Percutaneous retrogasserian glycerol rhizotomy for tic douloureux: Part 1. Technique and results in 112 patients

The technique and results of treatment of tic douloureux by percutaneous retrogasserian glycerol rhizotomy ( PRGR ) were assessed in a series of 112 patients. All patients were refractory to or intolerant of medical therapy. Many of these patients had recurrent pain despite such surgical treatment as microvascular decompression (21%) or one or more percutaneous radiofrequency thermal rhizotomies (19%). The follow-up duration after glycerol rhizotomy ranged from 4 to 28 months. At the final assessment, 67% had complete pain relief; 23% were improved, with pan relieved by minimal drug therapy; and 10% had poor results with unsatisfactory pain relief even with medications. Before the final assessment, 19 patients required a second PRGR because of an initially suboptimal injection (10%) or recurrent pain (16.9%). Seventy-three per cent had no demonstrable change in facial sensation after operation. H akanson 's original procedure based on anatomic verification by cisternography provided precise localization, required no intraoperative stimulation or lesion generators, and allowed varied anesthetic options during operation. In contrast to thermal rhizotomy, PRGR offers patients relief of painful tic douloureux without altering facial sensation in most cases.     

Percutaneous retrogasserian glycerol rhizotomy for treatment of trigeminal neuralgia

The treatment of trigeminal neuralgia by percutaneous retrogasserian glycerol rhizotomy was assessed in a series of 58 patients with a follow-up period ranging from 2 to 40 months postoperatively. All patients were considered medical failures prior to the procedure. Idiopathic trigeminal neuralgia was the diagnosis in 54 patients, and four patients had trigeminal neuralgia associated with multiple sclerosis. Forty-two patients (72%) reported complete relief from the procedure and are taking no medications. Four patients (7%) are much improved and require only minimal drug therapy. Twelve patients (21%) were considered treatment failures. The recurrence rate after initial relief of symptoms was 11%. Ten patients (17%) noticed a mild decrease in facial sensation following the procedure, and one additional patient had a profound sensory loss including loss of corneal reflex. The authors conclude that, while percutaneous retrogasserian glycerol rhizotomy may be useful in the treatment of trigeminal neuralgia, more clinical series and documentation of recurrence rate and complications are needed before any firm conclusions can be reached as to the efficacy of this therapy.     

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia. A prospective study of 100 cases

A prospective study of percutaneous retrogasserian glycerol rhizotomy (PRGR) with and without metrizamide trigeminal cisternography is reported in the treatment of the trigeminal neuralgia. A series of 100 patients with typical trigeminal neuralgia were allocated randomly to two treatment groups: Group I patients received PRGR with trigeminal cisternography (50 cases) and Group II patients received PRGR without trigeminal cisternography (50 cases). The results indicate that PRGR without trigeminal cisternography is a valid alternative to the original technique. Factors that assured the accurate performance of the modified technique proposed in this study were: spontaneous cerebrospinal fluid drainage; radiologically confirmed placement of the thin spinal needle at the clival edge into the trigeminal impression of the petrous apex and in the center of the foramen ovale; a positive response to the glycerol test; clinical control of the final glycerol injection; and an alert and cooperating patient throughout the entire procedure.     

Recurrent trigeminal cistern glycerol injections for tic douloureux

Summary Fourteen of 60 cases (23%) of trigeminal neuralgia underwent a repeat trigeminal cistern glycerol injection for recurrent pain. The mean time to recurrence was 14 months and the mean follow-up time following the last injection 10 months. Measurement of trigeminal cistern volume at the first and second procedure with metrizamide showed a significant decrease in the cistern volume from 0.38 ml to 0.29 ml. Clumping of nerve roots indicative of arachnoiditis was observed in 4 cases. In 2 further cases difficulty was encountered in emptying the cistern of metrizamide. After the repeat injection 2 patients developed painful dysesthesia. Six patients showed either new or increased facial sensory deficits. These findings may indicate trigeminal cistern arachnoiditis. The possibility of deafferentation pain developing after trigeminal glycerol rhizolysis should prompt caution in the use of this technique in the younger patient.     

