Sponsor Spotlight: Mayo Clinic

Mayo Clinic’s multidisciplinary team approach means people with facial pain receive care based on their individual needs. A team of specialists takes time to thoroughly examine patients, and discuss their pain experiences, before recommending possible treatments.

“As a group practice, there is no incentive to do any particular procedure. We talk about what is best for the patient. That’s the core of the Mayo model of care,” says Mayo Clinic neurosurgeon Dr. Richard S. Zimmerman.

A member of the FPA Medical Advisory Board, Dr. Zimmerman led a session on multidisciplinary care at the 2024 FPA Conference. He was joined by colleagues from Mayo Clinic’s large facial pain team, which includes neurologists, neurosurgeons, interventional radiologists, psychologists and rehabilitation specialists.

“We all understand facial pain, as it’s part of our practice,” Dr. Zimmerman says.

Getting the diagnosis right

Pinpointing the cause of facial pain is key to Mayo Clinic’s approach. That starts with a thorough patient history.

“When it comes to someone with facial pain, it really is all about the details,” says Mayo Clinic neurologist Dr. Laine L. Green. “Understanding a patient’s early experiences with pain can be very helpful. We also want to understand what’s happening now on pain days — things like frequency, location, radiation, quality and severity — and also what’s happening on any pain-free days.”

Detailed neurological and physical examinations are also performed. “That’s important because facial pain can be a manifestation of systemic diseases or disorders,” Dr. Green says. Problems with anatomy are considered, including not just the cranial nerves but also the upper neck, eyes, teeth and sinuses.

Additional testing might include:

• Spinal fluid analysis, which can indicate an autoimmune condition.
• Imaging, such as MRI, CT or X-rays.
• Electrical tests of nerves and muscles (electromyography or EMG).

“Patients don’t always fit into a perfect silo,” Dr. Green says. “As a multispecialty practice, we are afforded the time to get this information, and as a team, we communicate well among ourselves.”

The right treatment for the right patient

A multidisciplinary team approach provides patients with a range of treatment options. If medication doesn’t work, neurosurgeons can perform microvascular decompression surgery, which involves moving or removing blood vessels that touch the trigeminal nerve to stop its malfunctioning.

Mayo Clinic in Arizona strives to rely on microsurgical transposition and maneuvering of blood vessels to avoid overuse of artificial cushions. They can cause inflammatory tissue or leave continued pressure on the trigeminal nerve and cause recurrent or continued pain.

“There is more than one way to perform this surgery,” Dr. Zimmerman says. “We prefer a method that uses the person’s own tissue, to be part of a regenerative solution.”

Interventional neuroradiologists can provide nonsurgical treatments. Needles or probes are inserted under CT guidance to deliver various therapies that selectively damage the trigeminal nerve and block pain.

The options include:

• Nerve block.
• Pulse radiofrequency ablation, which delivers intermittent bursts of energy to nerve fibers.
• Continuous radiofrequency ablation, which delivers higher energy to nerve fibers.
• Balloon compression, which involves inflating a balloon inside the trigeminal nerve.
• Glycerol injection.
• Stereotactic radiosurgery, which delivers a focused dose of radiation to the base of the trigeminal nerve.

“We prefer to start with the least destructive treatment, which is nerve block,” says Mayo Clinic interventional radiologists Dr. Ameet C. Patel “The next step would be pulse radiofrequency ablation and finally, any of the other treatments.”

Neuromodulation is a newer approach that uses various means of changing nerve activity to normalize how nerves function. “Neuromodulation is not the first-stage option. We have to understand where the circuitry may be disrupted. This is a very personalized approach,” says Mayo Clinic neurosurgeon Dr. Jonathon J. Parker.

There are several types of neuromodulation, including transcranial magnetic stimulation, peripheral nerve stimulation, ganglion stimulation and deep brain stimulation. “A lot of these devices have minimal or no risk and can provide some degree of pain relief,” Dr. Parker says.

Multidisciplinary care also encompasses pain rehabilitation. “Even if we can’t cure people’s chronic pain, we can offer hope that their quality of life can improve,” says Dr. Cynthia O. Townsend, a psychologist and clinical director of the Mayo Clinic Pain Rehabilitation Center. The strategy simultaneously addresses physical and occupational therapy, psychotherapy and relaxation exercises.

For people with facial pain, individualized treatment requires a multidisciplinary team approach. “As an integrated group practice, we have many ways to address the needs of patients with facial pain,” Dr. Zimmerman says. “Each of our facial pain champions contributes to the care of patients.”