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Trigeminal neuralgia--a coherent cross-specialty management program.

Heinskou T, Maarbjerg S, Rochat P, Wolfram F, Jensen RH, Bendtsen L - J Headache Pain (2015)

Bottom Line: First out-patient visit and subsequent 3.0 Tesla MRI scan was booked in an accelerated manner.From May 2012 to April 2014, 130 patients entered the accelerated program.The described cross-speciality management program proved to be feasible and to have acceptable waiting times for referral and highly specialized work-up of TN patients in a public tertiary referral centre for headache and facial pain.

View Article: PubMed Central - PubMed

Affiliation: Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical sciences, University of Copenhagen, Copenhagen, Denmark, Tone.Bruvik.Heinskou@regionh.dk.

ABSTRACT

Background: Optimal management of patients with classical trigeminal neuralgia (TN) requires specific treatment programs and close collaboration between medical, radiological and surgical specialties. Organization of such treatment programs has never been described before. With this paper we aim to describe the implementation and feasibility of an accelerated cross-speciality management program, to describe the collaboration between the involved specialties and to report the patient flow during the first 2 years after implementation. Finally, we aim to stimulate discussions about optimal management of TN.

Methods: Based on collaboration between neurologists, neuroradiologists and neurosurgeons a standardized program for TN was implemented in May 2012 at the Danish Headache Center (DHC). First out-patient visit and subsequent 3.0 Tesla MRI scan was booked in an accelerated manner. The MRI scan was performed according to a special TN protocol developed for this program. Patients initially referred to neurosurgery were re-directed to DHC for pre-surgical evaluation of diagnosis and optimization of medical treatment. Follow-up was 2 years with fixed visits where medical treatment and indication for neurosurgery was continuously evaluated. Scientific data was collected in a structured and prospective manner.

Results: From May 2012 to April 2014, 130 patients entered the accelerated program. Waiting time for the first out-patient visit was 42 days. Ninety-four percent of the patients had a MRI performed according to the special protocol after a mean of 37 days. Within 2 years follow-up 35% of the patients were referred to neurosurgery after a median time of 65 days. Five scientific papers describing demographics, clinical characteristics and neuroanatomical abnormalities were published.

Conclusion: The described cross-speciality management program proved to be feasible and to have acceptable waiting times for referral and highly specialized work-up of TN patients in a public tertiary referral centre for headache and facial pain. Early high quality MRI ensured correct diagnosis and that the neurosurgeons had a standardized basis before decision-making on impending surgery. The program ensured that referral of the subgroup of patients in need for surgery was standardized, ensured continuous evaluation of the need for adjustments in pharmacological management and formed the basis for scientific research.

No MeSH data available.


Related in: MedlinePlus

Flowchart of included patients. Inclusion period lasted from May 2012 to April 2014. TN: Classical trigeminal neuralgia, DHC: Danish Headache Center. *Diagnosis changed to: persistent idiopathic facial pain (PIFP) (N = 33), symptomatic trigeminal neuralgia (N = 12), cluster headache (N = 6), headache not elsewhere classified (N = 5), tension type headache (N = 3), migraine (N = 3), medication-overuse headache (N = 2), occipital neuralgia (N = 1), painful trigeminal neuropathy attributed to other disorder (N = 1). **Diagnosis changed from: PIFP (N = 4), tension type headache (N = 2), cluster headache (N = 1), headache not elsewhere classified (N = 1). ***Reasons for missing inclusion: pain free and did not want further controls (N = 7), unknown (N = 4), patient preferred treatment closer to home (N = 3), tumor not related to TN (N = 3), communication barrier ((Alzheimer’s) N = 1), death not related to TN (N = 1). **** Type of surgery: microvascular decompression (MVD) (N = 29), balloon compression (N = 10), both balloon compression and MVD within 12 months (N = 2), glycerol injection (N = 1), failed balloon compression due to bradycardia (N = 1). *****Did not undergo surgery due to: the neurosurgeon decided not to operate (N = 2), surgery was cancelled as the patient was pain free (N = 1)
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Fig2: Flowchart of included patients. Inclusion period lasted from May 2012 to April 2014. TN: Classical trigeminal neuralgia, DHC: Danish Headache Center. *Diagnosis changed to: persistent idiopathic facial pain (PIFP) (N = 33), symptomatic trigeminal neuralgia (N = 12), cluster headache (N = 6), headache not elsewhere classified (N = 5), tension type headache (N = 3), migraine (N = 3), medication-overuse headache (N = 2), occipital neuralgia (N = 1), painful trigeminal neuropathy attributed to other disorder (N = 1). **Diagnosis changed from: PIFP (N = 4), tension type headache (N = 2), cluster headache (N = 1), headache not elsewhere classified (N = 1). ***Reasons for missing inclusion: pain free and did not want further controls (N = 7), unknown (N = 4), patient preferred treatment closer to home (N = 3), tumor not related to TN (N = 3), communication barrier ((Alzheimer’s) N = 1), death not related to TN (N = 1). **** Type of surgery: microvascular decompression (MVD) (N = 29), balloon compression (N = 10), both balloon compression and MVD within 12 months (N = 2), glycerol injection (N = 1), failed balloon compression due to bradycardia (N = 1). *****Did not undergo surgery due to: the neurosurgeon decided not to operate (N = 2), surgery was cancelled as the patient was pain free (N = 1)