Percutaneous retrogasserian glycerol rhizotomy. Predictors of success and failure in treatment of trigeminal neuralgia

Eighty-five medically intractable trigeminal neuralgia patients treated by percutaneous retrogasserian glycerol rhizotomy (PRGR) were followed for 6 to 54 months. The median time to recurrence of symptoms refractory to medical therapy and requiring further intervention was 3 years (by Kaplan-Meier survival analysis). The median time to recurrence of symptoms requiring some form of medical treatment was 2 years. Following repeat PRGR for recurrent symptoms, the median time to recurrence was 1 year. Univariate log rank statistics and multivariate Cox proportional hazards modeling revealed significant associations between favorable outcome and female sex, absence of atypical features or associated cluster headache symptoms, success of prior carbamazepine therapy, duration of symptoms, and cerebrospinal fluid return during the procedure. A scoring system using prognostic factors has been developed based upon these findings. Assessment of published studies of PRGR and of other treatments for trigeminal neuralgia is made difficult by the variety of outcome measures employed and variable follow-up intervals. The present study attempts to address these issues by definition of endpoints, statistical analysis of the data, and identification of important prognostic factors in a manner useful to the clinician.     

Percutaneous thermocontrolled differential retrogasserian rhizotomy for idiopathic trigeminal neuralgia

Summary Percutaneous thermocontrolled radiofrequency trigeminal rhizotomy enables the clinical destruction of pain fibres with preservation of touch sensation, thereby avoiding deterrent side-effects caused by conventional methods. The long-term results in 400 consecutive patients with idiopathic trigeminal neuralgia who underwent this procedure are reported. Satisfactory pain relief was achieved in 93.3% of cases. The follow-up period ranged from one to six years. The technique and its rationale are analysed, and the results, side-effects, indications, and limitations are discussed.     

Selectivity of retrogasserian glycerol rhizotomy in the treatment of trigeminal neuralgia.

The possibility of obtaining a selective effect on different trigeminal branches by glycerol rhizotomy was studied in the treatment of trigeminal neuralgia. Transcutaneous electrical stimulation was used to quantify sensory impairment. An attempt was made to direct the neurotoxic effect by maintaining the patient's head in different positions during and after glycerol injection. The amount of glycerol injected varied according to the estimated size of the trigeminal cistern and/or to which branch that was involved. The study demonstrated a good selective effect on the ophthalmic branch, less selective on the maxillary, and a poorly selective effect on the mandibular branch. However, the clinical result following glycerol rhizotomy was equal regardless of the affected trigeminal branch.     

Technical difficulties and perioperative complications of retrogasserian glycerol rhizotomy for trigeminal neuralgia

In 139 patients, 260 consecutive retrogasserian glycerol rhizotomies for trigeminal neuralgia were retrospectively analyzed regarding technical surgical difficulties and immediate and early complications. Technical obstacles occurred in 47.3%. In 21 cases (8.1%), the surgical procedure had to be interrupted due to circumstances such as vasovagal reactions, cardiac arrest, or difficulties to find the trigeminal cistern. Complications or side effects, being either transient or persistent, occurred in 67.3%. In the vast majority, those unwanted effects were related to mild sensory deficits. However, in 28.1% the complications were other than mild affection of facial sensibility. These slightly graver complications included labial herpes (3.8%), anesthesia dolorosa (0.8%), moderate or severe affection of sensibility (18.8%), dysesthesia (22.7%), chemical meningitis (1.5%) and infectious meningitis (1.5%). In 5 patients (1.9%) hearing was affected. In one of them, this condition was also brought about by tinnitus, and in another patient a preexisting tinnitus deteriorated. Although the frequency of surgical difficulties was high, the success of the glycerol injection was hampered only in a minor number of procedures. The frequency of complications and side effects was high, but they were mostly mild due to their nature and non-disabling for the patient. However, long-lasting disabling side effects occurred, and this should not be neglected when informing patients preoperatively. The surgical training needed to perform the procedure is stressed, and the use of prophylactic antibiotics when accidentally penetrating the oral bucca is recommended. We consider retrogasserian glycerol rhizotomy to be a good surgical option for patients with trigeminal neuralgia not suitable for microvascular decompression and when pharmacological therapy is not sufficient or is not tolerated.     

