1421 - Refractory Trigeminal Neuralgia Following Microvascular Decompression Successfully Treated with Ultrasound-Guided Trigeminal and Mental Nerve Blocks: A Case Report

Right-sided trigeminal neuralgia refractory to medical management and microvascular decompression

Case Description: A 62-year-old female with a history of occipital neuralgia presented with severe right-sided trigeminal neuralgia in the V2/V3 distribution. She underwent microvascular decompression of cranial nerve V in January 2025 with initial pain relief for one month. Her pain subsequently recurred, described as constant, burning, 10/10 in severity, and exacerbated by chewing, talking, and brushing teeth. She also reported numbness and tingling of the right cheek with mild facial edema. Trials of carbamazepine and pregabalin yielded no significant improvement. The patient was treated with trigeminal and mental nerve blocks with complete relief of pain one month post-procedure.

Discussions: Trigeminal neuralgia is often managed with anticonvulsant medications, nerve blocks, and surgical interventions, including microvascular decompression. Recurrence of symptoms after decompression can present a therapeutic challenge. SPG block has been described as a minimally invasive option for refractory facial pain, targeting parasympathetic fibers contributing to trigeminal pain transmission. In this case, dynamic ultrasound guidance facilitated precise needle placement and avoidance of intravascular injection during the SPG and mental nerve blocks.

Conclusions: This case highlights the role of ultrasound-guided SPG and mental nerve blocks in patients with recurrent trigeminal neuralgia after surgical decompression and inadequate response to pharmacologic therapy. The patient reported complete relief one month post-procedure, demonstrating that peripheral and autonomic nerve blocks can provide meaningful pain reduction and functional improvement in refractory cases. Further studies are warranted to assess the durability of response and to optimize procedural protocols.