Methylprednisolone/Bupivacaine Injection Provides Immediate Pain Relief for Patients with Refractory Type 2A Trigeminal Neuralgia with Reduced Risk of Neuropathic Pain Deterioration

Introduction: Patients with type 2a trigeminal neuralgia (TN2a) have mixed dull and sharp/lancinating pain and constitute a challenging population to treat when no active neurovascular compression is identified. Lesioning procedures such as rhizotomies are associated with a high risk of neuropathic pain deterioration. Meckel’s cave methylprednisolone/bupivacaine injections may afford pain control in patients with TN2a with decreased risk of neuropathic pain deterioration; however, there is a paucity of evidence to support this. Our aim was to identify clinical and operative factors that predict pain response following methylprednisolone/bupivacaine injections in patients with medically refractory TN2a. Methods: A retrospective analysis of percutaneous methylprednisolone/bupivacaine injections for patients with TN2a from 2020–2025 at a single institution was conducted. Demographics at presentation and operative data were collected. The primary outcomes were short- (at first follow-up) and long-term (at last follow-up) pain relief. Univariate and multivariable Cox proportional hazards regression analysis and Kaplan-Meier survival analysis assessed prognostic factors for short- and long-term-pain-relief. Results: A total of 42 patients underwent 54 percutaneous methylprednisolone/bupivacaine injections. No procedures were performed in the setting of active neurovascular compression. All procedures targeted a mixed pain profile; 55.6% with predominantly dull pain and 44.4% with predominantly sharp/lancinating pain. Short-term pain resolution was achieved in 86.2% of procedures. At last follow-up, 35.2% of cases were associated with pain resolution, resulting in a median long-term duration of pain relief of 19.9 months. On multivariate analysis, predominately dull pain at presentation was associated with improved short-term pain relief (HR: 0.26; 95%CI [0.08–0.91]; p = 0.04), whereas age ≥ 61 was associated with a higher risk of short-term pain recurrence (HR: 4.93; 95%CI [1.05–23.1]; p = 0.04). Nine (16.7%) procedures underwent subsequent repeat methylprednisolone/bupivacaine injections and were associated with left-sided pain ( p = 0.04), a history of prior glycerol rhizotomy ( p = 0.03), and longer symptom duration ( p = 0.03). Notably, on multivariate analysis, repeat injections were associated with higher risk of long-term pain recurrence (HR: 2.84; 95%CI [1.17–6.86]; p = 0.02). Post-operative transient hypoesthesia was reported in 12.9% cases. Importantly, no patients had deterioration of their neuropathic pain component. No other complications were observed. Conclusion: Percutaneous Meckel’s cave methylprednisolone/bupivacaine injections provide short term pain relief for patients with TN2a and have minimal risk of neuropathic pain deterioration, making them a more beneficial option for multiple treatments. Fig. 1 Kaplan-Meier survival curves across various subgroups: ( A ) Predominantly dull pain profile is a protective factor for improved short-term pain control compared with those with a primarily sharp pain profile. ( B ) Individuals greater than or equal to the age of 61 are at increased risk for poor short-term pain control compared with those below the age of 61. ( C ) Repeat methylprednisolone/bupivacaine injections are a risk factor for poor long-term pain control compared with those receiving an index injection. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany