Radiofrequency Thermoablation of the Gasserian
Ganglion Versus the Peripheral Branches of the
Trigeminal Nerve for Treatment of Trigeminal
Neuralgia: A Randomized, Control Trial

Background: Trigeminal neuralgia is the most painful condition of facial pain leading to impairment of routine activities. Although radiofrequency thermoablation (RFT) of the Gasserian ganglion is widely used for the treatment of idiopathic trigeminal neuralgia in patients having ineffective pain relief with medical therapy, the incidence of complications like hypoesthesia, neuroparalytic keratitis, and masticatory muscles weakness is high. Recent case reports have shown the effectiveness of RFT of the peripheral branches of the trigeminal nerve for relief of refractory chronic facial pain conditions including trigeminal neuralgia. Objectives: This study was conducted to compare the efficacy and safety of RFT of the peripheral branches of the trigeminal nerve with RFT of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia. Study Design: Prospective, randomized, observer-blinded, clinical trial. Setting: Tertiary care hospital and medical education and research institute. Methods: A total of 40 adult patients of idiopathic trigeminal neuralgia were randomly allocated into 2 groups. The control group received RFT of the Gasserian ganglion while the study group received RFT of the peripheral branches of trigeminal nerve. The procedures were performed in the operation room under all aseptic precautions with fluoroscopic guidance. Post-procedure, the patients were assessed for loss of sensation along the nerve distribution and the adequacy of pain relief on the Numerical Rating Scale (NRS). The patients were followed up for 3 month to assess the quality of pain relief by the NRS and the Barrow Neurological Institute (BNI) pain intensity scale. Improvement in pain was considered excellent if patients had complete pain relief without any medication, good if there was significant reduction in pain (> 50%) with or without medication, and poor if there was less than 50% reduction in pain with medications. Patients were also assessed for numbness and any other side effects. Patients’ satisfaction with the procedure was recorded. Results: Nineteen patients in the control group and 18 in study group had effective pain relief of up to 3 months. Their pain scores were comparable at all time intervals, though the number of patients receiving supplementary medications was more in study group at 2 months (P = 0.015). The patients showed overall satisfaction score of 8.5 (8-9) and 8 (7-9) in control and study groups respectively. The average procedure duration was 30 (30-38) minutes in the control group and 28 (25-40) minutes in the study group. Most of the patients in both groups had mild numbness after the procedure. One patient in the control group had lower eyelid swelling and another had mild weakness of the masseter muscle, which resolved few days later. No major complication was reported in the study group except for 1 patient who reported local ecchymosis. Limitations: The main limitation of the study is that the patients and the investigator performing the procedure were not blinded, though the person who assessed the patient during follow-up was blinded to the group assignment. Another limitation is that we could not follow up with the patients after 3 months due to time constraints. Conclusion: We found that radiofrequency thermoablation of the peripheral branches of the trigeminal nerve is an effective and safe procedure for the management of idiopathic trigeminal neuralgia. Key words: Idiopathic trigeminal neuralgia, radiofrequency thermoablation, Gasserian ganglion, peripheral nerve branches, pain, trigeminal nerve

Download Full-text

Evaluation of endorphin content in the CSF of patients with trigeminal neuralgia before and after Gasserian ganglion thermocoagulation

Journal of Neurosurgery ◽

10.3171/jns.1981.55.6.0935 ◽

1981 ◽

Vol 55 (6) ◽

pp. 935-937 ◽

Cited By ~ 5

Author(s):

Giuseppe Salar ◽

Salvatore Mingrino ◽

Marco Trabucchi ◽

Angelo Bosio ◽

Carlo Semenza

Keyword(s):

Cerebrospinal Fluid ◽

Trigeminal Neuralgia ◽

Control Group ◽

Gasserian Ganglion ◽

Content Type ◽

Group Of Seven ◽

Idiopathic Trigeminal Neuralgia ◽

Significant Difference ◽

Before And After ◽

Fine Print

✓ The β-endorphin content in cerebrospinal fluid (CSF) was evaluated in 10 patients with idiopathic trigeminal neuralgia during medical treatment (with or without carbamazepine) and after selective thermocoagulation of the Gasserian ganglion. These values were compared with those obtained in a control group of seven patients without pain problems. No statistically significant difference was found between patients suffering from trigeminal neuralgia and those without pain. Furthermore, neither pharmacological treatment nor surgery changed CSF endorphin values. It is concluded that there is no pathogenetic relationship between trigeminal neuralgia and endorphins.

