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ANALGESIC EFFECTS OF PERIPHERAL

INJECTIONS OF STREPTOMYCIN AND
LIGNOCAINE IN THE TREATMENT OF
TRIGEMINAL NEURALGIA- A CLINICAL STUDY
Dr. Fakhrul Imam
FCPS Part II Trainee
Oral & Maxillofacial Surgery Department,
Dhaka Dental College Hospital

ANALGESIC EFFECTS OF PERIPHERAL

INJECTIONS OF STREPTOMYCIN AND
LIGNOCAINE IN THE TREATMENT OF
TRIGEMINAL NEURALGIA- A CLINICAL STUDY
AUTHORS:
Gupta Ankur, Siwach Amit
Department of Oral and Maxillofacial Surgery, Kalka
Dental College and Hospital, Meerut
Bhatnagar Aditi,
Department of Oral and Maxillofacial Surgery,
Narsinhbhai Patel Dental College, Visnagar, Gujarat
Deep Anchal,
Department of Prothodontics Kalka Dental College
and Hospital, Meerut.

Objectives

To study the analgesic effects of streptomycin/lignocaine injection in the

treatment of trigeminal neuralgia. Methodology : 10 patients were
undertaken for this study from January 2011 to September 2011, afflicted
with trigeminal neuralgia affecting maxillary (3 patients) and mandibular (7
patients) division of trigeminal nerve. In these patients
streptomycin/lignocaine injection was administered in relation to the
affected nerve branch at the interval of 1 week for 4-6 weeks and regular
follow up was obtained. Results : 8 patients had excellent pain relief while
1 patient had a good result and 1 patient had a poor result. Conclusion :
Streptomycin/lignocaine injection is effective for the symptomatic
treatment of trigeminal neuralgia. It is simple, quick, economical and easy
to perform and can be practiced as outpatient procedure.

Introduction
The International Association for the Study of Pain defines trigeminal
neuralgia as sudden, recurrent, severe pain in the distribution of one
or more branches of fifth cranial nerve. Although compression of the
on nerve root is the most common reported cause of trigeminal
neuralgia, most cases are idiopathic. It is characterized by sudden
attacks of pain that are typically brief, lasting only seconds to few
minutes. These attacks are severe and are described as intense,
stabbing or electrical shock- like. The management of TN is primarily
focuse on medical interventions involving anticonvulsant drugs or on
various surgical techniques, including peripheral injections of various
agents having neurolytic properties, peripheral neurectomy,
cryotherapy, microvascular decompression, radiofrequency
thermocoagulation and gamma knife radiosurgery. . An ideal
treatment is one that causes no morbidity and preserves the normal
sensation of the face. Such a sensation-preserving, absolutely
safe and permanently successful treatment unfortunately does not
exist yet. The present study was conducted to examine the role of
streptomycin as a neuroablative agent in the subjects suffering with
trigeminal neuralgia.

METHODOLOGY
10 patients were selected for the study ranging from 42-60 year of age
irrespective of sex with clinical diagnosis of trigeminal neuralgia
affecting the maxillary division in 3 patients and mandibular division in
7 patients. The purpose and procedure of study was explained to the
patients, risk/benefit ratio was discussed followed by a written informed
consent. The patients were administered injections containing 1 g
streptomycin sulfate solution in 2 ml of 2% lignocaine hydrochloride
injection around the nerve branch involved with trigeminal neuralgia.
These injections were administered after a subcutaneous test dose
injection in these patients. The test dose injection site was observed for
fifteen minutes for any signs of allergic reaction. These were standard
nerve block injections namely; mental nerve block, inferior alveolar
nerve block, infra-orbital nerve block and posterior superior alveolar
nerve block injection depending upon the involved nerve branch
respectively. Patients were administered the repeated dose at an
interval of 1 week for 4-6 weeks and were followed for six months post
treatment.

At every appointment patients were required to score their

pain intensity on a visual analogue scale (VAS). Patients were
asked to keep a daily record of pain severity (0-10) and
frequency of attacks and any adverse effects that could be
attributed to the injections. The success rate of the procedure
was categorized into excellent, good and poor according to
pain relief.
Excellent: complete pain relief after the use of injections.
Good: complete pain relief with occasional pain attacks
lasting for few seconds.
Poor: complete recurrence of pain despite regular injections
and compliance.

