Postoperative pain is a major concern in surgical patients and is often difficult to treat. Studies have shown that carboxytherapy can be helpful in some cases of persistent pain because it increases tissue oxygenation. This report describes the case of a patient who received carboxytherapy after three years of persistent postoperative neuropathic facial pain and was successful in reducing her symptoms.
About 80% of patients who undergo oral and maxillofacial surgery report moderate or severe pain after the operation . Many strategies have been adopted to manage postoperative pain in these patients, including nerve block, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, local anesthetics, relaxation techniques, and acupuncture. . Even with these many therapies available, postoperative pain remains a challenge in this type of surgery, as it can last for long periods of time and be difficult to treat, especially when it comes to neuropathic pain. .
Transcutaneous application of carbon dioxide gas (CO2) has been considered for pain management in a few settings . The rationale for its analgesic properties is that it appears to increase tissue oxygenation due to a vasodilating effect after CO2 application. Additionally, the increased carbon dioxide in the area is also thought to induce hemoglobin to release oxygen through the Bohr effect, contributing to this increased tissue oxygenation. .
In this study, we describe the case of a patient with refractory postoperative neuropathic perioral pain after orthognathic surgery in which carboxytherapy was used as a treatment and successfully reduced the patient’s symptoms.
Presentation of the case
A 67-year-old woman presented to our care for regular dermatological treatment. At her appointment, she complained of persistent circumoral pain for three years (Figure 1A), which began after undergoing two orthognathic surgeries to realign his jaw and teeth. She said the pain started immediately after her second surgery and she initially attributed it to local swelling. However, the pain persisted after the swelling subsided and the patient described it as constant throbbing pain, intermittent throbbing pain and allodynia, which suggested neuropathic pain. The pain was rated 8 on a numerical rating scale (NRS), where zero represents “no pain” and 10 represents “worst possible pain”. Stress, restlessness and hot temperatures have been identified as aggravating factors. One identified relieving factor was the use of moisturizers, but the positive effect quickly faded after absorption. Many over-the-counter pain relievers had been tried in the three years following surgery including paracetamol (750 mg orally) and NSAIDs (nimesulide 100 mg orally), but improvement was only partial and temporary The patient consults a neurologist for an evaluation of neuropathic pain and physiotherapy is offered but the patient does not comply with the therapy.
An experimental session of carboxytherapy in the painful area was proposed to the patient. The technique consisted of 12 intradermal injections of carbon dioxide to cover the entire perioral area (Figure 1B). Each injection lasted approximately three seconds and the flow of CO2 used was 150 mL/min. The needle used had a length of 13 mm and a diameter of 0.3 mm, and the angle of inclination of the needle during the injection was between 10oh and 15oh. After a single session of carboxytherapy, the patient reported complete resolution of pain in the lower perioral region (NRS: 0) and a marked decrease in pain in the upper perioral region (NRS: 4) within one week of treatment (Picture 1 C). The only reported side effect was moderate pain during the procedure.
The patient returned for a follow-up visit two months after the treatment and reported that the analgesic effect remained unchanged from the first week after the procedure.
Postoperative neuropathic pain can be difficult to treat, as it can become chronic and disabling . Adequate treatment is important because severe pain after surgery increases the risk of chronic postoperative pain due to ongoing nociceptive stimuli causing neuroplastic changes . Several treatment strategies have been adopted, including pharmacological and psychological therapies, but their results are not always satisfactory. . Therefore, the development of more effective strategies to control postoperative pain could help improve the quality of life of patients.
Carboxytherapy is a well-known technique in dermatology, and it has been used for several years for both aesthetic and pathological pathologies. [3-6]. It is considered a simple and safe procedure, with mostly mild and temporary adverse events such as pain and bruising . The use of this technique for the treatment of conditions associated with pain, such as myofascial syndrome and fibromyalgia, has also been described. , although we did not find any clinical trials on the subject. A clinical trial that investigated the effect of carbon dioxide application in diabetic peripheral neuropathy found that many patients reported improvement in pain, although the outcomes measured did not include pain. . Therefore, further clinical trials focusing on carboxytherapy in pain management could help determine its clinical significance.
In this patient, a significant improvement in postoperative neuropathic facial pain was observed with a carboxytherapy session. However, the limitations of this study include the exclusive use of the NRS to measure improvement in pain, while other factors such as sleep and quality of life were not assessed. In addition, the patient has not followed other treatments frequently used in the management of neuropathic pain such as psychological therapies and pharmacotherapy with antidepressants or antiepileptics .
Further studies are needed to determine the significance of the analgesic effect of carboxytherapy in larger populations and to investigate whether or not additional sessions of the procedure might provide additional benefit. It is also necessary to determine which types of pain might benefit from the treatment and how long the effect might last.
Carboxytherapy is a simple and safe procedure that may hold promise for the treatment of pain in some settings. This case report illustrates the successful use of this therapy on a patient with postoperative chronic neuropathic facial pain. However, further studies are needed to determine the role of carboxytherapy in pain management.