Download Full-text

Effects of Pulsed Versus Conventional Versus Combined Radiofrequency for the Treatment of Trigeminal Neuralgia: A Prospective Study

January 2018 - Pain Physician ◽

10.36076/ppj.20.5.e873 ◽

2017 ◽

Vol 6 (20;6) ◽

pp. E873-E881

Author(s):

Ghaydaa A. Ghaydaa A.

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Prospective Study ◽

University Hospital ◽

Gasserian Ganglion ◽

Pulsed Radiofrequency ◽

Group Setting ◽

Idiopathic Trigeminal Neuralgia ◽

Number Of Patients ◽

A Prospective Study

Background: During radiofrequency bursts of energy are applied to nervous tissue. The clinical advantages of this treatment remain unclear. Objectives: We compared the effectiveness and pain relief for idiopathic trigeminal neuralgia (TN) after continuous radiofrequency (CRF), pulsed radiofrequency (PRF), and combined continuous and pulsed radiofrequency (CCPRF) treatment of the Gasserian ganglion (GG). Study Design: We conducted a randomized prospective study. Forty-three patients were included. Eleven patients were treated with PRF at 42°C for 10 minutes (PRF group), 12 patients received CRF for 270 seconds at 75 °C (CRF group), and 20 patients received PRF for 10 minutes at 42°C followed by CRF for at 60°C for 270 seconds (CCPRF group). Setting: Assuit University Hospital, Pain and Neurology outpatient clinics. Methods: Patients were assessed for pain, satisfaction, and consumption of analgesics at baseline and 7 days, one month, 6 months, 12 months, and 24 months after the procedure. The incidence of complications, anesthesia dolorosa, weakness of muscles of mastication, numbness, and technical complications, was evaluated after the procedure. Results: Excellent pain relief was achieved after 6, 12, and 24 months, respectively in 95%, 85%, and 70% of patients with CCPRF; 75%, 75%, and reduced to 50% among patients with CRF; and 82%, reduced to 9.1%, and 0% of patients with PRF. No complications were recorded in 75% of patients in the CCPRF and PRF groups. There was one case of anesthesia dolorosa, 4 cases of masseter muscle weakness, and 5 cases of severe numbness recorded in the CRF group. Limitation: There was a small number of patients in each group. Conclusion: The best results were observed in the CCPRF group, followed by the CRF group, and then the PRF group.

Download Full-text

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

Pain Medicine ◽

10.1093/pm/pnz006 ◽

2019 ◽

Vol 20 (7) ◽

pp. 1370-1378 ◽

Cited By ~ 3

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.

Download Full-text

Idiopathic Trigeminal Neuralgia: A Case Report

Homœopathic Links ◽

10.1055/s-0039-1677861 ◽

2018 ◽

Vol 31 (04) ◽

pp. 254-258

Author(s):

Shruti Jain ◽

Chetna Lamba

Keyword(s):

Case Report ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Conventional Medicine ◽

Positive Role ◽

Idiopathic Trigeminal Neuralgia ◽

Adequate Pain Relief ◽

The Face

AbstractTrigeminal neuralgia (TN) is the most frequent type of neuropathic facial pain affecting one or more branches of trigeminal nerve. Here, a 51-year-old woman diagnosed with idiopathic trigeminal neuralgia (ITN) presented with complaints of pain over right side of the face with redness of the eyes and excessive lachrymation since 5 years with weekly acute episodes of shooting pain. Chelidonium was chiefly prescribed followed by few doses of Spigelia as per indications which provided adequate pain relief. The complaints flared up following stressful circumstances for which Pulsatilla was prescribed after detailed case taking. The frequency, duration and intensity of pain reduced after homoeopathic treatment. The need for conventional medicine was also reduced. This suggests positive role of individualised homoeopathy in the treatment of ITN. Further studies should be undertaken to evaluate the role of homoeopathy in ITN.

Download Full-text

CYBERKNIFE RADIOSURGERY FOR TRIGEMINAL NEURALGIA TREATMENT

Neurosurgery ◽

10.1227/01.neu.0000317313.46826.dc ◽

2008 ◽

Vol 62 (3) ◽

pp. 647-655 ◽

Cited By ~ 59

Author(s):

Alan T. Villavicencio ◽

Michael Lim ◽

Sigita Burneikiene ◽

Pantaleo Romanelli ◽

John R. Adler ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Radiation Doses ◽

