Percutaneous Radiofrequency Thermocoagulation in Trigeminal Neuralgia : Analysis of Early and Late Outcomes of 156 Cases and 209 Interventions

ObjectiveTrigeminal neuralgia is one of the most common causes of facial pain. Our aim is to investigate the efficacy and borders of percutaneous radiofrequency thermocoagulation in the treatment of trigeminal neuralgia. MethodsBetween May 2007 and April 2017, 156 patients with trigeminal neuralgia were treated with radiofrequency thermocoagulation. These 156 patients underwent 209 procedures. In our study, we investigated the early and late results of percutaneous radiofrequency thermocoagulation under guiding fluoroscopic imaging in the treatment of trigeminal neuralgia. Barrow Neurological Institute (BNI) pain scale was used for grading the early results. In addition, Kaplan-Meier survival analysis was used to assess long-term outcomes. Of the 156 patients who underwent radiofrequency thermocoagulation for trigeminal neuralgia, 45 had additional disease. Patients with this condition were evaluated with their comorbidities. Early and late results were compared with those without comorbidity. ResultsIn 193 of 209 interventions BNI pain scale I to III results were obtained. Out of the 193 successful operation 136 patients (65.07%) were discharged as BNI I, 14 (6.70%) as BNI II, 43 (20.58%) as BNI III. Sixteen patients (7.65%) remained uncontrolled (BNI IV and V). While the treatment results of trigeminal neuralgia patients with comorbidity seem more successful in the early period, this difference was not observed in follow-up examinations. ConclusionFinally, we concluded that percutaneous radiofrequency thermocoagulation of the Gasserian ganglion is a safe and effective method in the treatment of trigeminal neuralgia. However, over time, the effectiveness of the treatment decreases. Neverthless, the reapprability of this intervention gives it a distinct advantage.     

Percutaneous approach to the trigeminal ganglion in dogs.

This report describes a percutaneous approach to the dog's trigeminal ganglion via the oval foramen. The relatively simple and non-traumatic procedure duplicates the one widely used clinically in the treatment of trigeminal neuralgia with radiofrequency thermocoagulation lesion of the ganglion. It makes possible long-term post-lesion studies and will facilitate investigations of both basic and clinical interest.     

Inhibition by transcutaneous electrical stimulation of noxious heat elicited in human Gasserian ganglion.

During percutaneous thermocoagulation of the Gasserian ganglion for trigeminal pain, the pain perception threshold was established in a series of 25 awake patients by measuring the temperature at the electrode tip within the ganglion during slow increase of the radiofrequency current. Between 42 and 48 degress C pain perception was regularly reported by the patients. A cutaneous-stimulating system was then applied to the trigeminal area which was reported to be painful during the heating. The external stimulation attempted to preferentially stimulate the A afferent nerve fibres. When external stimulation was applied during the heating of the Gasserian ganglion, the pain perception threshold was enhanced in about half of the cases. A transcutaneous electrical stimulation of part of the body not related with the investigated pain sensation did not produce the same inhibitory action in 3 out of 5 cases.     

CAS-R-2型机器人导航下射频治疗三叉神经痛的基础与临床研究

目的为临床提供三叉神经节穿刺术的应用解剖学资料,探讨机器人导航下卵圆孔定位在三叉神经节热凝术中的临床应用价值。方法对颅骨标本卵圆孔的解剖学观察、测量,对其形态、大小、位置及变异性进行描述;并对21例患者进行卵圆孔导航定位,射频热凝治疗,对其疗效进行评估。结果卵圆孔的解剖结构变异性很大,位置不恒定,经验定位可靠性低,手术创伤大,效果不满意;利用CASR2型机器人导航,精确度高,可获个性化治疗,疗效满意。结论CASR2型机器人导航定位卵圆孔精确度高,提高了三叉神经痛的射频热凝效果,减少并发症,在三叉神经痛治疗中具有重要的临床应用价值。     

