A prospective case series of sphenopalatine ganglion pulsed radiofrequency therapy for refractory chronic cluster headache

15. Cluster Headache

INTRODUCTION

Cluster headache is a rare primary headache disorder characterized by excruciating unilateral pain around the eye, lasting between 15 and 180 min, accompanied by ipsilateral cranial autonomic symptoms. Cluster headache is classified into two forms: episodic and chronic, with chronic cluster headache defined by pain-free intervals of less than 3 months between bouts. Both drug-based and invasive treatments are available for abortive and preventive purposes. Treatment selection depends on individual efficacy and tolerance, with invasive options considered when pharmacological treatments prove ineffective.

METHODS

This narrative review summarizes the literature on common practice and the evidence in the treatment of cluster headache.

RESULTS

Oxygen therapy and subcutaneous sumatriptan are the most effective abortive treatments for cluster headache. Oral corticosteroid tapering regimens can be used as bridging therapy. Verapamil, lithium, topiramate, and CGRP antagonists are potential preventive medication options. Greater occipital nerve (GON) injections and radiofrequency (RF) therapy can be used as preventive treatments, though their effects are often temporary. For refractory chronic cluster headache, occipital nerve stimulation (ONS) has proven to be effective. Deep brain stimulation (DBS) may also be considered if all other treatments have failed.

CONCLUSIONS

The management of cluster headache is complex due to the variable efficacy of treatments across different patients and limited evidence.

Efficacy and Safety of Ultrasound-Guided Pulsed Radiofrequency Therapy of Stellate Ganglion on Refractory Painful Diabetic Peripheral Neuropathy

Background

The best tool for the management of pain associated with distal symmetric peripheral neuropathy (DSPN) is a matter of debate. Therefore, the study aimed to explore whether ultrasound-guided pulsed radiofrequency (PRF) therapy of the stellate ganglion (SG) in type 2 diabetes mellitus (T2DM) patients with painful DSPN could decrease pain severity and the need for analgesics.

Methods

Fifty-six T2DM patients with refractory painful DSPN were enrolled in this study, who then received bilateral ultrasound-guided PRF therapy of SG. The patients completed visual analog scale (VAS), simplified McGill pain questionnaire (SF-MPQ), Toronto clinical score system (TCSS), sleep duration at night (SDN), pain disability index (PDI), Karnofsky performance status (KPS), and depression screening scale (PHQ-9). After procedures, the degree of perceived pain relief, numbness relief and chills relief of the patients, and side effects were assessed. All patients underwent evaluation after the last procedure at 1, 4, 12 and 24-week follow-up periods.

Results

The postoperative VAS, SF-MPQ, TCSS, PDI and PHQ-9 scores were significantly lower, while the KPS values higher than the preoperative (P<0.05). The postoperative SDN was longer than the preoperative (P<0.05). The degree of perceived pain relief, chills relief, and numbness relief at 4, 12, and 24 weeks were lower than that at 1 week after the procedures (P<0.05). The postoperative rates of administration of analgesic were lower than those of preoperative period (P<0.05). The significant effective rates at 1, 4, 12, and 24 weeks after the procedure were 67.86%, 42.86%, 21.43%, and 17.86% and the total effective rates were 89.29%, 71.43%, 46.43%, and 32.14%. No serious complication was observed.

Conclusion

Ultrasound-guided stellate ganglion PRF therapy can effectively relieve pain and improve the quality of life in T2DM patients with refractory painful DSPN.

Ultrasound combined with DSA-guided pulsed radiofrequency for perineal herpes zoster pain management: clinical outcomes and complications

Background

Herpes zoster (HZ) in the perineal area is a rare disease. There are limited treatment options for this disease. This study aimed to assess the efficacy of ultrasound combined with digital subtraction angiography (DSA)-guided pulsed radiofrequency (PRF) for perineal herpes zoster-related pain.

Methods

Two hundred and twelve patients with perineal HZ were enrolled at the pain department. From January 1, 2018 to December 30, 2019, patients with HZ in the perineal area were treated with PRF under DSA guidance, and from January 1, 2020 to October 30, 2023, patients with HZ in the perineal area were treated with PRF under ultrasound combined with DSA guidance. The included patients were divided into two groups: DSA group and ultrasound + DSA group. The visual analog scale (VAS), central sensitization inventory (CSI), sleep quality scores (SQS), the 36-Item Short Form Health Survey questionnaire (SF-36) at baseline and after the PRF treatment were analyzed to evaluate clinical efficacy.

Results

The mean VAS scores, CSI scores, SQS, and SF-36 scores were statistically significantly lower after treatment compared to baseline (p < 0.001). There was no significant change in VAS scores, CSI scores, SQS, and SF-36 scores between the DSA group and the ultrasound + DSA group (p > 0.05). The time it took from the start of the puncture to the successful puncture was significantly shorter in the ultrasound + DSA group compared to the DSA group (41.2 ± 21.2 vs. 48.1 ± 20.3, p = 0.035). The ultrasound + DSA group had a higher percentage of satisfaction with the procedure than the DSA group (90/99, 90.9% vs. 62/78, 79.5%, p = 0.030). A total of 27 postoperative complications occurred. The incidence of puncture site hematoma was significantly higher in the DSA group (10/78, 12.8%) than that in the ultrasound + DSA group (4/99, 4.0%) (p = 0.032).

Conclusion

PRF can reduce pain from HZ in the perineal region, alleviate central sensitization, enhance sleep quality, and improve overall quality of life. When PRF is performed under ultrasound guidance combined with DSA, it shortens the puncture time and reduces the risk of hematoma formation at the puncture site, making it the recommended method for clinical use.

Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis

BACKGROUND

Preventive treatment for refractory chronic cluster headache (rCCH) is challenging and many therapies have been tried.

OBJECTIVE

To study what could be considered the therapy of choice in rCCH through a systematic review and meta-analysis.

METHODS

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in PROSPERO (ID CRD42021290983). A systematic search was performed in MEDLINE, Embase, Cochrane, clinicaltrials.gov, and the WHO's-International-Clinical-Trials-Registry-Platform. Studies on the preventive treatment for rCCH as defined by the European Headache Federation consensus statement were included. A meta-analysis of the pooled response rate was conducted for the different therapies.

RESULTS

Of 336 results, 45 were eligible for inclusion. Most articles studied the effect of neuromodulation as a preventive treatment for rCCH. The most studied neuromodulation technique was occipital nerve stimulation (ONS), with a pooled response rate in the meta-analysis of 57.3% (95% CI 0.481-0.665). Deep brain stimulation (DBS) was the second most studied treatment with a pooled response rate of 77.0% (95% CI 0.594-0.957). DBS results were more heterogeneous than ONS, which could be related to the different stimulation targets in DBS studies, and reported more serious adverse events than in ONS studies. The remaining therapies (anti-CGRP pathway drugs, warfarin, ketamine-magnesium infusions, serial occipital nerve blocks, clomiphene, onabotulinum toxin A, ketogenic diet, sphenopalatine ganglion radiofrequency or stimulation, vagus nerve stimulation, percutaneous bioelectric current stimulation, upper cervical cord stimulation, and vidian neurectomy) present weaker results or have less quality of evidence.

CONCLUSIONS

The results of this systematic review and meta-analysis suggest that ONS could be the first therapeutic strategy for patients with rCCH based on the current evidence.

High-voltage long-duration pulsed radiofrequency attenuates neuropathic pain in CCI rats by inhibiting Cav2.2 in spinal dorsal horn and dorsal root ganglion

Inclinicalpractice, high-voltage, long-duration pulsed radiofrequency (HL-PRF) is effective for several types of intractable neuropathic pain (NP), but the mechanisms have not been well explored. Cav2.2 channels could increase neuronal excitability and neurotransmission accompanying NP. This study investigated the relationship of the efficacy of HL-PRF on NP with the levels of Cav2.2 in the spinal dorsal horn (SDH) and dorsal root ganglions (DRGs) of chronic constriction injury (CCI) in rats. Sham HL-PRF, GVIA (a specific Cav2.2 channel blocker), HL-PRF, or GVIA + HL-PRF was applied to CCI rats. The results showed: compared with the sham group, the PWT and PWL of CCI rats decreased significantly (P < 0.05), and Cav2.2 expression was elevated significantly in the SDH and DRGs (P < 0.05). Compared with the CCI group, both HL-PRF and ω-conotoxin GVIA treatment reversed the increased PWT and PWL (P < 0.05) and downregulated the overexpression of Cav2.2 in the SDH and DRGs (P < 0.05). Furthermore, PWT, PWL, and the expression of Cav2.2 in the SDH and DRGs were not significantly different among the 3 treatment groups. HL-PRF on L₅ DRG reversed the hyperalgesia behavior of NP and reduced the levels of Cav2.2 in the ipsilateral SDH and DRGs in CCI rats. Moreover, the underlying mechanism may be related to the downregulation of CaV2.2 protein levels in both SDH and DRG.

Safety and Efficacy of CT-Guided Pulsed Radiofrequency Combined with Steroid and Ozone Injection-Treated Cervical 3-8 Herpes Zoster Neuralgia Using a Posterior and Upper Quarter of the Cervical Foramina Puncture Approach

Background

Herpes zoster neuralgia has a considerable impact on people’s quality of life, especially after the development of postherpetic neuralgia. There are many clinical reports on the treatment of herpes zoster neuralgia, but there have been no special reports on the treatment of herpes zoster involving the neck. Our research focuses on a posterior and upper quarter of the cervical foramina puncture approach for herpes zoster involving the cervical 3–8 (C3-8) nerve region and to consider the safety and efficacy of pulsed radiofrequency combined with steroid injection and ozone injection in this puncture path under CT guidance.

