Kai-Jun Zhang,Jia-Chun Xu,Zhen Zhou,*

1Graduate School,Tianjin University of Traditional Chinese Medicine,Tianjin,China.2Department of Neurology,The Second Hospital Affiliated to Tianjin University of Traditional Chinese Medicine,Tianjin,China.

Introduction

Trigeminal neuralgia(TN)is a syndrome of unilateral,paroxysmal and stabbing facial pain,which originates from the trigeminal nerve.It is a chronic disorder characterized by sudden onset and arrest as well as lightning-like,knife-like orburning-like unbearable severe pain.The pain always is limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli.

Epidemiological studies report that the incidence rate of TN is 4-29 per 100,000 inhabitants in the world[1].The mandibular and maxillary divisions are affected more frequently than the ophthalmic division.It is more common in females than males,and the right side is more frequently affected than the left side[2].

The diagnosis of TN is based purely on clinical grounds by characteristic symptoms and signs[3].Many medical and surgical treatments are available,such as carbamazepine(CBZ)or oxcarbazepine,the first-choice medical treatments according to the guidelines on TN management jointly published by the American Academy of Neurology and the European Federation of Neurological Societies.However,the side effects of CBZ and oxcarbazepine caused withdrawal from treatment in an important percentage of patients[4].Subcutaneous injections of botulinum toxin-A (BT-A) are a non-invasive treatment option,which is suitable for patients where the drug or neurosurgical intervention therapy have failed,proved to be a potentially safe and efficient additional treatment option for TN.However,there is still no existing evidence that treatment of BT-A can be maintained for a long time[5].Medically refractory cases and patients who cannot tolerate the side effects of the medication may benefit from surgical management.Microvascular decompression remains the best approach for patients when the result of MRI shows a loop of the aberrant vessel.Selecting an appropriate approach and using reasonable decompression methods can bring complete postoperative pain relief in most cases.However,itcould lead to facialnumbnessmore frequently [6].Otheroptionsare the percutaneous ablative procedure and Gamma Knife Radiosurgery(GKRS).The GKRS can relieve the pain that might be related to the atrophy of the trigeminal nerve root.However,due to the high cost of GKRS,few patients choose it[7].

In traditional Chinese medicine(TCM)theory,TN is a disease syndrome,which is classified as “face pain”,“cheek pain,and bone cheek pain”.As recorded in the ancient books ofZhangshiyitong·Toutong(A.D.1695,Qing Dynasty)andZhubingyuanhoulun·Toutong(A.D.610,Sui Dynasty),this disease was caused by the stagnation of Qi and blood,external resistance of pathogenic cold,and deficiency of vital Qi[8].Through its fiery nature,the fire needle has the potentials to eliminate cold to relieve pain and promote Qi and blood circulation.Suwen·Tiaojinglun(B.C.475~221,Qin Dynasty)said that“patients with blood deficiency prefer warm to cold.When cold,the blood is astringent and cannot circulate.When warm,the blood stagnation is eliminated.”Besides,the combination of fire needle with blood-letting therapy is a minor traumatic treatment of the skin for the patient,and it is more acceptable for patients who refuse to undergo surgery or minimally invasive injection[9-10].

Thus,in the present case,we applied the fire needle combined with the filiform needle,and blood-letting therapy to treat this patient and the report is as follows.

Case report

An 81-years-old woman presented with a right facial pain and emphasized the pain on the right side of the nose,eyebrows and the philtrum in October 2017.Chewing on hard food or dramatic emotional changes could lead to the irritating facial pain,often accompanied by a right migraine.She had a lessdiet,sleeplessness,and emotional fluctuations.Neurology examination showed no obvious defect symptoms and signs.Brain CT and MR examination showed mild brain atrophy and no obvious infarction or bleeding.Physical examination showed that the patient was slightly thin(BMI:17.4)in body figure and well in the mental state.The blood pressure was 140/90 mmHg and the heart rate was 74 beats/min.