Carotid-cavernous fistula following percutaneous trigeminal ganglion approach

A case of carotid-cavernous fistula following percutaneous trigeminal ganglion approach is presented. The case was treated by a combination of trapping and emobilsation of the carotid artery.Percutaneous approach to the trigeminal ganglion via the foramen ovale was described by taptas (1911) and hartel (1914). Since then this procedure has been used in large series, for the injection of alcohol (harris. 1940), electrocoagulation (kirschner, 1942) or the injection hot water (jeager, 1957) to the trigeminal ganglion for the treatment of trigeminal neuralgia.In 1965 white and sweet used the percutaneous trigeminal ganglion approach for the radio-frequency (R.F.) thermocoagulation of the trigeminal ganglion. This procedure is a simple and safe method. It has been used in large series in the treatment of trigeminal neuralgia.In our department we have performed 252 R.F. thermocoagulation of the gasserion ganglion in 228 patients since 1975. In 252 interventions using the percutaneous trigeminal ganglion approach, via the foramen ovale, we observed only one carotid-cavernous fistula following the procedure. This is the second report in the literature of a carotid-cavernous fistula following the percutaneous trigeminal ganglion approach.     

经颌下-卵圆孔入路穿刺射频热凝治疗三叉神经痛

目的 探讨经颌下-卵圆孔入路穿刺射频热凝治疗三叉神经第Ⅲ支病变导致的原发性三叉神经痛的可行性和有效性。方法 2016年1月至2017年4月收治三叉神经第Ⅲ支病变导致的原发性三叉神经痛40例,采用经颌下-卵圆孔入路20例,采用Hartel前入路20例。两组均在三维CT定位下穿刺卵圆孔,定位成功后,行温控射频热凝治疗。结果 两组术后各有1例治疗无效,有效率均为95%,未见严重的并发症和其他神经损伤。两组手术时间大致相同（P>0.05）。术后6个月随访,疼痛缓解效果相同（P>0.05）。结论 三维CT定位下,经颌下-卵圆孔入路方法治疗三叉神经第Ⅲ支病变导致的原发性三叉神经痛具有可行性和有效性,并且可弥补Hartel前入路方法的局限。     

选择性射频热凝治疗原发性三叉神经痛的临床观察

目的研究选择性射频热凝术治疗三叉神经痛的穿刺方法、疗效、复发率、并发症。方法分别采用眶上孔、眶下孔、侧入路卵圆孔或Hartel前入路卵圆孔穿刺法,射频温控热凝术治疗三叉神经痛64例。结果总有效率98.4%,复发率21.9%。结论选择性射频热凝术治疗三叉神经痛是安全、简便、有效、适应证广的方法。     

Electromagnetic Navigation Technology for More Precise Electrode Placement in the Foramen Ovale: A Technical Report

Introduction. Interventional pain management techniques require precise positioning of needles or electrodes, therefore fluoroscopic control is mandatory. This imaging technique does however not visualize soft tissues such as blood vessels. Moreover, patient and physician are exposed to a considerable dose of radiation. Computed tomography (CT)‐scans give a better view of soft tissues, but there use requires presence of a radiologist and has proven to be laborious and time consuming. Objectives. This study is to develop a technique using electromagnetic (EM) navigation as a guidance technique for interventional pain management, using CT and/or magnetic resonance (MRI) images uploaded on the navigation station. Methods. One of the best documented interventional procedures for the management of trigeminal neuralgia is percutaneous radiofrequency treatment of the Gasserian ganglion. EM navigation software for intracranial applications already exists. We developed a technique using a stylet with two magnetic coils suitable for EM navigation. The procedure is followed in real time on a computer screen where the patient's multislice CT‐scan images and three‐dimensional reconstruction of his face are uploaded. Virtual landmarks on the screen are matched with those on the patient's face, calculating the precision of the needle placement. Discussion. The experience with EM navigation acquired with the radiofrequency technique can be transferred to other interventional pain management techniques, for instance, for the placement of a neuromodulation electrode close to the Gasserian ganglion. Currently, research is ongoing to extend the software of the navigation station for spinal application, and to adapt neurostimulation hardware to the EM navigation technology. This technology will allow neuromodulation techniques to be performed without x‐ray exposure for the patient and the physician, and this with the precision of CT/MR imaging guidance.     