Maximal Dose ◽

Median Length ◽

Pain Medications ◽

Idiopathic Trigeminal Neuralgia ◽

Cyberknife Radiosurgery ◽

The Mean

Abstract OBJECTIVE Radiosurgery has gained acceptance as a treatment option for trigeminal neuralgia. We report our preliminary multicenter experience treating trigeminal neuralgia with the CyberKnife (Accuray, Inc., Sunnyvale, CA). METHODS A total of 95 patients were treated for idiopathic trigeminal neuralgia between May 2002 and October 2005. Radiosurgical dose and volume parameters were retrospectively analyzed in relation to pain response, complications, and recurrence of symptoms. Optimal treatment parameters were identified for patients who had excellent and sustained pain relief with no complications, including severe or moderate hypesthesia. RESULTS Excellent pain relief was initially experienced by 64 out of 95 patients (67%). The median time to pain relief was 14 days (range, 0.3–180 d). Posttreatment numbness occurred in 45 (47%) of the patients treated. Using higher radiation doses and treating longer segments of the nerve led to both better pain relief and a higher incidence of hypesthesia. The presence of posttreatment numbness was predictive of better pain relief. The overall rate of complications was 18%. At the mean follow-up time of 2 years, 47 of the 95 patients (50%) had sustained pain relief, all of whom were completely off pain medications. CONCLUSION The results of this study suggest the following optimal radiosurgical treatment parameters for treatment of idiopathic trigeminal neuralgia: a median maximal dose of 78 Gy (range, 70–85.4 Gy) and a median length of the nerve treated of 6 mm (range, 5–12 mm).

Download Full-text

Gamma Knife radiosurgery for trigeminal neuralgia: the impact of magnetic resonance imaging–detected vascular impingement of the affected nerve

Journal of Neurosurgery ◽

10.3171/2009.9.jns09196 ◽

2010 ◽

Vol 113 (1) ◽

pp. 53-58 ◽

Cited By ~ 22

Author(s):

Jason P. Sheehan ◽

Dibyendu Kumar Ray ◽

Stephen Monteith ◽

Chun Po Yen ◽

James Lesnick ◽

...

Keyword(s):

Pain Relief ◽

Mr Imaging ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Trigeminal Nerve ◽

Gamma Knife Radiosurgery ◽

Vascular Compression ◽

Pain Intensity Score ◽

The Impact

Object Trigeminal neuralgia is believed to be related to vascular compression of the affected nerve. Radiosurgery has been shown to be reasonably effective for treatment of medically refractory trigeminal neuralgia. This study explores the rate of occurrence of MR imaging–demonstrated vascular impingement of the affected nerve and the extent to which vascular impingement affects pain relief in a population of trigeminal neuralgia patients undergoing Gamma Knife radiosurgery (GKRS). Methods The authors performed a retrospective analysis of 106 cases involving patients treated for typical trigeminal neuralgia using GKRS. Patients with or without single-vessel impingement on CISS MR imaging sequences and with no previous surgery were included in the study. Pain relief was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at the last follow-up. Degree of impingement, nerve diameter preand post-impingement, isocenter placement, and dose to the point of maximum impingement were evaluated in relation to the improvement of BNI score. Results The overall median follow-up period was 31 months. Overall, a BNI pain score of 1 was achieved in 59.4% of patients at last follow-up. Vessel impingement was seen in 63 patients (59%). There was no significant difference in pain relief between those with and without vascular impingement following GKRS (p > 0.05). In those with vascular impingement on MR imaging, the median fraction of vessel impingement was 0.3 (range 0.04–0.59). The median dose to the site of maximum impingement was 42 Gy (range 2.9–79 Gy). Increased dose (p = 0.019) and closer proximity of the isocenter to the site of maximum vessel impingement (p = 0.012) correlated in a statistically significant fashion with improved BNI scores in those demonstrating vascular impingement on the GKRS planning MR imaging Conclusions Vascular impingement of the affected nerve was seen in the majority of patients with trigeminal neuralgia. Overall pain relief following GKRS was comparable in those with and without evidence of vascular compression on MR imaging. In subgroup analysis of those with MR imaging evidence of vessel impingement of the affected trigeminal nerve, pain relief correlated with a higher dose to the point of contact between the impinging vessel and the trigeminal nerve. Such a finding may point to vascular changes affording at least some degree of relief following GKRS for trigeminal neuralgia.