Mentions: Two hundred and seven patients with suspected TN were referred to DHC from May 2012 to April 2014 (Fig. 2). Sixty-six (31 %) patients were referred from general practitioners, 41 (19 %) from private neurologists and 68 (32 %) from other hospital departments. Forty (19 %) patients were re-directed from the Department of Neurosurgery. In 66 (31 %) patients the referral diagnosis of TN was not correct. Referral diagnosis was most frequently changed to persistent idiopathic facial pain (33 (50 %)), symptomatic trigeminal neuralgia (12 (18 %)) and cluster headache (6 (9 %)) (Fig. 2). Eight patients were referred to DHC with other diagnosis than TN and were diagnosed with TN at the first out-patient visit. Thus, 149 patients were diagnosed with TN in the inclusion period. Hereof 130 patients entered the accelerated treatment program. Nineteen (13 %) patients were not included in the accelerated program. Seven patients were pain free at their first visit and did not want further controls, four patients did not enter the program for unknown reasons, three patients preferred treatment closer to home, three had tumors not related to TN, one patient had Alzheimer’s and one died of cause unrelated to TN, before further follow-up.Fig. 2


Trigeminal neuralgia--a coherent cross-specialty management program.

Heinskou T, Maarbjerg S, Rochat P, Wolfram F, Jensen RH, Bendtsen L - J Headache Pain (2015)

Flowchart of included patients. Inclusion period lasted from May 2012 to April 2014. TN: Classical trigeminal neuralgia, DHC: Danish Headache Center. *Diagnosis changed to: persistent idiopathic facial pain (PIFP) (N = 33), symptomatic trigeminal neuralgia (N = 12), cluster headache (N = 6), headache not elsewhere classified (N = 5), tension type headache (N = 3), migraine (N = 3), medication-overuse headache (N = 2), occipital neuralgia (N = 1), painful trigeminal neuropathy attributed to other disorder (N = 1). **Diagnosis changed from: PIFP (N = 4), tension type headache (N = 2), cluster headache (N = 1), headache not elsewhere classified (N = 1). ***Reasons for missing inclusion: pain free and did not want further controls (N = 7), unknown (N = 4), patient preferred treatment closer to home (N = 3), tumor not related to TN (N = 3), communication barrier ((Alzheimer’s) N = 1), death not related to TN (N = 1). **** Type of surgery: microvascular decompression (MVD) (N = 29), balloon compression (N = 10), both balloon compression and MVD within 12 months (N = 2), glycerol injection (N = 1), failed balloon compression due to bradycardia (N = 1). *****Did not undergo surgery due to: the neurosurgeon decided not to operate (N = 2), surgery was cancelled as the patient was pain free (N = 1)
© Copyright Policy - open-access
Related In: Results  -  Collection