Optimal duration of percutaneous microballoon compression for treatment of trigeminal nerve injury简

Percutaneous microballoon compression of the trigeminal ganglion is a brand new operative technique for the treatment of trigeminal neuralgia. However, it is unclear how the procedure mediates pain relief, and there are no standardized criteria, such as compression pressure, compression time or balloon shape, for the procedure. In this study, percutaneous microballoon compression was performed on the rabbit trigeminal ganglion at a mean inflation pressure of 1,005 ± 150 mmHg for 2 or 5 minutes. At 1, 7 and 14 days after percutaneous microballoon compression, the large-diameter myelinated nerves displayed axonal swelling, rupture and demyelination under the electron microscope. Fragmentation of myelin and formation of digestion chambers were more evident after 5 minutes of compression. Image analyzer results showed that the diameter of trigeminal ganglion cells remained unaltered after compression. These experimental findings indicate that a 2-minute period of compression can suppress pain transduction. Immunohistochemical staining revealed that vascular endothelial growth factor expression in the ganglion cells and axons was significantly increased 7 days after trigeminal ganglion compression, however, the changes were similar after 2-minute compression and 5-minute compression. The upregulated expression of vascular endothelial growth factor in the ganglion cells after percutaneous microballoon compression can promote the repair of the injured nerve. These findings suggest that long-term compression is ideal for patients with recurrent trigeminal neuralgia.     

神经导航引导经皮穿刺三叉神经半月节射频热凝治疗三叉神经痛的研究

目的 探讨神经导航引导下经皮穿刺三叉神经半月节射频热凝术在治疗三叉神经痛中的应用.方法 选取我科神经导航引导下经皮穿刺三叉神经半月节射频热凝治疗的156例患者资料.所有患者术前均经头部3D-CT薄层连续平扫,并将影像资料导入SteahhStation Tria Plus手术导航系统,图像经三维重建后,确认患侧卵圆孔作为靶点,在导航实时引导下进行卵圆孔穿刺,并行电生理测试,再次确认靶点的位置无误后,进行射频热凝治疗.结果 所有患者顺利穿刺成功,射频热凝术后,患者原有的面部疼痛均明显缓解或消失,术前患者VAS评分为9.67±0.47,术后VAS评分为0.22±0.57,差异有明显的统计学意义,且所有患者术后均无严重并发症.结论 神经导航引导下经皮穿刺三叉神经半月节射频热凝术是一种微创,安全和疗效显著的三叉神经痛外科治疗手段.     

经皮穿刺射频温控热凝治疗神经病理性疼痛131例

目的探讨经皮穿刺射频温控热凝治疗神经病理性疼痛的疗效。方法对门诊及住院的顽固性神经病理性疼痛病人采用经皮穿刺半月神经节或外周神经,应用射频温控热凝毁损治疗神经病理性疼痛。结果共治疗各类神经病理性疼痛患者131例。其中三叉神经痛115例,偏头痛12例,带状疱疹后神经痛3例,开胸术后肋间神经痛1例。随访8~46个月,平均12个月。获得优良者106例(80.9%),良好21例(16.0%)。除原疼痛部位有不同程度的感觉减退外,无其他严重、永久并发症。结论采用经皮穿刺射频温控热凝治疗神经病理性疼痛操作安全,治疗效果良好,是一种微创治疗方法,具有较高临床实用价值。     

射频热凝术与颅后窝探查手术治疗原发性三叉神经痛的疗效比较

目的 比较经皮半月节射频热凝术和颅后窝探查手术治疗原发性三叉神经痛的疗效.方法 回顾性分析126例三叉神经痛病人的治疗情况,其中经皮半月节射频热凝术(射频治疗组)治疗60例,颅后窝探查手术(颅后窝手术组)治疗66例.结果 射频治疗组术后有效率91.7%,颅后窝手术组为86.4%o颅后窝手术组三叉神经第1支病变病人术后7d并发症发生率显著低于射频治疗组(P = 0.033),但两组疼痛缓解度无明显差别;对于三叉神经第2、3支病变的病人,术后7d两组疼痛缓解度和并发症发生率无统计学差异.随访18个月,射频治疗组远期并发症发生率为15%,复发4例;颅后窝手术组远期并发症发生率为3%,未见复发.结论 颅后窝探查手术是治疗由三叉神经第1支病变引起的三叉神经痛的良好方法;对于由三叉神经第2、3支病变引起的三叉神经痛,经皮半月节射频热凝术和颅后窝探查手术疗效相当.     

