Utility of Percutaneous Meckel's Cave Methylprednisolone/Bupivacaine Injection for Patients With Refractory Trigeminal Neuralgia With Concomitant Continuous Pain

BACKGROUND AND OBJECTIVES: Patients with trigeminal neuralgia (TN) with concomitant continuous pain constitute a challenging population to treat. Lesioning procedures are associated with high rates of neuropathic pain deterioration. Meckel's cave methylprednisolone/bupivacaine injections may afford pain control in this subset of patients with low rates of neuropathic pain deterioration. Our aim was to identify predictors of pain response after methylprednisolone/bupivacaine injections in patients with medically refractory TN with concomitant continuous pain. METHODS: A retrospective analysis of percutaneous methylprednisolone/bupivacaine injections for TN with concomitant continuous pain from 2020 to 2024 with a minimum of 1-year follow-up at a single institution was conducted. Demographics and operative data were collected. The primary outcomes were immediate (at first follow-up) and long-term (at last follow-up) pain relief. Univariate and multivariable Cox proportional hazards regression analysis and Kaplan-Meier survival analysis assessed prognostic factors for immediate and long-term pain relief. RESULTS: A total of 42 patients underwent 54 percutaneous methylprednisolone/bupivacaine injections. No procedures were performed in the setting of active neurovascular compression. Dull pain was the predominant pain component in 55.6% and the minor component in 44.4% of cases. The immediate pain relief rate was 78.4%. On multivariable analysis at the first follow-up, predominantly dull pain predicted improved immediate pain relief (hazard ratio [HR]: 0.26; 95% CI [0.08-0.91]; P = .04), whereas age ≥61 years was associated with a higher risk of persistent immediate pain (HR: 4.93; 95% CI [1.05-23.1]; P = .04). The long-term pain relief rate was 35.2%, resulting in a median pain relief duration of 19.9 months. On multivariable analysis at the last follow-up, only repeat injections were associated with higher risk of inadequate long-term pain relief (HR: 2.84; 95% CI [1.17-6.86]; P = .02). Postoperative transient hypoesthesia was reported in 12.9% of cases. Importantly, no patients had deterioration of the neuropathic pain component. CONCLUSION: Percutaneous methylprednisolone/bupivacaine injections provide effective immediate pain relief for patients with TN with concomitant continuous pain with minimal risk of deteriorating neuropathic symptoms.