Predictors of response for percutaneous balloon compression for the treatment of recurrent trigeminal neuralgia following surgical procedures: a retrospective study

Neurosurgical Review - Recurrent trigeminal neuralgia (TN) after surgical procedures can be rather difficult to treat, and standardized treatment measures are not available yet. It is unclear...     

Trochlear nerve palsy after repeated percutaneous balloon compression for recurrent trigeminal neuralgia: case report and pathogenic considerations

OBJECTIVE AND IMPORTANCE: Repeated percutaneous balloon compression for the treatment of idiopathic trigeminal neuralgia is infrequent. When a second procedure is performed, the outcome is unknown. A patient developed an isolated trochlear nerve palsy after undergoing percutaneous trigeminal ganglion balloon compression for a second time. The mechanism of diplopia and the complications associated with this technique were studied. CLINICAL PRESENTATION: The patient was a 67-year-old woman with a history of medically refractory idiopathic trigeminal neuralgia involving all three divisions of the right trigeminal nerve. INTERVENTION: Percutaneous balloon compression was performed. Despite initial total relief from pain without complications, the patient again displayed manifestations of trigeminal neuralgia 3 months after the procedure. The pain disappeared after she underwent a second balloon compression procedure, but she developed an isolated trochlear nerve palsy, which spontaneously resolved in 2 months. CONCLUSION: Isolated trochlear nerve palsy is a rare and reversible complication after percutaneous balloon compression for trigeminal neuralgia. This case illustrates that the mechanism of injury to the fourth nerve is the result of an erroneous technique: excessive penetration of the Fogarty catheter in Meckel's cave beyond the porus trigemini and compression of the cisternal segment of the trochlear nerve when the inflated balloon is pushed against the tentorium.     

构建模型预测经皮球囊压迫治疗后三叉神经痛复发

目的 构建预测三叉神经痛（TN）经皮球囊压迫（PBC）治疗后复发模型,分析疼痛复发相关因素。方法回顾性分析261例经PBC治疗的TN患者,以其中167例为训练集、94例为测试集;根据疼痛是否复发将前者分为复发亚组（n=95）与未复发亚组（n=72）,比较亚组间基本资料,获取疼痛复发相关因素,建立多因素logistic回归模型;以受试者工作特征曲线评估模型预测训练集和测试集PBC后PN复发的效能,比较模型在训练集与验证集曲线下面积（AUC）的差异。结果 训练集中,相比未复发亚组,复发亚组肥胖、合并多发性硬化症、TN病程≥5年、治疗前巴罗神经病学研究所疼痛分级Ⅳ或Ⅴ、非典型疼痛及球囊压迫时间>120 s者占比较高,而V3分区疼痛者占比较低（P均<0.05）。肥胖[OR=1.662,95%CI(1.176,2.350)]、合并多发性硬化症[OR=1.707,95%CI(1.195,2.439)]、TN病程≥5年[OR=2.016,95%CI(1.364,2.979)]、非典型疼痛[OR=2.551,95%CI(1.508,4.310)]及球囊压迫时间>120 s[OR=2....     

Prognostic nomogram for percutaneous balloon compression in the treatment of trigeminal neuralgia

Because of its convenience and safety, percutaneous balloon compression (PBC) has become a more popular remedy for trigeminal neuralgia (TN) recently. The objective of this study was to establish a nomogram that can be used to preoperatively prognosticate the likelihood of pain-free based on preoperative disease characteristics. Clinical data were collected from those TN cases who had undergone PBC during the period of 2015 and 2020 in Qingdao Municipal Hospital. We excluded the cases caused by space-occupying lesion or had undergone MVD, percutaneous glycerol rhizotomy (PGR), and glycerol rhizotomy (GR). A nomogram was established based on the results of multivariable logistic analysis. A receiver operating characteristic curve (ROC) analysis was applied to evaluate the reliability of models. The plotted decision curves were also used to assess the net benefit of nomogram-assisted decisions. Internal validation was performed using the ROC by bootstrap sampling. Finally, 16 cases and 69 cases were included into the ineffective and effective groups respectively. In the crude, adjust I and adjust II models, response to carbamazepine positively, the grade II or III compression severity score, and classical TN type were all considered to be significant predictors of pain relief (BNI grades I–III) at 3 months’ follow-up. The AUC, accuracy, specificity, and sensitivity of the nomogram system were 0.83, 0.85, 0.75, and 0.87 respectively for predicting patient outcomes. The decision curves showed good performance for the nomogram system in terms of clinical application, while more research with validation in multiple, external independent patient populations is needed.