Percutaneous radiofrequency thermocoagulation of the semilunar ganglion for treating trigeminal neuralgia. Report of 325 cases

325 cases of trigeminal neuralgia were treated by percutaneous semilunar ganglion radiofrequency thermocoagulation from March 1982 to March 1985. All patients were followed-up for more than one year. The effective rate was 98% and the recurrence rate was 20%. 46 recurred cases were successfully treated by reoperation. There were no severe complications and mortality. In this article, the operative method, advantages and prevention of complication are discussed.     

三叉神经痛不同术式疗效分析：附178例报告

目的 :观察比较三叉神经痛三种不同手术方式的疗效。方法 :采用经颞硬膜外三叉神经感觉根切断术 ,经皮三叉神经半月节射频热凝术和三叉神经显微血管减压术治疗 178例患者 ,对其疗效、不良反应和复发率进行评估。结果 :感觉根切断术组 :疗效尚好 ,不良反应中面部感觉障碍发生率较高 ,易误伤运动根 ,也较易复发 ;射频热凝术组 :简单、安全、有效 ,面部感觉障碍发生率较低 ,唯复发率较高 ;血管减压术组 ;疗效肯定 ,不良反应少 ,复发率低 ,但手术风险相对较大。结论 :三叉神经感觉根切断术逐渐少用。射频热凝术适用于年老体弱 ,不能耐受手术及首次外科治疗者。对于射频热凝术后复发者 ,可酌情行显微血管减压术。     

神经导航下三叉神经半月节射频热凝术中的电生理研究

目的探讨三叉神经半月节射频热凝术中电生理监测的内容和意义。方法神经导航下三叉神经半月节射频热凝术患者30例,记录术中电生理监测的数据:刺激诱发面部感觉异常的范围和阈值、刺激诱发面部运动的部位和阈值、毁损前的电阻值。毁损术前、术后分别评估视觉模拟评分(VAS)。结果 30例患者电刺激诱发面部感觉异常的阈值0.05~0.5V,平均0.21V。刺激诱发面部运动反应的阈值0.08~0.5V,平均0.27V。毁损前电阻值283~580Ω,平均396Ω。29例患者疼痛的术后明显缓解或者消失。1例患者术后出现咬肌肌力减弱。结论完整细致的电生理监测有助于提高三叉神经半月节射频热凝术的有效率及减少手术不良反应。     

C形臂或CT靶点定位射频治疗三叉神经痛2816例研究简

目的介绍C形臂或CT靶点精确定位卵圆孔半月神经节选择性射频热凝治疗原发性三叉神经痛的手术方法、技巧和效果。方法回顾性分析本组2816例射频治疗病例,术中采用C形臂X线或CT定位,靶点位于卯圆孔半月神经节,射频温控热凝术温度设定65～80℃,时间设定为30—60s。近、远期疗效观察并总结分析并发症。结果本组近期随访病例2760例,疼痛完全消失2661例,总有效率96．41％,2年内复发率192例（6．9％）,无效39例（1．4％）。结论本手术方法弥补了传统的徒手穿刺的缺陷,提高了定位准确性和疗效。对行开颅微血管减压术（MVD）复发或无效的三叉神经痛患者可以做为一项补充治疗。对本病伴有高龄心脑血管疾病的患者仍是一种安全可靠的治疗方法。     

