Unconventional Facial Entry Points Confirmed Using a 3D CT Reconstruction–Guided Stereotactic Approach to Radiofrequency Thermocoagulation for the Treatment of Trigeminal Neuralgia: A Series of Case Reports

Pain Medicine ◽  
2018 ◽  
Vol 20 (8) ◽  
pp. 1551-1558 ◽  
Author(s):  
Zhigang Guo ◽  
Zhijia Wang ◽  
Kai Li ◽  
Chao Du ◽  
Xingli Zhao ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Anatomical Variation ◽  
Preoperative Imaging ◽  
Gasserian Ganglion ◽  
Ct Reconstruction ◽  
Foramen Ovale ◽  
Radiofrequency Thermocoagulation ◽  
Patient Reported ◽  
Entry Points

Abstract Objectives Patients with trigeminal neuralgia who are refractory to medical therapy may choose to undergo Gasserian ganglion percutaneous radiofrequency thermocoagulation. However, in cases where the foramen ovale is difficult to access due to various anatomical anomalies, the typical estimation of the facial entry point is suboptimal. Methods Three-dimensional computed tomography reconstruction imaging performed before surgery revealed anatomical variations in each of the four adult patient cases that made it more difficult to successfully access the foramen ovale (FO) for percutaneous radiofrequency thermocoagulation. Using measurements collected from preoperative imaging that showed each specific anatomical variation in the FO, researchers marked alternate facial entry points that would allow successful probe placement into the FO and recorded the arc angle data in the stereotactic instrument. Results Patients were evaluated during follow-up visits ranging from seven to 26 months after surgery and asked to rate postoperative pain using a visual analog scale. These scores decreased from 10 to 3 in all four patients by the third day after the procedure. There were no permanent complications or morbidities from the surgery. One patient experienced mild facial numbness; however, this side effect subsided within three months after surgery. During the follow-up period, no patient reported pain recurrence. Conclusions The expectation for clinicians approaching trigeminal nerve block using a peri-oral approach should be to expect a great degree of potential variability in terms of both distances from the corner of the mouth and needle angle taken to successfully navigate the anatomy and access the foramen ovale.

scholarly journals Radiofrequency Thermocoagulation Through Foramen Rotundum Versus Foramen Ovale for the Treatment of V2 Trigeminal Neuralgia

2019 ◽  
Vol 6 (22;6) ◽  
pp. E609-E614
Author(s):  
Cong-yang Yan
Keyword(s):  
Trigeminal Neuralgia ◽  
Facial Pain ◽  
Operation Time ◽  
Controlled Clinical Trial ◽  
Gasserian Ganglion ◽  
Internal Opening ◽  
Foramen Ovale ◽  
Maxillary Nerve ◽  
Radiofrequency Thermocoagulation ◽  
Foramen Rotundum

Background: Percutaneous radiofrequency thermocoagulation through the foramen rotundum (FR) is a new approach for the treatment of V2 trigeminal neuralgia (TN). Objectives: This study aimed to compare the efficacy and safety of the FR approach with that of the foramen ovale (FO) approach. Study Design: Nonrandomized controlled clinical trial. Setting: The study was conducted at Huaian Hospital of Huaian City, Huaian, China. Methods: From July 2014 to December 2016, 80 consecutive patients with V2 TN were prospectively assigned into the FO group (n = 40) or the FR group (n = 40). All radiofrequency thermocoagulation procedures were performed under the guidance of digital subtraction angiography (DSA). Patients in the FO group were treated with Gasserian ganglion ablation through the Hartel approach. Patients in the FR group received ablation of the maxillary nerve at the internal opening of the FR. Facial pain was evaluated using the Visual Analog Scale preoperatively and postoperatively at 1 week, 6 months, and 1 year. Results: All surgical procedures were successfully completed using DSA guidance. The FR group had no facial pain at postoperative 1 week, 6 months, and 1 year. The facial fain was not relieved in 4 patients of the FO group. They were treated with radiofrequency thermocoagulation of the maxillary nerve through the FR and maintained painless at postoperative 1 week, 6 months, and 1 year. At postoperative 1 year, another 3 patients relapsed in the FO group. The incidences of facial numbness and swelling did not differ significantly between the 2 groups (all P > 0.05). There was no postoperative corneal involvement or masticatory weakness in the FR group. However, corneal involvement and masticatory weakness occurred postoperatively in 22 (55%) patients and 31 (77.5%) patients in the FO group. The FR group had significantly shorter operation time than the FO group (19.3 ± 5.9 vs. 32.7 ± 8.7 minutes; P < 0.05). Limitations: We were unable to avoid the V1 and V3 branches, despite multiple adjustments of the needed position in 35 of the 40 patients in this group. Conclusions: For the treatment of V2 TN, thermocoagulation of the maxillary nerve through the FR had better efficacy and fewer complications in comparison with the Gasserian ganglion ablation through the FO

