Novel fluoroscopic landmark to significantly facilitate the visualization of foramen ovale in treating idiopathic trigeminal neuralgia

Background and objectivesAccess through the foramen ovale (FO) is essential in performing trigeminal ganglion injection, glycerol rhizolysis, balloon compression, and radiofrequency thermocoagulation (RFT) to treat idiopathic trigeminal neuralgia (ITN). However, identification of the FO under fluoroscopy can be difficult and time-consuming, and thus exposes patients to increased radiation and procedure risks. Here we present the ‘H-figure’ as a novel fluoroscopic landmark to quickly visualize the FO.MethodsThe H-figure landmark can be recognized as the medial border of the mandible and the lateral edge of the maxilla as the two vertical lines, and the superior line of petrous ridge of temporal bone (S-P-T line) as the horizontal line, and the FO fluoroscopic view is then optimized at the center of the H-figure immediately above the S-P-T line. We applied this landmark in a clinical cohort of 136 patients with ITN who underwent fluoroscopy-guided RFT of the trigeminal ganglion. We also compared the H-figure method with the traditional method. The primary outcome was the total number of fluoroscopic images required to visualize the FO (as a proxy of radiation exposure). Secondary measures included the procedure time required to finalize the FO view and the sensory testing voltage for paresthesia.ResultsWith the H-figure approach we were able to view the FO with an average of 4.2 fluoroscopic shots at an average time of 6.8 min. When compared with the non-H-figure traditional technique, the H-figure method required almost half the fluoroscopic shots in nearly half the procedure duration time, and paresthesia was evoked with half of the voltage.ConclusionThe H-figure is an easy fluoroscopic landmark that can help to view the FO with less radiation and procedure time, and the needles placed with this approach can be closer to the target for the RFT treatment of patients with ITN.

Clinical Outcome of Percutaneous Radiofrequency Rhizotomy for Trigeminal Neuralgia at a Tertiary Care Hospital.

Background: - Trigeminal neuralgia is a disease typically characterized by involuntary attacks of lancinating pain in the distribution of the trigeminal nerve that are activated by non-noxious stimuli. Numerous anticonvulsants, either alone or in combination, remain the first choice in the medical treatment of trigeminal neuralgia.3If the disease becomes non responsive, there are numerous surgical options like micro vascular decompression or minimally invasive percutaneous lesioning of the trigeminal nerve, such as glycerol rhizolysis, Radiofrequency Rhizotomy, and balloon compression. Objective: - To determine efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of early pain relief in a tertiary care hospital. Methods: - 62 patients with refractory trigeminal neuralgia or lancinating, recurrent episodes of pain in the distribution of Ophthalmic (V1) and Mandibular (V3) branches of trigeminal nerve, not responsive to 6 months of conservative treatment were included. Study was completed in one year i.e. from March 2015 to Feb 2016. Result: - In our study population, 62 included patients were had mean age 56.08 ± 7.39 years. 44 patients (71%) were male. Our treatment was effective in 58 patients (93.5%) while there was recurrence among 4 (6.5%) only. Conclusion: - It is concluded that the efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of complete relief of pain with intact sensations in treated branch region is excellent (93.5%).

Primary Nongestational Ovarian Choriocarcinoma Mistaken for Ectopic Pregnancy: A Case Report

Trigeminal neuralgia (TN) or tic douloureux is one of the commonest cause of fascial pain after 50 years of age. It is characterized by recurrent, episodic, lancinating pain over the distribution of trigeminal nerve. There is a lack of certainty regarding the aetiology and pathophysiology of TN. Evidence suggests that the likely etiology is vascular compression of the trigeminal nerve leading to focal demyelination and aberrant neural discharge. Secondary causes such as multiple sclerosis or brain tumors can also produce symptomatic TN. The treatment of TN can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best. For patients refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife surgery and microvascular decompression are the most promising invasive treatment options. Among them three common interventions commonly carried out by interventional pain physician to provide pain relief are balloon compression, Glycerol rhizolysis and RF rhizotomy. J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 73-77

Trigeminal Neuralgia: Role of Interventional Pain Physician

Trigeminal neuralgia (TN) or tic douloureux is one of the commonest cause of fascial pain after 50 years of age. It is characterized by recurrent, episodic, lancinating pain over the distribution of trigeminal nerve. There is a lack of certainty regarding the aetiology and pathophysiology of TN. Evidence suggests that the likely etiology is vascular compression of the trigeminal nerve leading to focal demyelination and aberrant neural discharge. Secondary causes such as multiple sclerosis or brain tumors can also produce symptomatic TN. The treatment of TN can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best. For patients refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife surgery and microvascular decompression are the most promising invasive treatment options. Among them three common interventions commonly carried out by interventional pain physician to provide pain relief are balloon compression, Glycerol rhizolysis and RF rhizotomy. J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 73-77

The Effectiveness of Percutaneous Balloon Compression, Thermocoagulation, and Glycerol Rhizolysis for Trigeminal Neuralgia in Multiple Sclerosis

