The extracapsular capsule phenomenon of percutaneous balloon compression provides adequate compression of the third branch of the trigeminal nerve: a retrospective study

BACKGROUND

Percutaneous balloon compression (PBC) is an effective, low-cost, and simple treatment for primary trigeminal neuralgia (TN). However, PBC has poor efficacy and no better solution for the third branch (V3) of TN.

METHODS

Clinical data of 52 patients with trigeminal neuralgia treated with PBC were retrospectively analyzed. Postoperative numbness of the patient was evaluated by facial numbness at the Barrow Neurological Institute (BNI-N). The main observation was the incidence of higher numbness in the V3 than in the other two branches or equally strong numbness in the three branches in the immediate postoperative period.

RESULTS

The efficacy values in the pear-shaped balloon group at the first postoperative day (T1), the first month (T2), in the third month (T3), and the sixth month (T4) were 96.7%, 93.3%, 93.3%, and 90%, respectively, and 1 patient (3.3%) had recurrence. The efficacy value for the extracapsular capsule group was 95.5% at all times and there were no patients with recurrence within 6 months after surgery. In the immediate postoperative period, the effective compression rate of V3 in the pear-shaped balloon group was 43.3%, and 86.4% in the extracapsular capsule group (P = 0.020). At six months of follow-up, the effective compression rate of V3 was higher in the extracapsular capsule group than in the pear-shaped balloon group.

CONCLUSIONS

The riveted structure of the extracapsular capsule can effectively compress V3, thus performing PBC with a balloon shaped as an extracapsular capsule is a new, effective, and safe treatment option for TN V3.

TRIAL REGISTRATION

ClinicalTrials.gov ChiCTR2300067313.

Three-dimensional printed personalised digital guide plate for greater palatine block in trigeminal neuralgia

The nerve block is a safe and effective method to theat trigeminal neuralgia (TN). In terms of the V2 trigeminal neuralgia, the most difficult procedure in nerve block is accurate and fast greater palatine foramen (GPF) insertion. In this study, we developed a new technique using a personalised digital tooth-supported guide plate to increase insertion accuracy and success rates and reduce the pain of patients during injection. A total of 18 patients with TN (11 female and 7 male) were enrolled and treated between September 2020 and June 2022. Before injection, the guide plate was designed via Mimics three-dimensional (3D) reconstruction technology and printed via 3D printer. Then, all patients underwent maxillary nerve block with a guide plate for each injection. In this study, placement of all guide plates was completed within one minute and all punctures were successful the first time. The depth of the injection needle was over 2.5 cm in all cases and the guide plate was stability-supported by the maxillary teeth. The various pain scores had an obvious improvement. No patients presented symptoms of local anaesthetic toxicity or onset of new neurological sequelae. Using this new technology, we can significantly reduce the difficulty of GPF insertion and decrease patient pain during injection. The enhanced success rate of nerve block can achieve better therapeutic effect. For surgeons, personalised digital tooth-supported guide plates make the operation easier, especially for novice surgeons.

Efficacy and Challenges: Minimally Invasive Procedures for Trigeminal Neuralgia Treatment in Multiple Sclerosis - A Systematic Review and Meta-Analysis

INTRODUCTION

Trigeminal neuralgia (TGN) poses a therapeutic challenge, particularly within the context of multiple sclerosis (MS). This study aimed to conduct a comprehensive meta-analysis and systematic review of four less-invasive treatment modalities for TGN in MS patients, namely, gamma knife radiosurgery (GKRS), glycerol rhizotomy (GR), balloon compression (BC), and radiofrequency ablation (RFA).

METHODS

Single-armed meta-analyses were employed to assess the overall efficacy of each treatment, while double-armed analyses compared the efficacy between different treatment options in double-armed studies. Outcome evaluations included acute pain relief (within 1 month post-procedure), recurrence rates throughout 18 months of follow-up, and reported complication rates.

