High Cervical Intrathecal Targeted Drug Delivery for Refractory Neuropathic Craniofacial Pain.

Objectives: Neuropathic craniofacial pain syndromes are heterogeneous with regards to clinical presentation and etiology. As such, they pose a diagnostic and management challenge, and are often refractory to medical and interventional management. High cervical intrathecal drug delivery has been reported in the management of refractory cancer-related craniofacial pain, although the literature regarding its use in neuropathic craniofacial pain remains limited. This study aims to describe the successful management of a series of patients with refractory neuropathic craniofacial pain who underwent implantation of a high cervical intrathecal drug delivery system (IDDS).

Materials and methods: A single-center retrospective chart review was conducted in patients with refractory non-cancer neuropathic craniofacial pain who underwent implantation of an IDDS with the intrathecal catheter tip placed at a high cervical level. A variety of medical, interventional, and neuromodulation modalities had failed in these patients. Data collection spanned 2016 through March 2025. Medical charts were reviewed for demographic data, operative details, pain severity outcomes, intrathecal medication dosing, and the incidence of complications.

Results: Overall, 12 patients (ten women, two men) underwent a high cervical intrathecal catheter trial. Nine patients had successful trials with reported improvement in pain >50%, with no significant reported side effects to a combination of fentanyl/bupivacaine. All patients suffered from neuropathic pain in the trigeminal distribution, with three patients experiencing corneal neuropathy. Patients were observed for a mean of 64.8 ± 48.1 months. Pain severity was significantly lower at last follow-up than at baseline (numeric rating scale of 9.5 ± 0.9 vs 4.3 ± 2.3) (p < 0.01). Three patients required catheter revision owing to migration. No patients were explanted for loss of efficacy.

Conclusions: High cervical intrathecal drug delivery can be an effective treatment option for patients with refractory neuropathic craniofacial pain, even in patients presenting with heterogeneous pain of differing etiologies and failure with other treatments.