2026 Proffered Presentations
S009: METHYLPREDNISOLONE/BUPIVACAINE INJECTION PROVIDES IMMEDIATE PAIN RELIEF FOR PATIENTS WITH REFRACTORY TYPE 2A TRIGEMINAL NEURALGIA WITH REDUCED RISK OF NEUROPATHIC PAIN DETERIORATION
Adway Gopakumar, BS1; Shovan Bhatia, BS1; Poliana Hartung, BS1; Dongwon Lee, BS1; Ajay Pathakamuri, BS1; William McKay, MS1; Sri Sridhar1; Stephen C Frederico, MS, MMSc1; Nikhil Sharma, MD1; Hussam Abou-Al-Shaar, MD2; Arka N Mallela, MD, MS3; Edward G Andrews, MD1; Georgios A Zenonos, MD1; 1University of Pittsburgh Medical Center; 2University of Texas Health Science Center at Houston; 3Rush University Medical Center
Introduction: Patients with type 2a trigeminal neuralgia (TN2a) have mixed dull and sharp/lancinating pain and constitute a challenging population to treat when no active neurovascular compression is identified. Lesioning procedures such as rhizotomies are associated with a high risk of neuropathic pain deterioration. Meckel’s cave methylprednisolone/bupivacaine injections may afford pain control in patients with TN2a with decreased risk of neuropathic pain deterioration; however, there is a paucity of evidence to support this. Our aim was to identify clinical and operative factors that predict pain response following methylprednisolone/bupivacaine injections in patients with medically refractory TN2a.
Methods: A retrospective analysis of percutaneous methylprednisolone/bupivacaine injections for patients with TN2a from 2020-2025 at a single institution was conducted. Demographics at presentation and operative data were collected. The primary outcomes were short- (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 short- 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. All procedures targeted a mixed pain profile; 55.6% with predominantly dull pain and 44.4% with predominantly sharp/lancinating pain. Short-term pain resolution was achieved in 86.2% of procedures. At last follow-up, 35.2% of cases were associated with pain resolution, resulting in a median long-term duration of pain relief of 19.9 months. On multivariate analysis, predominately dull pain at presentation was associated with improved short-term pain relief (HR: 0.26; 95%CI [0.08–0.91]; p=0.04), whereas age ≥ 61 was associated with a higher risk of short-term pain recurrence (HR: 4.93; 95%CI [1.05–23.1]; p=0.04). Nine (16.7%) procedures underwent subsequent repeat methylprednisolone/bupivacaine injections and were associated with left-sided pain (p=0.04), a history of prior glycerol rhizotomy (p=0.03), and longer symptom duration (p=0.03). Notably, on multivariate analysis, repeat injections were associated with higher risk of long-term pain recurrence (HR: 2.84; 95%CI [1.17–6.86]; p=0.02). Post-operative transient hypoesthesia was reported in 12.9% cases. Importantly, no patients had deterioration of their neuropathic pain component. No other complications were observed.
Conclusion: Percutaneous Meckel’s cave methylprednisolone/bupivacaine injections provide short term pain relief for patients with TN2a and have minimal risk of neuropathic pain deterioration, making them a more beneficial option for multiple treatments.
Figure 1. Kaplan-Meier survival curves across various subgroups: A) Predominantly dull pain profile is a protective factor for improved short-term pain control compared to those with a primarily sharp pain profile. B) Individuals greater than or equal to the age of 61 are at increased risk for poor short-term pain control compared to those below the age of 61. C) Repeat methylprednisolone/bupivacaine injections are a risk factor for poor long-term pain control compared to those receiving an index injection.