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Fig2: Flowchart of included patients. Inclusion period lasted from May 2012 to April 2014. TN: Classical trigeminal neuralgia, DHC: Danish Headache Center. *Diagnosis changed to: persistent idiopathic facial pain (PIFP) (N = 33), symptomatic trigeminal neuralgia (N = 12), cluster headache (N = 6), headache not elsewhere classified (N = 5), tension type headache (N = 3), migraine (N = 3), medication-overuse headache (N = 2), occipital neuralgia (N = 1), painful trigeminal neuropathy attributed to other disorder (N = 1). **Diagnosis changed from: PIFP (N = 4), tension type headache (N = 2), cluster headache (N = 1), headache not elsewhere classified (N = 1). ***Reasons for missing inclusion: pain free and did not want further controls (N = 7), unknown (N = 4), patient preferred treatment closer to home (N = 3), tumor not related to TN (N = 3), communication barrier ((Alzheimer’s) N = 1), death not related to TN (N = 1). **** Type of surgery: microvascular decompression (MVD) (N = 29), balloon compression (N = 10), both balloon compression and MVD within 12 months (N = 2), glycerol injection (N = 1), failed balloon compression due to bradycardia (N = 1). *****Did not undergo surgery due to: the neurosurgeon decided not to operate (N = 2), surgery was cancelled as the patient was pain free (N = 1)
Mentions: Two hundred and seven patients with suspected TN were referred to DHC from May 2012 to April 2014 (Fig. 2). Sixty-six (31 %) patients were referred from general practitioners, 41 (19 %) from private neurologists and 68 (32 %) from other hospital departments. Forty (19 %) patients were re-directed from the Department of Neurosurgery. In 66 (31 %) patients the referral diagnosis of TN was not correct. Referral diagnosis was most frequently changed to persistent idiopathic facial pain (33 (50 %)), symptomatic trigeminal neuralgia (12 (18 %)) and cluster headache (6 (9 %)) (Fig. 2). Eight patients were referred to DHC with other diagnosis than TN and were diagnosed with TN at the first out-patient visit. Thus, 149 patients were diagnosed with TN in the inclusion period. Hereof 130 patients entered the accelerated treatment program. Nineteen (13 %) patients were not included in the accelerated program. Seven patients were pain free at their first visit and did not want further controls, four patients did not enter the program for unknown reasons, three patients preferred treatment closer to home, three had tumors not related to TN, one patient had Alzheimer’s and one died of cause unrelated to TN, before further follow-up.Fig. 2

Bottom Line: First out-patient visit and subsequent 3.0 Tesla MRI scan was booked in an accelerated manner.From May 2012 to April 2014, 130 patients entered the accelerated program.The described cross-speciality management program proved to be feasible and to have acceptable waiting times for referral and highly specialized work-up of TN patients in a public tertiary referral centre for headache and facial pain.

View Article: PubMed Central - PubMed

Affiliation: Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical sciences, University of Copenhagen, Copenhagen, Denmark, Tone.Bruvik.Heinskou@regionh.dk.

ABSTRACT

Background: Optimal management of patients with classical trigeminal neuralgia (TN) requires specific treatment programs and close collaboration between medical, radiological and surgical specialties. Organization of such treatment programs has never been described before. With this paper we aim to describe the implementation and feasibility of an accelerated cross-speciality management program, to describe the collaboration between the involved specialties and to report the patient flow during the first 2 years after implementation. Finally, we aim to stimulate discussions about optimal management of TN.

Methods: Based on collaboration between neurologists, neuroradiologists and neurosurgeons a standardized program for TN was implemented in May 2012 at the Danish Headache Center (DHC). First out-patient visit and subsequent 3.0 Tesla MRI scan was booked in an accelerated manner. The MRI scan was performed according to a special TN protocol developed for this program. Patients initially referred to neurosurgery were re-directed to DHC for pre-surgical evaluation of diagnosis and optimization of medical treatment. Follow-up was 2 years with fixed visits where medical treatment and indication for neurosurgery was continuously evaluated. Scientific data was collected in a structured and prospective manner.

Results: From May 2012 to April 2014, 130 patients entered the accelerated program. Waiting time for the first out-patient visit was 42 days. Ninety-four percent of the patients had a MRI performed according to the special protocol after a mean of 37 days. Within 2 years follow-up 35% of the patients were referred to neurosurgery after a median time of 65 days. Five scientific papers describing demographics, clinical characteristics and neuroanatomical abnormalities were published.

Conclusion: The described cross-speciality management program proved to be feasible and to have acceptable waiting times for referral and highly specialized work-up of TN patients in a public tertiary referral centre for headache and facial pain. Early high quality MRI ensured correct diagnosis and that the neurosurgeons had a standardized basis before decision-making on impending surgery. The program ensured that referral of the subgroup of patients in need for surgery was standardized, ensured continuous evaluation of the need for adjustments in pharmacological management and formed the basis for scientific research.

No MeSH data available.


Related in: MedlinePlus