Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study.

OBJECTIVE: To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. BACKGROUND: Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. METHODS: A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. RESULTS: In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338). CONCLUSIONS: In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Treatment of pediatric trigeminal neuralgia with microvascular decompression: a case series and systematic review.

OBJECTIVE: Trigeminal neuralgia (TN) is a rare disorder, affecting 4-13 per 100,000 people annually. Only 1%-1.5% of these cases are reported before the age of 18 years. The initial management of pediatric TN is based on symptomatic treatment, using first-line medications including carbamazepine, based on data from adult treatment studies. Many of these children are refractory to medication and undergo excessive workup and ineffective therapies before neurosurgical referral. The objective of this study was to perform a comprehensive review of literature-reported pediatric-onset TN, analyzing demographics, diagnostic practices, and complications in this population. METHODS: An institutional, retrospective chart review was performed to identify patients younger than 18 years old who were diagnosed with classic TN and referred for surgical evaluation at Oklahoma Children's Hospital (OCH). A systematic review of all pediatric patients undergoing microvascular decompression (MVD) for pediatric-onset TN was also performed. RESULTS: Three patients from OCH were identified, ranging in age from 3 to 11 years. All 3 patients had received multiple ineffective medical therapies before referral for neurosurgical evaluation. In 2 cases, imaging demonstrated potential vascular compression of the trigeminal nerve. In the final case, imaging demonstrated no vascular compression, but compression was found at the time of MVD. All cases were successfully treated using MVD. The literature review identified 49 cases of pediatric TN treated using MVD. All 49 cases were identified as classic TN with neurovascular compression demonstrated either on imaging or found at the time of surgery. The average age at symptom onset was 11.72 years, while the average age at MVD was 19.6 years. The average duration of symptoms before undergoing MVD was 8.2 years. There was a female predominance in the literature review, with a female-to-male ratio of 1.88:1. The right side was involved in 56% of cases, the left side in 40%, and bilateral involvement occurred in 4% of cases. The most common distribution of TN was both V2/3 branches (38%) of the trigeminal nerve, followed by solely the V2 branch (22%). A successful outcome (Barrow Neurological Institute pain intensity score of I or II) was reported in 79% of patients at the last follow-up (mean 69.1 months). CONCLUSIONS: There are currently no guidelines for diagnosing or treating pediatric TN. MVD is a safe and effective option in this patient population. Early evaluation for surgical intervention could be critical for early pain relief and reduced disease morbidity.

Endoscopic Endonasal Infrapetrous Transpterygoid Approach to the Petroclival Junction for Petrous Apex Chondrosarcoma: Technical Report.

Chondrosarcomas of the skull base are rare tumors that present difficult management considerations due to the pathoanatomical relationships of the tumor to adjacent structures. We present the case of a 25-year-old female patient presenting with a chondrosarcoma of the right petrous apex extending inferiorly, medial to the cranial nerves. The tumor was resected via an endoscopic endonasal infrapetrous transpterygoid approach that achieved complete resection and an excellent long-term outcome with no complications. Technical nuances and potential pitfalls of the case are discussed in depth including measures to protect the carotid artery while performing the required drilling of the skull base to access the lesion.