BACKGROUND Balloon compression (BC), thermocoagulation (TC), and glycerol rhizolysis (GR) are percutaneous surgical options for trigeminal neuralgia (TN). Whether the outcomes of these procedures in multiple sclerosis -related TN (MS-TN) are as effective as in idiopathic TN (ITN) is unknown. OBJECTIVE To retrospectively compare pain relief, complications, and durability achieved by these 3 types of procedures in MS-TN and ITN. METHODS Two hundred and four patients with typical TN were treated percutaneously: 33 had MS-TN (64 procedures) and 171 had ITN (329 procedures). All were performed by 1 of 2 neurosurgeons; interviews enabled long-term data to be gathered by an independent observer. RESULTS MS-TN patients (53.1%) had Barrow Neurological Institute pain scores of I or II after a percutaneous procedure, compared with 59.3% in the ITN cohort; there was no difference in initial relief between the 2 groups overall (P = .52). There was a trend toward fewer complications in MS-TN compared with ITN (23.4% vs 33.7%, respectively; P = .058). Kaplan–Meier analysis demonstrated no difference in durability of relief in MS-TN (median 23.0 mo) compared with ITN overall (median 24.0 mo; P = .75). Subgroup analysis demonstrated longer relief from BC and TC compared with GR in MS-TN (P = .013). Multivariate analysis confirmed that although the presence of MS does not predict durability of outcome, postoperative numbness (P = .0046) and undergoing a repeat procedure (P = .037) were significant predictors. CONCLUSION BC and TC are safe and effective in MS-TN. Postoperative numbness is the strongest prognostic factor in MS-TN.

Some experience of trigeminal neuralgia treatment by glycerol rhizolysis

<p><strong>Aim.</strong> The study was to evaluate the advantages and disadvantages of trigeminal neuralgia treatment by Hakanson S. glycerol rhizolysis method. <br /><strong>Methods.</strong> The results of glycerol rhizolysis treatment were retrospectively evaluated in 96 patients with trigeminal neuralgia, who had been operated at Neurosurgical Department of Irkutsk City Hospital over a period from 2009 to 2016. To study the prospective follow-up, 53 patients operated during 2009 – 2014 were surveyed over the phone. The comparison of our long-term results and the results of other authors from literature sources was then performed.<br /><strong>Results.</strong> The median of follow-up period was 43 months. The pain recurrence (III-V rate of Barrow Neurological Institute score for trigeminal neuralgia) was observed in 30.2 % of patients, with the mean rate of the visual analogue scale amounting to 1.96. Complications included aseptic meningitis in 3.1 % cases, intracerebral hematoma – 1.04 %, hyperesthesia in appropriate trigeminal region – 3.8%, labial herpes – 40.7 %, temporary anesthesia in appropriate trigeminal region – 30.2%, temporary decrease of corneal reflex sensitivity – 41.5 %. There was no postoperative mortality.<br /><strong>Conclusion.</strong> Glycerol rhizolysis is an effective method of trigeminal neuralgia treatment and its results are comparable with those of other surgical methods. Strict adherence to all surgical steps and contrast cistenography is the key to success of intervention. The method is minimally invasive, applicable for anesthesia and particularly promising for patients over 70 years old.</p><p>Received 25 May 2016. Accepted 14 September 2016.</p><p><strong>Funding:</strong> The study had no sponsorship. <br /><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p>

Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia

BACKGROUND: Despite &gt;30 years of clinical use, the literature is still sparse when it comes to comparisons between percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizolysis (PRGR) as treatments for trigeminal neuralgia. OBJECTIVE: To perform a retrospective cohort comparison between PBC and PRGR with regard to therapeutic effect, side effects, and complications. METHODS: Medical records and follow-up data from 124 primary PRGRs performed from 1986 to 2000 and 82 primary PBCs performed from 2000 to 2013 were reviewed. All patients had undergone clinical sensory testing and assessment of sensory thresholds. Analyses were performed to compare duration of pain relief, frequency of sensory disturbances, and side effects. RESULTS: Median duration of pain relief was 21 months after PRGR and 20 months after PBC. Both methods carried a high risk of hypesthesia/hypalgesia (P &lt; .001) that was partly reversed with time. Decreased corneal sensibility was common after PRGR (P &lt; .001) but not after PBC. Dysesthesia was more common after PRGR (23%) compared after PBC (4%; P &lt; .001). Other side effects were noted but uncommon. CONCLUSION: PBC and PRGR are both effective as primary surgical treatment of trigeminal neuralgia. Both carry a risk of postoperative hypesthesia, but in this series, the side effect profile favored PBC. Furthermore, PBC is technically less challenging, whereas PRGR requires fewer resources. Between these 2 techniques, we propose PBC as the primary surgical technique for percutaneous treatment of trigeminal neuralgia on the basis of its lower incidence of dysesthesia, corneal hypesthesia, and technical failures.