Neurovascular decompression with selective partial rhizotomy of the trigeminal nerve for tic douloureux

Fourteen patients with classic tic douloureux were treated with neurovascular decompression of the trigeminal nerve at its zone of entry into the pons. In addition, selective rhizotomy of the portio major was performed in each patient. This combined procedure gave excellent relief of pain with no recurrences in a 23-month postoperative period. Technical observations and postoperative complications in 3 patients are discussed. Routine selective partial rhizotomy of the sensory root of the trigeminal nerve may be a useful adjunct to neurovascular decompression for tic douloureux.     

Percutaneous retrogasserian glycerol rhizotomy for patients with idiopathic trigeminal neuralgia: a prospective analysis of factors related to pain relief

OBJECT: The goal of this study was to analyze prospectively factors associated with facial pain outcomes after percutaneous retrogasserian glycerol rhizotomy (PRGR) for patients with medically unresponsive idiopathic trigeminal neuralgia. METHODS: Between July 1999 and December 2003, 98 patients underwent PRGR in the manner described by H?kanson. The mean patient age was 72.1 years and the average pain duration prior to PRGR was 8.6 years. Fifty patients (51%) had previously undergone surgery. In six patients (6%), the trigeminal cistern could not be defined and the procedure was aborted; six patients were lost to follow-up review. An excellent facial pain outcome was defined as the absence of facial pain without medications. Thirty-two (35%) of 92 patients either received no benefit (17 patients) or experienced recurrent pain (15 patients) and required additional surgery at a mean of 7.5 months after PRGR; the mean duration of follow-up review in the other 60 patients was 28.7 months (range 3-52 months). Including patients who did not receive a glycerol injection, the 1- and 3-year chances of an excellent facial pain outcome were 61 and 50%, respectively. A multivariate analysis of clinical and surgical factors showed that the facial pain exhibited on glycerol injection correlated with excellent facial pain outcomes (relative risk [RR] = 1.02; 95% confidence interval [CI] 0.26-1.77; p < 0.01), whereas patients who experienced any constant pain less frequently had excellent outcomes (RR = 1.13; 95% CI 0.06-2.20; p = 0.04). Forty-six patients (53%) experienced either mild numbness/parathesias (39 patients) or dysesthesias (seven patients). New trigeminal deficits after PRGR were associated with excellent facial pain outcomes (RR = 1.25; 95% CI 0.56-1.93; p < 0.001). CONCLUSIONS: Percutaneous retrogasserian glycerol rhizotomy remains a good operation for patients with medically unresponsive trigeminal neuralgia who are considered poor candidates for posterior fossa exploration. Predictive factors for success include patients without any constant facial pain, patients with immediate facial pain during glycerol injection, and patients with new trigeminal deficits after PRGR.     

Percutaneous retrogasserian glycerol rhizolysis in the management of trigeminal neuralgia

Sixty patients with trigeminal neuralgia or atypical facial pain were followed for an average of 1 year after percutaneous retrogasserian glycerol rhizolysis. The procedure was initially effective in relieving pain in 80% of the patients with typical trigeminal neuralgia and symptomatic trigeminal neuralgia secondary to multiple sclerosis. However, life-table analysis indicated that 50% of this group had persistence or recurrence of pain within 18 months after the operation. Percutaneous retrogasserian glycerol rhizolysis was ineffective in relieving atypical trigeminal neuralgia or atypical facial pain. Minor complications occurred in 23% of patients, and major morbidity was seen in 1.6%. Facial sensory loss which persisted for more than 1 month was found in 72% of patients, corneal hypesthesia occurred in 15%, and an additional 7% had corneal anesthesia. The data indicate that the success of percutaneous retrogasserian glycerol rhizolysis in relieving trigeminal neuralgia is directly related to the production of facial sensory loss.     

Percutaneous glycerol rhizotomy for trigeminal neuralgia: safety and efficacy of repeat procedures

Percutaneous glycerol rhizotomy (PGR) is an established technique to treat trigeminal neuralgia. Our aim was to establish how safe and efficacious repeat glycerol rhizotomies were on a study of 179 PGRs performed in our institution. There was an overall success rate of 92.1% in improvement of facial pain. Nine patients had reduced facial sensation post-operatively. There were no cases of anaesthesia dolorosa. The mean time to repeat injection was 22.9 months (1-108 months). Of those requiring repeat glycerol rhizotomies within 6 months, 23% had multiple sclerosis. There was no evidence that the number of repeat glycerol rhizotomies affects the probability of them having a complication (p?=?0.87). Glycerol rhizotomy for trigeminal neuralgia is a safe and efficacious method of pain relief, which is particularly useful in the elderly. It can be repeated many times with no increase in morbidity and most importantly, in our practice, no anaesthesia dolorosa.     