     

Rare vascular complication of percutaneous balloon compression of trigeminal neuralgia treated endovascularly

Trigeminal neuralgia is commonly treated with percutaneous balloon compression due to the high success rate, technical simplicity and cost efficiency.1-3 The procedure carries certain risks, most notably dysesthesias and masseter muscle weakness.4 5 However, more severe complications are rare. In this report, the case of a rare complication of percutaneous balloon compression for trigeminal neuralgia is presented, resulting in a carotid cavernous fistula treated via an endovascular approach.     

Frequency of postoperative complications after balloon compression for idiopathic trigeminal neuralgia: prospective study.

BACKGROUND: Idiopathic trigeminal neuralgia (ITN) is often treated with balloon compression, considered in the literature to be a safer and more efficient procedure than other surgeries, with a high success rate. METHODS: This study evaluated 105 patients with idiopathic trigeminal neuralgia who underwent balloon compression of the trigeminal ganglion, with a follow-up of 210 days, and clinical questionnaires and a systematic physical evaluation used as instruments. RESULTS: There was a significant decrease in the shock-like complaint (P < .001), although 66.3% still experienced pain after 7 days of surgery from other causes; 50.5% presented limitation during jaw activities. Other complaints were hearing, taste and/or smelling loss, and visual difficulties. One patient had a TMJ ankylosis and needed surgical TMJ treatment. CONCLUSIONS: Although neurosurgery in the treatment of severe ITN pain is known to provide relief and its importance is recognized, there may also be severe complications that could compromise habitual tasks to various degrees. Therefore, the patient needs to be alerted about all complaints that he or she might present after the procedure. The professional has a duty to correctly inform and alert every patient under his or her care.     

Percutaneous trigeminal ganglion balloon compression for treatment of trigeminal neuralgia,part II: results related to compression duration

OBJECTIVE: The purpose of this study is to find out how different compression time affects the results of percutaneous trigeminal ganglion compression for treatment of trigeminal neuralgia. METHODS: This study includes 80 patients with intractable third-branch trigeminal (V3) neuralgia who had received percutanious trigeminal ganglion balloon compression. All the patients received some treatment protocol except for the duration of compression. Group 1 patients received 60-second and group 2 patients received 180-second compression. A computerized pressure recording system was used for pressure monitoring and analysis. RESULTS: Both groups had 100% immediate pain relief and all patients experienced mastication weakness immediately after the procedure. The facial numbness was severe in group 2 in the first trigeminal (V1) distribution (p<0.05) but not in the second or third trigeminal (V2,3) distribution (p>0.05) in the immediate period after the operation. The recurrence rate in the first year follow-up was higher in group 1 (5%) than in group 2 (2.5%) but did not reach the statistical difference (p>0.05). At 1 year follow-up after the procedure, group 1 and lower incidence of facial numbness over all trigeminal distribution (V1,2,3) than group 2 (p<0.05) mastication weakness all recovered during the first-year follow up. CONCLUSIONS: With accurate monitoring of the balloon pressure during the percutaneous trigeminal ganglion compression, it was found that the shorter duration of compression had less side effect. At one year follow-up, the incidence of recurrrence rate was slightly higher in the patients who received 60-second compressions than in those who received 180-second compressions, but there was no significant statistical difference. Whether patients with first or second branch of trigeminal neuralgia require longer compression duration needs further study.     

Microvascular decompression for trigeminal neuralgia: a long-term follow-up study.

In this report, we present our experience with microvascular decompression (MVD) as treatment for trigeminal neuralgia (TN) and discuss factors related to recurrence after this procedure. Between 1986 and 2004, 90 patients underwent MVD for treatment of idiopathic TN at the Marmara University Department of Neurosurgery and Marmara University Neurological Sciences Institute. Individuals with atypical and secondary forms of TN were excluded from the study. The patient characteristics, work-up findings, observations during surgery, and results of MVD for the 90 cases are reviewed. In 87 (97%) of the patients, exposure of the pontocerebellar angle revealed a vascular structure compressing the trigeminal nerve. In the patients with vascular compression, the problem vessel was an artery in 80 (92%) cases and a vein in 7 (8%) cases. In 77 cases, all symptoms were completely resolved by the operation. Ten patients experienced significant partial relief, and the intensity of the residual pain in these cases was not severe enough to require medication. Three patients experienced no improvement after MVD. There was no mortality associated with MVD in the 90 cases. The findings for our series of 90 patients with TN who underwent MVD indicate that this operation is an effective and reliable treatment for this condition. We recommend MVD as the first-line surgical approach for patients with TN who do not respond to medical management.     

Neurovascular compression in trigeminal neuralgia: a clinical and anatomical study.

