5%（p < 0.05，Fisher 精确检验），而非 TN1 面部疼痛患者则没有。在非手术组中，长期随访时阿片类药物使用率无统计学显著降低（n = 81）。
尽管阿片类药物具有高度滥用潜力，但阿片类药物的使用在面部疼痛患者中仍然很普遍，主要作为 AED 的辅助药物。在 TN1 中减少阿片类药物使用的机会包括早期神经外科干预。