立体定向射频热凝治疗三叉神经痛的心血管反应

目的探讨立体定向导航下经皮穿刺射频热凝术治疗三叉神经痛中,对心血管所产生的副作用。方法对256原发性三叉神经痛患者采用立体定向导航技术对三叉神经半月节进行经皮穿刺热凝毁损,术中全程监测患者的心率、血压及心电图。结果所有256例(100%)患者进行射频毁损治疗中均出现不同程度的心率及血压的升高,静脉应用硝酸甘油调控效果良好。在穿刺卵圆孔过程中有22例(8.6%)患者出现即时的不同程度的心率和血压的降低(最低心率60次/min有12例(4.7%),最低心率≥60次/min有10例(3.9%),对心率下降但心率≥60次/min的患者采用立刻终止手术操作,患者心率可以逐渐好转。对心率下降并且心率60次/min的患者静脉注射阿托品干预后,患者心率能恢复正常。结论经皮穿刺半月节射频热凝术治疗三叉神经痛,术中进行持续的心电监测可以实时了解心率及血压变化,立即予以停止手术操作和药物干预可以有效避免严重心血管事件的发生。     

Dyna-CT引导下经皮穿刺三叉神经半月节微球囊压迫术治疗三叉神经痛

目的 探讨Dyna-CT引导下经皮穿刺三叉神经节微球囊压迫术（PBC）治疗三叉神经痛的临床效果。方法 对2017年9月至2018年11月采用Dyna-CT 引导下PBC治疗的17例三叉神经痛的临床资料进行回顾性分析。在Dyna-CT引导下穿刺，颅底3D-CT重建证实穿刺针抵达卵圆孔。通过穿刺针将带导丝CTZ-14球囊导入Meckel腔，球囊压迫三叉神经半月节。结果 住院时间3~9 d，平均5.6 d。术后随访6~12个月。术后症状完全消失14例，明显缓解2例，无缓解1例；总有效率为94.2%（16/17）。术后出现面部麻木15例、咀嚼略乏力9例、眼角干涩2例、口角疱疹5例，均经治疗后痊愈。结论 Dyna-CT 引导下PBC，是针对复发三叉神经痛、高龄、不愿或不能耐受开颅手术的三叉神经痛的有效微创手术方法，具有良好的临床应用价值。     

应用卵圆孔定位仪治疗三叉神经痛

目的总结卵圆孔定位仪在选择性经皮温控射频热凝治疗三叉神经痛的应用方法和技巧。方法对三叉神经第Ⅱ、Ⅲ支疼痛者或第Ⅰ、Ⅱ、Ⅲ支同时疼痛者应用Hartel前入路半月神经节射频热凝治疗,其中260例患者应用三叉神经卵圆孔定位仪辅助定位,对39例患者术中应用X线或三维CT进行卵圆孔靶点验证。结果所有病例穿刺成功。术后即刻疗效:优良206例,良好42例,无疗效12例,总有效率95.4%,无严重并发症发生。结论卵圆孔定位仪可用于射频热凝治疗三叉神经痛的辅助定位,可以提高穿刺的成功率和安全性。     

A prospective study of Gasserian ganglion pulsed radiofrequency combined with continuous radiofrequency for the treatment of trigeminal neuralgia

We conducted a prospective randomized controlled study to evaluate whether continuous radiofrequency (CRF) combined with pulsed radiofrequency (PRF) to the Gasserian ganglion (GG) decreases the side effects of CRF while preserving efficacy. Sixty patients diagnosed with classic trigeminal neuralgia (TN) were treated with either 75°C CRF for 120 s to 180 s (SCRF group), 75°C CRF for 240 s to 300 s (LCRF group), or 42°C PRF for 10 minutes (min) followed by 75°C CRF for 120 s to 180 s (PCRF group). Patients were assessed for pain intensity, quality of life (QOL), and intensity of facial dysesthesia before (baseline), and at seven days, three months, six months, and 12 months after the procedure. The efficacy in pain relief was most significant on the seventh day after treatment and there were no significant differences between groups. After 12 months, >70% of patients in each group had complete pain relief, and the QOL in all three groups had increased significantly compared to baseline. The intensity of facial dysesthesia was mildest in the SCRF group and most severe in the PCRF group on the seventh day after the procedure, but most persistent in the LCRF group. Patients who receive PRF combined with CRF to the GG can achieve comparable pain relief to those who receive CRF alone, and shorter exposure of CRF could result in less destruction of the target tissue.