Download Full-text

Ultrasound-Guided Trigeminal Nerve Block via the Pterygopalatine Fossa: An Effective Treatment for Trigeminal Neuralgia and Atypical Facial Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2013/16/e537 ◽

2013 ◽

Vol 5;16 (5;9) ◽

pp. E537-E545

Author(s):

Mark C. Kendall

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Nerve Block ◽

Trigeminal Nerve ◽

Local Anesthetic ◽

Facial Pain ◽

Case Series ◽

Pterygopalatine Fossa ◽

Atypical Facial Pain ◽

Ultrasound Guided

Background: Patients presenting with facial pain often have ineffective pain relief with medical therapy. Cases refractory to medical management are frequently treated with surgical or minimally invasive procedures with variable success rates. We report on the use of ultrasound-guided trigeminal nerve block via the pterygopalatine fossa in patients following refractory medical and surgical treatment. Objective: To present the immediate and long-term efficacy of ultrasound-guided injections of local anesthetic and steroids in the pterygopalatine fossa in patients with unilateral facial pain that failed pharmacological and surgical interventions. Setting: Academic pain management center. Design: Prospective case series. Methods: Fifteen patients were treated with ultrasound-guided trigeminal nerve block with local anesthetic and steroids placed into the pterygopalatine fossa. Results: All patients achieved complete sensory analgesia to pin prick in the distribution of the V2 branch of the trigeminal nerve and 80% (12 out of 15) achieved complete sensory analgesia in V1, V2, V3 distribution within 15 minutes of the injection. All patients reported pain relief within 5 minutes of the injection. The majority of patients maintained pain relief throughout the 15 month study period. No patients experienced symptoms of local anesthetic toxicity or onset of new neurological sequelae. Limitations: Prospective case series. Conclusion: We conclude that the use of ultrasound guidance for injectate delivery in the pterygopalatine fossa is a simple, free of radiation or magnetization, safe, and effective percutaneous procedure that provides sustained pain relief in trigeminal neuralgia or atypical facial pain patients who have failed previous medical interventions. Key words: Trigeminal nerve, ultrasound-guided, atypical facial pain, trigeminal neuralgia, tic douloureux.

Download Full-text

Percutaneous Microcompression for Idiopathic Trigeminal Neuralgia: curative effects and complications

10.21203/rs.3.rs-19565/v1 ◽

2020 ◽

Author(s):

yi ma ◽

Yan-feng Li ◽

Hai-tao Huang ◽

Bin Wang ◽

Quan-cai Wang

Keyword(s):

Side Effects ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Intracranial Hemorrhage ◽

Long Term Results ◽

Base Line ◽

Intracranial Infection ◽

Idiopathic Trigeminal Neuralgia

Abstract Background. We aimed to present the immediate and long term effect of percutaneous balloon compression (PBC) for idiopathic trigeminal neuralgia (ITN). Methods. ITN patients who underwent PBC for the first time in the past seven years were enrolled. Base line data and immediate postoperative outcomes were collected by reviewing the medical records and long term results. Kaplan-Meier curve, life-table analysis proportional-hazards analysis were utilized to assess the long term results and the likelihood of tic recurrence. Results. 12,797 patients were enrolled. Immediate after the PBC procedure, complete and partial pain relief were achieved in 95.6% and 1.1% patients respectively, with no relief in 1.7 % patients; the common side effects on the affected side of face included the sense loss in 98.9% patients, with 3.8% of them experienced sense loss combined abnormal sense; masseter weakness in 90.6%, herpes eruption in 51.4%, corneal reflex weakness or loss in 12.7% patients. The fewer perioperative complications covered diplopia in 139 patients (1.1%), partial hearing loss in 190 patients (1.5%), vascular complications in 5 patients (0.05%), brainstem hematoma in one patient (0.01%), ischemic stroke in two patients (0.02%), intracranial hemorrhage in 11 patents (0.09%), and intracranial infection in one patient (0.01%) patients. Of three deaths happened in the perioperative period, two died of intracranial hemorrhage, and the other one died of intracranial infection. 5794 (49.2%) patients, who were followed than one year after the procedure, were included in the follow-up study, with the median follow-up period of 7.2 years. Complete and partial pain relief were obtained in 82.9% and 6.8% patients respectively, while the pain recurrence occurred in 8.5% patients. Side effects included sense loss without abnormal sense in 54.3%, with acceptable abnormal sense in 6.0%, and with severe abnormal sense in 2.0% patients. Masseter weakness was reported by 7.5% patients. 96.4% patients were satisfied with the procedure. Conclusion. Our study shows PBC is a safe, simple and effective procedure, with both immediate and long-term success rates, acceptable side effects and fewer deadly complications, should be considered as one of the best choice for the treatment of ITN patients.