History of present illness:the patient has suffered from TN for 20 years and been given 3 tablets of CBZ orally once a day for 10 years.She was not treated with other drugs and refused surgical treatment.She also has suffered from hypertension,coronary atherosclerotic heart disease and diabetes,and receives the conventional therapies.

Discussion

The trigeminal nerve is a mixed nerve,divided into three branches,namely theophthalmicbranch,maxillary branch and mandibular branch.The majority of patients suffering from TN have three types of mixed pains.The primary TN is the most typical clinical neuralgia.According to the theory of TCM,the face is dominated by three Yang meridians of hand and foot.Therefore the point selection is mainly on the distributed region of three Yang meridians of hand and foot,especially on the affected area where three branches of trigeminal nerve distributed.

Zhang Jingyue said that:Fan needle is also called burned needle.Rapidly piercing the needle with fire heat can disperse cold pathogen.(A.D.1624,Ming Dynasty).The fire needle can warm the meridians and encourage Yangqi of the body,thereby dispelling the pathogenic cold,harmonizing the collaterals,and relieving the pain[11,14].Modern research suggests that acupuncture can achieve analgesic effects via acting on the entire nervous system,including the spinal cord,brain stem,thalamus,and limbic system and so on[15-21].Clinical observation ofprimaryTN showedthatthethree-combination needling therapy containing fire-needle,acupuncture,and acupoint-injection has a better clinical curative effect than the combination of acupuncture and acupoint-injection.

Table 1 The first and second treatment

To reconcile Qi and blood,the filiform needle applied to the right face of this patient.The filiform needle always plays the significant role of “Deqi”in Chinese medicine(it is also named as the needling sensation and the patient will feel the sense of soreness,numbness,and heaviness around the acupuncture point),which may transmit to other place along the course of channel,and adjust Qi and blood by retaining needle[22,23].This filiform needle modality in which the needle insertion sites are corresponding to the pain spots is considered as a safe and viable therapy for pain control.As shown in a randomized controlled trial,the patients with the diagnosis of rib fractures treated with filiform needles had more effective pain relief than those in the thumbtack intradermal needle group[24].

Blood stasis is mainly responsible for the pain according to the theory of Chinese medicine.Blood stasis is not only the pathological basis but also the clinical manifestations of microcirculatory disturbances[25].The bookZhenJiuZhaiYingJi(B.C.215~282,Yuan Dynasty)pointed out that“dredging heat and bloodletting is suitable for abreacting the chronic malady”,meaning the patient with the chronic disease usually suffered from the symptoms of Qi and blood stasis as well as Yin deficiency and inner heat.The combined blood-letting puncture and cupping have the potentials to force blood outgoing directly,purging blood stasis and smooth meridians,thereby relieving pain immediately.There is also evidence that venesection directly dilutes painful substances released by noxious stimuli in local tissues,such as K+,H+,and 5-HT peptides.The combination of quick cupping can regulate the vasomotor function of small blood vessels,improve local microcirculatory disturbances,promote tissue repair and then relieve pain[26].

Therefore,the chronic diseases are prone to transmit to collaterals and lead to the Qi deficiency and blood stasis.The application of fire needle achieve the aim of warming Yang and dispelling pathogenic cold as well as promoting the circumstance of Yangqi of the whole body and relieving the pain.Then the filiform needle acupuncture points were selected in accordance with the patient’s symptoms to promote circulation of Qi and blood.Moreover,fire needle combined with filiform needles were applied to abdominal points in order to warm the Middle-Jiao,regulate Qi,and activate blood and dredge collaterals.Finally,the three-edged fire needle pricked the points of Yangbai(GB41),Shangguan(GB3),Jiache(ST6)located on the tripod of the trigeminal nerve and made it bleed a bit in order to dispel stasis and stop the pain when in combination with the usage with cupping.

Conclusion

This case report suggests that fire needle combined with blood-letting therapy could effectively improve and cure the pain symptoms of TN.It might provide an alternative for patients who still suffered from TN after other medical treatments without obvious effect or who refused surgical treatment.

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