RESULTS
Post-operative pain severity follow-up:
Patient's score on Visual Analogue Scale was categorized as
VAS zero (0)= no pain, VAS of 1-3= mild pain, VAS of 4-7=
moderate pain, VAS of 8-10= severe/extreme pain. Eight
patients had a score of zero (0) on VAS while one patient had
a score of two (2) and one patient had a score of eight(8)

Post-operative pain frequency follow-up:

Patients with excellent results had no paroxysm following therapy
while the patient with good results had 3 paroxysms after 2 weeks
of initiation of therapy and patient with poor results had no relief in
pain and frequency of attacks after the therapy. Three months post
operatively there were no changes in the frequency of paroxysms
and same holds good for six months post treatment. None of the
patients recorded any adverse effects that could be attributed to the
given dose of streptomycin injections.

DISCUSSION
Bittar and Graff radford in 1993 investigated the long term effect of
peripheral streptomycin injections on trigeminal neuralgia and observed
that sensory function of the treated nerves was not affected. Author also
observed side effects including facial swelling and pain.
In present study no side effects of streptomycin injections were
reported. In 1986 Sokolovic et al used peripheral injections of
streptomycin/lidocaine in 20 patients with trigeminal neuralgia. The
patients were given 5 injections at 1 week intervals. All patients obtained
pain relief, without any sensory loss, only 4 having a recurrence. The
remaining 16 patients remained free of pain after period of upto 30
months6. The results of present study are comparable to Sokolovic et al as
sensory nerve function completely recovered in all patients after 1st month
post- operative. Stajcic in 1989 in his preliminary study investigated the
role of peripheral glycerol injections in the treatment of TN. 13 patients
with 17 nerves affected by trigeminal neuralgia underwent peripheral
glycerol injections. 12 nerves were pain free for between 6-26 months postoperatively. Pain recurred in the areas of 6 nerves, 3-18 months following
treatment. 3 nerves were successfully reinjected. Decreased sensation was
noticed in the area of 6 nerves. Nouf al Hammad studied the efficacy of
peripheral glycerol injection in the management of trigeminal neuralgiain
2006. At one year follow-up 11 patients (44%) continued to have pain relief.

Recognizing that even the most potent medication may be inadequate

to suppress the pain, investigators have searched for ways to help those
patients who are incapacitated by their pain. Injections of neurolytic
drugs to interrupt the pain pathway is one such technique. A variety of
chemical and physical agents have been used to selectively destroy
painful nociceptive pathways. Currently, the ideal agent has yet to be
identified. Neurolytic effects of streptomycin following systemic use
such as damage to the acoustic nerve, inhibition of secretion of acetyl
choline at nerve endings and stabilization of the nerve cell membrane
have been well documented. Streptomycin produces a repolarization of
depolarized nerve due to a membrane stabilizing effect. After infiltration
of streptomycin, the conduction velocity of the nerve is reduced.
Streptomycin being a potentially selective neuroablative, does not affect
sensory function of the involved nerve. Streptomycin produces axonal
damage peripherally in the nerve bundles covering approximately onefifth of the entire circumference. This suggest that there is little
probability of affecting those axons that transmit trigger stimuli with a
single injection of streptomycin. This coincides with the pure clinical
observation that streptomycin should be given in 5 weekly peripheral
injections as mentioned by Sokolovicetal. and Stajcic et al.. The extent
of morphological changes affecting fibres responsible for the trigger
mechanism of peripheral nerve treated with streptomycin is
unpredictable regardless of the number of injections. Therefore, the

positive effects to unfavourable results. Due to insufficient research data

there is a need for high quality randomized controlled trials in this
area of medicine. Scientific evidence alone does not dictate the selection
of treatment. When making health care decisions, clinicians also should
consider intervention benefits are worth the cost. The application of
evidence into clinical practice has to be related to professional expertise
and the need of the patients.

CONCLUSION
Trigeminal neuralgia has long been recognized by medical health care
professionals. However, it is still an anigmatic disorder, and its
management remains controversial. Future multicenter, randomized,
controlled trials may help establish curative therapy.