Quantitative Sensory Changes Following Gasserian Ganglion Radiofrequency Thermocoagulation in Patients with Medical Refractory Trigeminal Neuralgia: A Prospective Consecutive Case Series

2020 ◽  
Vol 81 (05) ◽  
pp. 423-429
Author(s):  
Torge Huckhagel ◽  
Lars Bohlmann ◽  
Manfred Westphal ◽  
Jan Regelsberger ◽  
Iris-Carola Eichler ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Short Form ◽  
Research Network ◽  
Treatment Modalities ◽  
Mcgill Pain Questionnaire ◽  
Gasserian Ganglion ◽  
Radiofrequency Thermocoagulation ◽  
Before And After

Abstract Background and Objective Microsurgical vascular nerve decompression and percutaneous ablative interventions aiming at the Gasserian ganglion are promising treatment modalities for patients with medical refractory trigeminal neuralgia (TN). Apart from clinical reports on a variable manifestation of facial hypoesthesia, the long-term impact of trigeminal ganglion radiofrequency thermocoagulation (RFT) on sensory characteristics has not yet been determined using quantitative methods. Material and Methods We performed standardized quantitative sensory testing according to the established protocol of the German Research Network on Neuropathic Pain in a cohort of patients with classical (n = 5) and secondary (n = 11) TN before and after percutaneous Gasserian ganglion RFT (mean follow-up: 6 months). The test battery included thermal detection and thermal pain thresholds as well as mechanical detection and mechanical pain sensitivity measures. Clinical improvement was also assessed by means of renowned pain intensity and impairment questionnaires (Short-Form McGill Pain Questionnaire, Pain Disability Index, and Pain Catastrophizing Scale), pain numeric rating scale, and anti-neuropathic medication reduction at follow-up. Results All clinical parameters developed favorably following percutaneous thermocoagulation. Only mechanical and vibration detection thresholds of the affected side of the face were located below the reference frame of the norm population before and after the procedure. Statistically significant persistent changes in quantitative sensory variables caused by the intervention could not be detected in our patient sample. Conclusion Our data suggest that TN patients improving considerably after RFT do not undergo substantial long-term alterations regarding quantitative sensory perception.

scholarly journals Extracranial Non-Gasserian Ganglion Application of Radiofrequency Thermocoagulation on the Mandibular Branch of the Trigeminal through the Foramen Ovale for Trigeminal Neuralgia

2021 ◽  
pp. E424-E432
Keyword(s):  
Trigeminal Neuralgia ◽  
Intracranial Hemorrhage ◽  
Long Term Results ◽  
Transverse Diameter ◽  
Gasserian Ganglion ◽  
Foramen Ovale ◽  
Ct Guided ◽  
Radiofrequency Treatment ◽  
Radiofrequency Thermocoagulation ◽  
Mandibular Branch

BACKGROUND: Percutaneous radiofrequency ablation (RFA) of the trigeminal Gasserian ganglion via the foramen ovale is still one of the classic treatments for primary trigeminal neuralgia. However, the Gasserian ganglion is deep in the middle cranial fossa. Although it is a structure outside the brain tissue, the puncture needle must enter the encephalic to reach the Gasserian ganglion and so it is difficult to completely avoid the risk of intracranial hemorrhage and infection caused by puncture damage to intracranial blood vessels. It is not clear whether if it is possible for RFA at the extracranial non-gasserian-ganglion site via the exit of the cranial channel (foramen ovale) for patients with V3 trigeminal neuralgia (TN). STUDY DESIGN: Prospective, clinical research study SETTING: Department of Anesthesiology and Pain Medical Center, Jiaxing, China. METHODS: One hundred and seven patients with isolated mandibular branch trigeminal neuralgia were included. Radiofrequency thermocoagulation was performed by CT-guided percutaneous puncture through the foramen ovale. The puncture target was the midpoint of the horizontal transverse diameter of the oval foramen. If the tingling sensation in the mandibular nerve innervation area could be detected, the radiofrequency thermocoagulation (90°C, 120 sec) under intravenous anesthesia would be performed. We investigated the inclination angle, puncture angle and depth, puncture operation time, intraoperative complications and short-term and long-term results after operation. RESULTS: After radiofrequency thermocoagulation, the pain in the mandibular branch dominant area was completely diminished in 104 patients. Two patients were cured after the second radiofrequency treatment. No intracranial hemorrhage not infection complications occurred, except for facial hematoma during operation in 21 cases. After 12-24 months of follow-up, 9 patients had recurrence and were still effective after receiving additional extracranial radiofrequency treatment. LIMITATIONS: A control group should be established and more clinical data should be collected in future work. CONCLUSION: Extracranial non-Gasserian-ganglion RF can achieve satisfactory results and improve the safety of radiofrequency treatment for trigeminal neuralgia. KEY WORDS: Trigeminal neuralgia, foramen ovale, trigeminal ganglion

Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers

1974 ◽  
Vol 40 (2) ◽  
pp. 143-156 ◽  
Author(s):  
William H. Sweet ◽  
James G. Wepsic
Keyword(s):  
Trigeminal Neuralgia ◽  
Facial Pain ◽  
Electrical Heating ◽  
Gasserian Ganglion ◽  
Foramen Ovale ◽  
Content Type ◽  
Corneal Scarring ◽  
Radiofrequency Heating ◽  
Neurological Morbidity ◽  
Fine Print

✓ The authors report their experience in the treatment of trigeminal neuralgia with controlled increments of radiofrequency heating from an electrode placed in the Gasserian ganglion or its posterior rootlets. Touch is preserved in some or all of a trigeminal zone rendered analgesic. The electrode tip is introduced through the foramen ovale and placed among the desired rootlets with the help of a combination of radiographs and the conscious patient's response to electrical stimulation with a square wave signal and gentle electrical heating. The degree of heat is measured by a thermister at the electrode tip. The patient's cooperation is maintained by the use of the neurolept anesthetic Innovar and the production of brief unconsciousness for the painful parts of the operation by methohexital (Brevital). Of 274 patients with facial pain so treated, 214 had trigeminal neuralgia; 91% of the latter group experienced relief of pain and 125 followed for 2½ to 6 years had a recurrence rate of 22%. In a total of 353 procedures, there has been no mortality and no neurological morbidity outside the trigeminal nerve. Only six of the patients with trigeminal neuralgia have complained significantly of postoperative paresthesias. The most serious undesired result has been the production of an anesthetic cornea in 28 patients, one of whom lost the sight of one eye due to corneal scarring. Correlating findings in our patients with those in studies by other authors, we conclude that the preservation of some touch is due to resistance to heating by the heavily myelinated A-beta fibers.

Long-term Follow-up of Patients Treated with Percutaneous Radiofrequency Thermocoagulation via the Foramen Rotundum for Isolated Maxillary Nerve Idiopathic Trigeminal Neuralgia

Pain Medicine ◽  
2019 ◽  
Vol 20 (7) ◽  
pp. 1370-1378 ◽  
Author(s):  
Bing Ran ◽  
Jun Wei ◽  
Qiong Zhong ◽  
Min Fu ◽  
Jun Yang ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Sagittal Plane ◽  
Ct Guided ◽  
Radiofrequency Thermocoagulation ◽  
Complete Pain Relief ◽  
Idiopathic Trigeminal Neuralgia ◽  
Foramen Rotundum ◽  
The Mean

Abstract Objective The purpose of this study is to evaluate the effectiveness and safety of percutaneous radiofrequency thermocoagulation (PRT) via the foramen rotundum (FR) for the treatment of isolated maxillary (V2) idiopathic trigeminal neuralgia (ITN) and assess the appropriate puncture angle through the anterior coronoid process to reach the FR. Methods Between January 2011 and October 2016, 87 patients with V2 ITN refractory to conservative treatment were treated by computed tomography (CT)–guided PRT via the FR at our institution. The outcome of pain relief was assessed by the visual analog scale (VAS) and Barrow Neurological Institute (BNI) pain grade and grouped as complete pain relief (BNI grades I–III) or unsuccessful pain relief (BNI grades IV–V). Recurrence and complications were also monitored and recorded. The puncture angle for this novel approach was assessed based on intraoperative CT images. Results Of the 87 treated patients, 85 (97.7%) achieved complete pain relief, and two patients (2.3%) experienced unsuccessful pain relief immediately after operation. During the mean follow-up period of 44.3 months, 15 patients (17.2%) experienced recurring pain. No severe complications occurred, except for hypoesthesia restricted to the V2 distribution in all patients (100%) and facial hematoma in 10 patients (11.5%). The mean puncture angle to reach the FR was 33.6° ± 5.7° toward the sagittal plane. Discussion CT-guided PRT via the FR for refractory isolated V2 ITN is effective and safe and could be a rational therapy for patients with V2 ITN.

