Facial pain, caused by Torkildsen shunt migration

Introduction. The literature showed a limited number of cases of facial pain caused by pathology at the level of the craniovertebral junction, however there is no a single case of pain caused by the migration of elements of the shunt systems.

The objective is to describe a clinical case of successful surgical treatment of facial pain caused by the Torkildsen shunt migration.

Clinical case. A female patient, 58 years old, applied to the clinic complaining of constant pain with a paroxysmal component in the left part of the face and back of the skull associated with head movements. Other complaints included a headache accompanied by nausea, numbness in the limbs, instability in vertical position, urinary incontinence, abnormal proprioceptive sensitivity in the limbs. Medical history showed that in 2000 the patient underwent Torkildsen procedure (ventriculo-cisternostomy) due to occlusive hydrocephalus after a neurological infection. In 2013, due to shunt dysfunction endoscopic third ventriculostomy was performed with a good clinical effect. Deterioration started in January of 2018. At hospitalization, tomography of the brain showed migration of the distal end of the shunt into spinal matter, syringobulbia at the C₁ vertebra level. No signs of neurovascular conflict of the trifacial nerves were observed. Removal of the ventriculo-cisternal shunt irritating the spinal nucleus of the trifacial nerve was performed. In the postoperative period, intensity of the paroxysmal component of facial pain decreased. At day 5 after surgery, the patient was discharged in a satisfactory state. For 1 year and 6 months after the surgery, facial pain has been absent. Manifestations of hydrocephalus and spinal disorder (numbness of the limbs, instability, urinary incontinence) persist, but due to the patient’s compensated state, negative result of the tap-test, signs of functional third ventriculostomy, it was decided to abstain from further interventions.

Conclusion. This clinical case demonstrated successful treatment of facial pain developed due to a rare cause – migration of a Torkildsen shunt that currently is rarely encountered.

1. Torkildsen A. A new palliative operation in cases of inoperable occlusion of the Sylvian aqueduct; a preliminary report. Forh Norske Med. Selsk., 1938. Pp. 102–108. DOI: 10.1111/j.1600-0447.1939.tb06636.x.

2. Zinn P.O., Bozinov O., Burkhardt J.K. et al. Failure of a Torkildsen shunt after functioning for 50 years. J Neurosurg 2010;112(4):796–9. DOI: 10.3171/2009.7.JNS09729.

3. Than K.D., Sharifpour M., Wang A.C. et al. Chiari I malformation manifesting as bilateral trigeminal neuralgia: case report and review of the literature. J Neurol Neurosurg Psychiatry 2011;82(9):1058–9. DOI: 10.1136/jnnp.2009.196121.

4. Walkden J.S., Cowie R.A., Thorne J.A. Occipitocondylar hyperplasia and syringomyelia presenting with facial pain. J Neurosurg Pediatr 2013;12(6):655–9. DOI: 10.3171/2013.8.PEDS13288.

5. Randhawa P.A., Cooke L., Hill M.D. Headache, atypical facial pain, and a syrinx. Can J Neurol Sci 2016;43(3):452–3. DOI: 10.1017/cjn.2015.348.

6. Anderson N.E., Willoughby E.W., Wrightson P. The natural history and the influence of surgical treatment in syringomyelia. Acta Neurol Scand 1985;71(6):472–9. DOI: 10.1111/j.1600-0404.1985.tb03230.x.

7. Torkildsen A. Ventriculo-cistеrnostomy. A post-operative study. Acta Chir Scand 1941;85:254–60.

8. Fincher E.F., Strewler G.J., Swanson H.S. The Torkildsen procedure; a report of 19 cases. J Neurosurg 1948;5(3):213–29. DOI: 10.3171/jns.1948.5.3.0213.

9. Morota N., Ihara S., Araki T. Torkildsen shunt: re-evaluation of the historical procedure. Childs Nerv Syst 2010;26(12):1705–10. DOI 10.1007/s00381-010-1182-2.

10. Ehni G., Moiel R.H., Bragg T.G. Torkildsen’s ventriculocisternostomy: some complications and their prevention. Clin Neurol Neurosurg 1976;79(2):119–32. DOI: 10.1016/0303-8467(76)90004-4.

11. Rossitch E. Jr, Friedman A.H., Bullard D.E. Foreign body reaction to rubber Torkildsen catheters: a report of two cases. Neurosurgery 1985;17(5): 838–42. DOI: 10.1227/00006123-198511000-00021.