Clinical consult notes

neuro consults clinical notes

A call to the emergency department to see a patient with intractable facial pain. The patient was a 60 something-year-old woman with a history of trigeminal neuralgia who has had multiple at least 10 neurosurgical procedures in the past 20 years for facial pain. Two years ago she had a motor cortex stimulator implanted and has been using an unknown setting to help control facial pain. She is also taking carbamazepine which has been partially therapeutic. Recently in the last two weeks she has noticed that the stimulator is not helping her pain and she has been having breakthrough episodes of recurrent lancinating sharp-like episodic paroxysmal facial pain. These last anywhere between 30 seconds to two minutes and come in intervals which have been more or less constant for the previous week she has had very little sleep or food as a result. Aside from the carbamazepine she takes oxycodone with limited therapeutic effect. In the last few days she was seen in clinic and multiple setting changes were made both increasing and decreasing the voltage as well as changing the signal firing pattern. We are now been consulted by the emergency department for recommendations for this intractable facial pain. On exam she was otherwise stable but she was teary and the right face was flushed full a little swollen. Every now and again she would wretch forward with outbursts of moaning in pain. There were no focal neurological deficits

The most important first step is to control the patient's pain for which there are a couple of options. First we could increase the dose of the opioid medication in hopes that this could somehow treat the pain. Emergency Department personnel had already tried this, but it was not working after a few hours. Their method was to use oxycodone oral, approximately 30% stronger than oral morphine. We recommended intravenous opioids particularly hydromorphone as far stronger than oxycodone. The patient also kept a log of which stimulator settings worked best to control her pain. The current setting was not the most optimal setting that she previously had found. We recommended altering the setting to a prior pattern which she did with limited therapeutic effect.  These combined interventions were responsive for the patient in this instance and she was able to discharge with a prescription for oral opioids converted to the strength of the intravenous dose for the next day until she had follow up with her specialist. Had this not worked I have seen case reports of fosphenytoin loading for acute pain. And had that not worked unfortunately the last resort is general anesthesia and admission for intractable pain. Luckily for this patient she experienced symptomatic relief with stronger dose opioids for breakthrough pain and was able to leave the emergency department and make her clinic visit the day after.