Neurovascular decompression is a widely practiced technique for the treatment of trigeminal neuralgia, and yet there is still debate as to whether the beneficial effect results from relieving the nerve of compression by an anatomically abnormal vessel or from the manipulation and trauma the nerve undergoes during the procedure. The development of this operation has been hampered by the lack of adequate anatomical studies in normal controls. The authors present a combined study of clinical and anatomical material employing standardized definitions of the neurovascular relationships in both groups. Detailed simulations of the operative procedure were carried out on fresh cadavers matched for age, sex, and side, and a technique of in situ blood vessel perfusion was developed that enabled the normal neurovascular arrangement to be observed post mortem at physiological pressures. Neurovascular compression, typified by a large vessel distorting and creating a groove in the fifth cranial nerve, was found in 37 of the 41 cases of trigeminal neuralgia; recurrence of pain did not relate to the site of compression. A follow-up study was carried out for a median of 53 months (range 12 to 103 months). No distortion was found in a total of 50 normal cadaveric dissections; however, on perfusion to physiological pressures, the percentage of nerves with vessels adjacent or in simple contact increased from 16% to 40%. This study using this new technique confirms that vascular compression of the fifth cranial nerve is an anatomical abnormality specific to trigeminal neuralgia.     

A 20-year review of percutaneous balloon compression of the trigeminal ganglion

OBJECT: The aim of this study was to investigate outcomes and complication rates associated with percutaneous balloon compression (PBC) of the trigeminal ganglion over a long follow-up period. METHODS: This retrospective review was conducted in 496 patients with typical symptoms of unilateral trigeminal neuralgia who underwent 531 PBCs of the trigeminal ganglion between 1980 and 1999. The mean length of follow up was 10.7 years. The treatment used was a modification of that first described by Mullan and Lichtor in 1983. There were nine technical failures. Of the 522 successful procedures, prompt pain relief ensued in all patients except one. Recurrence of pain was found in 95 patients (19.2%) within 5 years and in 158 patients (31.9%) over the entire study period. Symptomatic dysesthesias occurred in 19 patients (3.8%), but corneal anesthesia and anesthesia dolorosa did not. CONCLUSIONS: In this review the authors present data on the largest cohort of patients with the longest follow up for this procedure in the current literature. The balance between the recurrence rate and troublesome sensory complications achieved in this series is favorable when compared with previously published studies on outcomes of PBC and the two alternative percutaneous methods, radiofrequency thermocoagulation and glycerol rhizolysis. The PBC procedure has additional advantages in that it is relatively straightforward and quick, and can be performed during a brief period of general anesthesia with no discomfort to the patient. This makes it an attractive first choice in the treatment of trigeminal neuralgia.     

Long-term outcome of percutaneous thermocoagulation for trigeminal neuralgia

A retrospective analysis of long-term efficacy of percutaneous radiofrequency thermocoagulation of the trigeminal ganglion or root for the relief of trigeminal neuralgia was carried out in our unit. From the medical records and questionnaires, outcomes of 108 procedures performed in 81 patients from January 1986 to December 1990 were obtained with a follow-up period of 6-11 years. The initial success rate was 87% and the probability of remaining pain-free 1, 2 and 11 years after the procedure was 65, 49 and 26%, respectively. Patients with typical symptoms had a better long-term efficacy than those with atypical presentations, and patients who had not undergone a previous surgical procedure also had a better outcome. There was no mortality in this series. Common adverse effects included dysaesthesia in 20 patients, corneal numbness in 12 patients and masseter weakness in three patients.     

Reoperation for recurrent trigeminal neuralgia after microvascular decompression

1. 1. The causes of RTN may be an offending vessel or Teflon felt effect. Further vascular compression of the trigeminal nerve can be relieved. In cases of severe adhesion caused by Teflon felt, the result is satisfactory if the fibrotic adhesion can be removed completely.

2. 2. In those patients with major recurrence of TN after MVD, radiologic examinations (e.g., CT scan and MRI) may reveal the etiology.

     

Treatment of essential trigeminal neuralgia by Gasserian compression using balloon (50 cases)]

Between 1985 and 1989, 50 patients with trigeminal neuralgia were submitted for percutaneous gasserian ganglion compression, the procedure is the technic described by Mullan with some variants. The Fogarty catheter is introduced through a teflon catheter. The balloon is inflated to 0.5 cc during 8 minutes. So 46 patients were relieved of their pain; there were 7 (14%) recurrence for an interval of between 6 and 54 months (average 30 months). Dysesthesias were noted in two patients when the duration of compression was more prolonged. Two patients had transient oculomotor nerve palsy. The success rate after gasserian compression is similar to this obtained in the other percutaneous procedures. Despite the general anesthesia with intubation which is useful, the procedure is technically very easy and can be performed by a neurosurgeon who has not a long experience.