Materials and Methods

A total of 104 patients with herpes zoster neuralgia involved in the cervical 3–8 nerve region use a posterior and upper quarter of the cervical foramina puncture approach received pulsed radiofrequency combined with steroid and ozone injection to the dorsal root ganglion. The total number of injection procedures, complications, NRS collection (preprocedure, postprocedure at once, two, four and 12 weeks) and drug dose decreases were documented.

Results

During a total of 257 procedures, 254 procedures successfully completed PRF (3 cases failed to reach the C8 aim points), and the rate of puncture failure was 1.17%. Drug injection was successfully performed in 252 procedures (the injection success rate was 99.21%); the NRSs (preprocedure, postprocedure at once, two, four and twelve weeks) were 5.75 ± 0.682, 2.6 ± 1.023, 2.21 ± 0.925, 1.89 ± 1.162, and 1.43 ± 1.369, and the difference among them was statistically significant. Drug dosages decreased before and after operation and showed statistically significant differences.

Conclusion

Pulsed radiofrequency combined with steroid and ozone injection for herpes zoster neuralgia involving the C3-8 nerves under CT guidance through a posterior superior quarter approach showed safety and efficacy and had a high success rate, and the NRS decreased significantly.

Long-term efficacy and patient satisfaction of pulsed radiofrequency therapy in temporomandibular disorders: A randomized controlled trial

BACKGROUND

Pulse radiofrequency (PRF) therapy is one of effective physical therapy modalities for treat temporomandibular disorders (TMD). This prospective randomized controlled trial aimed to evaluate the long-term treatment efficacy and patient satisfaction with PRF therapy in TMD.

METHODS

Eighty-six female patients with TMD were randomly assigned to either pulsed radiofrequency or placebo therapy in combination with other conventional treatments once a week for 12 weeks. A final analysis was performed 12 weeks after the completion of treatment. Clinical parameters and patient satisfaction were analyzed at baseline, 4, 8, and 12 weeks of intervention and at 24 weeks from baseline.

RESULTS

Pain intensity, comfortable and maximum mouth opening, and pain on capsule and masticatory muscle palpation were significantly improved after treatment in both groups. Notably, the pulsed radiofrequency group showed a significantly lower pain intensity at the final evaluation performed 3 months after the completion of treatment. Significantly more patients reported subjective pain improvement and satisfaction with treatment following intervention at baseline in the PRF group. Most patients did not report any discomfort following treatment in either group. However, significantly more patients in the PRF group reported a burning sensation with intervention.

CONCLUSION

Long-term regular pulsed radiofrequency therapy was effective in significantly reducing TMD pain, and the effect was long-lasting following treatment completion. Pulsed radiofrequency therapy should be considered as a supportive physical therapy modality for TMD.

Application and Therapeutic Effect of Puncturing of the Costal Transverse Process for Pulsed Radiofrequency Treated T1-T3 Herpes Zoster Neuralgia

Purpose

In CT-guided dorsal root ganglion puncture, especially T1–T3, it is often difficult to reach the target due to obstruction of the lamina, transverse process, and ribs. Therefore, a safe and effective puncture method with high success rate is urgently needed to guide us in our clinical work.

Patients and Methods

A total of 44 patients with dorsal root ganglion underwent pulsed radiofrequency therapy for pain T1–T3 herpes zoster neuralgia at the pain department of Affiliated Hospital of Jiaxing University from January 2019 to February 2020 were retrospectively reviewed. Each patient underwent the same surgical method. The patient’s operation time, CT filming times, nerve electrophysiological tests, the NRS scores before and after operation at one, four, eight, and 12 weeks, Pittsburgh Sleep Disorder Index (PSQI), dosage of gabapentin capsules and tramadol hydrochloride sustained-release tablets, surgical complications and incidence of postherpetic neuralgia (PHN) were recorded.

Results

The success rate of 44 patients who underwent puncturing of the costal transverse process to T1 target was 88.46%, to T2 target was 90.68%, and to T3 target was 90.68%, respectively. The NRS score of patients before surgery was 5.48±0.59, and those at one, four, eight, and 12 weeks after surgery were 3 (3,3), 1 (1,2), 0 (0, 1), and 0 (0, 0). The difference of NRS score between preoperation and postoperation is statistically significant. No intraoperative and postoperative complications occurred. Two patients developed PHN after standard treatment, and the incidence of it was 4.55%.

Conclusion

CT-guided puncturing of the costal transverse process in the dorsal root ganglion of patients who underwent pulsed radiofrequency treatment of T1–T3 herpes zoster neuralgia showed a high success rate and is considered to be safe and effective.