Percutaneous retrogasserian glycerol injection in the management of trigeminal neuralgia: long-term follow-up results

The results in 122 patients with trigeminal neuralgia who underwent percutaneous retrogasserian glycerol injection are presented. Eighty patients were followed from 38 to 54 months. The recurrence rate at 54 months was 72% (Kaplan-Meier analysis), and the median pain-free interval was 32 months. Complications associated with the procedure were significantly high: 63% of the patients had definite hypesthesia of the face and 29% had unpleasant dysesthesias, including two cases of anesthesia dolorosa. Sensory disturbances were most frequent in patients who had received a previous alcohol block procedure. Among the patients without previous peripheral procedures, 50% developed sensory disturbances. Because of the high rates of recurrence and sensory disturbances, the authors prefer microvascular decompression for the management of trigeminal neuralgia.     

Gardner neurovascular decompression of the trigeminal and facial nerves for tic douloureux and hemifacial spasm

Neurovascular decompession of the trigeminal and facial nerves for tic douloureux and hemifacial spasm has been performed for the past two decades, starting with W. James Gardner in 1959. Although other neurosurgeons have refined and further perfected the operation, reporting large series of successful results, the credit for the concept and original procedures, including use of the surgical microscope, has generally escaped the attention of present-day neurological surgeons. This paper attempts to correct this inequity.     

A comparision of percutaneous radiofrequency trigeminal neurolysis and microvascular decompression of the trigeminal nerve for the treatment of tic douloureux

In a 36-month period, 103 consecutive patients have been treated for classical trigeminal neuralgia with either percutaneous radiofrequency trigeminal neurolysis (PTN) (48 patients) or microvascular decompression (MVD) via a suboccipital craniectomy (55 patients). The results of these two procedures are tabulated, emphasizing especially the complications that have occurred with each. Successful initial relief of pain was achieved in 88% of the patients with PTN and 96% of the patients with MVD. Two significant complications occurred in the former group. Severe recurrences have occurred to date in 13% of the patients with PTN and in 5% of those with MVD. It is concluded that both procedures are effective, but that microvascular decompression offers the advantage of avoiding sensory loss and associated dysesthetic sensations. Follow-up is too short to conclude that MVD is a curative procedure, but the early results are very encouraging.     

Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients

OBJECTIVE: The objective of this study was to evaluate the effectiveness of percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR). The outcome of 1,600 patients with idiopathic trigeminal neuralgia after RF-TR was analyzed after a follow-up period of 1 to 25 years. METHODS: A total of 1,600 patients with idiopathic trigeminal neuralgia underwent 2,138 percutaneous radiofrequency rhizotomy procedures between 1974 and 1999. Sixty-seven patients had bilateral idiopathic trigeminal neuralgia, and 36 of them were treated with bilateral RF-TR; 1,216 patients (76%) were successfully managed with a single procedure, and the remainder were treated with multiple procedures. Benzodiazepines and narcotic analgesics were used for anesthesia because patient cooperation during the procedures was essential so that the physician could create selective, controlled lesions. RESULTS: The average follow-up time was 68.1 +/- 66.4 months (range, 12-300 mo). Acute pain relief was accomplished in 97.6% of patients. Complete pain relief was achieved at 5 years in 57.7% of the patients who underwent a single procedure. Pain relief was reported in 92% of patients with a single procedure or with multiple procedures 5 years after the first rhizotomy was performed. At 10-year follow-up, 52.3% of the patients who underwent a single procedure and 94.2% of the patients who underwent multiple procedures had experienced pain relief; at 20-year follow-up, 41 and 100% of these patients, respectively, had experienced pain relief. No mortalities occurred. After the first procedure was performed, early pain recurrence (<6 mo) was observed in 123 patients (7.7%) and late pain recurrence was observed in 278 patients (17.4%). Complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1 %), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis of Cranial Nerves III and VI in 12 (0.8%). Permanent Cranial Nerve VI palsy was observed in two patients, cerebrospinal fluid leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one. CONCLUSION: Percutaneous, controlled RF-TR represents a minimally invasive, low-risk technique with a high rate of efficacy. The procedure may safely be repeated if pain recurs.