Trigeminal neuralgia treated by differential percutaneous radiofrequency coagulation of the Gasserian ganglion

1974 ◽  
Vol 40 (4) ◽  
pp. 517-523 ◽  
Author(s):  
G. Robert Nugent ◽  
Bruce Berry
Keyword(s):  
Trigeminal Neuralgia ◽  
Percutaneous Penetration ◽  
Anesthetic Techniques ◽  
Gasserian Ganglion ◽  
Foramen Ovale ◽  
Content Type ◽  
The Face ◽  
Touch Sensation ◽  
Radiofrequency Coagulation ◽  
Radiographic Landmarks

✓ The authors describe surgical and anesthetic techniques for the treatment of trigeminal neuralgia by radiofrequency coagulation. Using radiographic landmarks derived from a stereotaxic study of 54 cadaver skulls, they delineate lateral and anteroposterior guidelines which aid in the percutaneous penetration of the foramen ovale. Controlled lesions can be made selectively in any division of the trigeminal nerve. The procedure has been effective in abolishing pain usually with preservation of touch sensation in the face. The percutaneous operation has the added advantage of a short hospitalization, usually 2 days. Of the 65 patients treated, only one still has the pain of trigeminal neuralgia. In six instances the procedure had to be repeated because insufficient sensory deficit was produced by the initial lesion. Three patients have developed anesthesia dolorosa; however, none has developed facial paralysis.

NONISOCENTRIC RADIOSURGICAL RHIZOTOMY FOR TRIGEMINAL NEURALGIA

Neurosurgery ◽  
2009 ◽  
Vol 64 (suppl_2) ◽  
pp. A84-A90 ◽  
Author(s):  
John R. Adler ◽  
Regina Bower ◽  
Gaurav Gupta ◽  
Michael Lim ◽  
Allen Efron ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Symptom Relief ◽  
Complete Response ◽  
Patient Reported ◽  
High Incidence ◽  
Facial Numbness ◽  
Prescription Dose ◽  
Trigeminal Root

Abstract OBJECTIVE Although stereotactic radiosurgery is an established procedure for treating trigeminal neuralgia (TN), the likelihood of a prompt and durable complete response is not assured. Moreover, the incidence of facial numbness remains a challenge. To address these limitations, a new, more anatomic radiosurgical procedure was developed that uses the CyberKnife (Accuray, Inc., Sunnyvale, CA) to lesion an elongated segment of the retrogasserian cisternal portion of the trigeminal sensory root. Because the initial experience with this approach resulted in an unacceptably high incidence of facial numbness, a gradual dose and volume de-escalation was performed over several years. In this single-institution prospective study, we evaluated clinical outcomes in a group of TN patients who underwent lesioning with seemingly optimized nonisocentric radiosurgical parameters. METHODS Forty-six patients with intractable idiopathic TN were treated between January 2005 and June 2007. Eligible patients were either poor surgical candidates or had failed previous microvascular decompression or destructive procedures. During a single radiosurgical session, a 6-mm segment of the affected nerve was treated with a mean marginal prescription dose of 58.3 Gy and a mean maximal dose of 73.5 Gy. Monthly neurosurgical follow-up was performed until the patient became pain-free. Longer-term follow-up was performed both in the clinic and over the telephone. Outcomes were graded as excellent (pain-free and off medication), good (&gt;90% improvement while still on medication), fair (50–90% improvement), or poor (no change or worse). Facial numbness was assessed using the Barrow Neurological Institute Facial Numbness Scale score. RESULTS Symptoms disappeared completely in 39 patients (85%) after a mean latency of 5.2 weeks. In most of these patients, pain relief began within the first week. TN recurred in a single patient after a pain-free interval of 7 months; all symptoms abated after a second radiosurgical procedure. Four additional patients underwent a repeat rhizotomy after failing to respond adequately to the first operation. After a mean follow-up period of 14.7 months, patient-reported outcomes were excellent in 33 patients (72%), good in 11 patients (24%), and poor/no improvement in 2 patients (4%). Significant ipsilateral facial numbness (Grade III on the Barrow Neurological Institute Scale) was reported in 7 patients (15%). CONCLUSION Optimized nonisocentric CyberKnife parameters for TN treatment resulted in high rates of pain relief and a more acceptable incidence of facial numbness than reported previously. Longer follow-up periods will be required to establish whether or not the durability of symptom relief after lesioning an elongated segment of the trigeminal root is superior to isocentric radiosurgical rhizotomy.

Sign in / Sign up

Export Citation Format

Share Document