Download Full-text

Gamma Knife surgery used as primary and repeated treatment for idiopathic trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns/2008/109/12/s27 ◽

2008 ◽

Vol 109 (Supplement) ◽

pp. 179-184 ◽

Cited By ~ 16

Author(s):

Chuan-Fu Huang ◽

Hsien-Tang Tu ◽

Wen-Shan Liu ◽

Shyh-Ying Chiou ◽

Long-Yau Lin

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Surgery ◽

Repeated Treatment ◽

Maximal Dose ◽

Idiopathic Trigeminal Neuralgia ◽

Facial Numbness ◽

The Mean

Object The purpose of this study was to assess the outcome of idiopathic trigeminal neuralgia (TN) treated with Gamma Knife surgery (GKS) as a primary and repeated treatment modality with a mean follow-up of 5.7 years. Methods Between July 1999 and September 2005, a total of 89 patients with idiopathic TN underwent GKS as a primary treatment. The entry zone of the TN was targeted with a 4-mm collimator and treated with a maximal dose of 60–90 Gy (mean 79 Gy). The dose to the pontine margin was always kept < 15 Gy. Twenty patients received repeated GKS for recurrent or residual pain with a maximal dose of 40–76 Gy (mean 52 Gy). For the second procedure, the target was positioned at the same location as the first treatment. Results The mean follow-up period was 68 months (range 32–104 months). Sixty-nine (77.5%) of the 89 patients experienced a favorable response, as follows: 50 (56%) had excellent, 12 (13.5%) had good, and 7 (7.8%) had fair outcomes. The mean time to pain relief was 1.1 months (range 2 days–6 months). No significant correlation, but more likely a tendency, was found between the dose and pain relief (p = 0.08). Also, no correlation was noted for facial numbness (p = 0.77). The mean follow-up period after repeated GKS was 60 months (range 32–87 months). Outcomes after repeated GKS were excellent in 11 patients (55%) and good in 1 (5%). Seven patients experienced facial numbness. No correlation was found between the additive dose and pain relief (p = 0.24) or facial numbness (p = 0.15). Final outcomes of primary and repeated GKS were excellent in 61 (68.5%), good in 13 (14.6%), and fair in 7 (7.9%). In total, 91% of the patients were successfully treated with this method. There was no statistical significance for efficacy between primary and repeated GKS (p = 0.65), but there was a significant difference for facial numbness (p = 0.007). Conclusions Gamma Knife surgery established durable pain relief when used as a primary and repeated surgery. Treatment was successful for a total of 91% of patients at a mean follow-up of 5.7 years, but facial numbness was also relatively higher.

Download Full-text

Gamma knife surgery for refractory postherpetic trigeminal neuralgia: targeting in one session both the retrogasserian trigeminal nerve and the centromedian nucleus of the thalamus

Journal of Neurosurgery ◽

10.3171/sup.2005.102.s_supplement.0276 ◽

2005 ◽

Vol 102 (Special_Supplement) ◽

pp. 276-282 ◽

Cited By ~ 2

Author(s):

Marcus F. Keep ◽

Paul A. DeMare ◽

Lynn S. Ashby

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Treatment Session ◽

Single Treatment ◽

Content Type ◽

Centromedian Nucleus ◽

Single Treatment Session ◽

Fine Print

Object. The authors tested the hypothesis that two targets are needed to treat postherpetic trigeminal neuralgia (TN): one in the trigeminal nerve for the direct sharp pain and one in the thalamus for the diffuse burning pain. Methods. Three patients with refractory postherpetic TN were treated with gamma knife surgery (GKS) through a novel two-target approach. In a single treatment session, both the trigeminal nerve and centromedian nucleus were targeted. First, the trigeminal nerve, ipsilateral to the facial pain, was treated with 60 to 80 Gy. Second, the centromedian nucleus was localized using standard coordinates and by comparing magnetic resonance images with a stereotactic atlas. A single dose of 120 to 140 Gy was delivered to the target point with a single 4-mm isocenter. Patients were followed clinically and with neuroimaging studies. Pain relief was scored as excellent (75–100%), good (50–75%), poor (25–50%), or none (0–25%). Follow up ranged from 6 to 53 months. There were no GKS-related complications. Two patients died of unrelated medical illnesses but had good or excellent pain relief until death. One patient continues to survive with 44 months follow up and no decrease in pain intensity, but with a decreased area of pain. Conclusions. Combined GKS of the centromedian nucleus and trigeminal nerve in a single treatment session is feasible and safe, and the effect was promising. A larger study is required to confirm and expand these results.

Download Full-text