RESULTS

The meta-analysis revealed diverse outcomes for each intervention. GKRS demonstrated favorable outcomes, achieving a 77% success rate in alleviating pain among a pooled cohort of 863 patients, reinforcing its status as a viable therapeutic option. Additionally, GR, BC, and RFA exhibited efficacy, with success rates of 77%, 71%, and 80%, respectively, based on outcomes observed in 611, 385, and 203 patients. Double-armed analyses highlighted distinctions between the treatments, providing nuanced insights for clinical decision-making.

CONCLUSION

This meta-analysis provides a comprehensive overview of less-invasive treatments for TGN in MS patients. GKRS emerges as a leading option with comparable efficacy and fewer complications. However, the study underscores the nuanced efficacy and considerations associated with GR, BC, and RFA. The findings offer valuable insights for clinicians navigating treatment choices in this challenging patient population, considering acute pain relief, recurrence rates, and complication profiles.

Efficacy and Safety of Computed Tomography-Guided Percutaneous Balloon Compression under Local Anesthesia for Recurrent Trigeminal Neuralgia: A Prospective Study

Purpose

There are several ways to treat trigeminal neuralgia (TN); however, TN may recur after treatment. This study investigated the efficacy and safety of computed tomography (CT)-guided percutaneous balloon compression (PBC) under local anesthesia for treatment of recurrent trigeminal neuralgia. Patients and Methods. This is a prospective and nonrandomized controlled clinical study. Forty-eight patients with classical TN were scheduled to undergo PBC surgery at the pain department of our institution between January 2021 and June 2021. The patients were prospectively divided into an initial onset group, A (21 cases), and a recurrence group, B (27 cases). All surgeries were performed with CT guidance and under local anesthesia. Postoperative complications were also observed. Pain was assessed using the visual analog scale (VAS) and Barrow Neurological Institute (BNI) scale. Efficacy indices were evaluated at 3, 6, 12, and 18 months after surgery.

Results

All participants reported complete pain relief at discharge. After 18 months of follow-up, the total effective rate of pain control was 89.5% (group A, 90.5%; group B, 88.8%). There was no significant difference in the BNI scores between the two groups before and after treatment. All patients had hypoesthesia on the affected side, and no severe complications such as diplopia, blindness, intracranial hemorrhage, or intracranial infection occurred.

Conclusions

CT-guided PBC under local anesthesia is safe and effective for the treatment of recurrent TN and thus acts as an effective alternative for geriatric patients and those with high-risk factors.

Comparison of microvascular decompression, percutaneous radiofrequency rhizotomy, and stereotactic radiosurgery in the treatment of trigeminal neuralgia: A long term quasi-experimental study

BACKGROUND

Microvascular decompression (MVD), radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS) are surgical techniques frequently used in the treatment of idiopathic trigeminal neuralgia (TN), although the results reported for each of these are diverse.

OBJECTIVE

This study aimed to compare long-term pain control obtained by MVD, SRS, and RFR in patients with idiopathic TN.

METHODS

To compare the results obtained by MVD, SRS, and RFR we chose a quasi-experimental, ambispective design with control groups but no pretest. A total of 52 participants (MVD n = 33, RFR n = 10, SRS n = 9) were included. Using standardized outcome measures, pain intensity, pain relief, quality of life, and satisfaction with treatment were assessed by an independent investigator. The TREND statement for reporting non-randomized evaluations was applied. Clinical outcomes were evaluated at the initial postoperative period and at 6 months, 1, 2, 3, 4, and 5 years postoperatively.

RESULTS

MVD has shown better results in pain scales compared to ablative procedures. Significant differences between groups were found regarding pain intensity and pain relief at the initial postoperative period (p < 0.001) and 6 months (p = 0.022), 1 year (p < 0.001), 2 years (p = 0.002), and 3 years (p = 0.004) after the intervention. Those differences exceeded the thresholds of the minimal clinically important difference. A higher percentage of patients free of pain was observed in the group of patients treated by MVD, with significant differences at the initial postoperative period (p < 0.001) and 6 months (p = 0.02), 1 year (p = 0.001), and 2 years (p = 0.04) after the procedure. Also, a higher risk of pain recurrence was observed in the RFR and SRS groups (HR 3.15, 95% CI 1.33-7.46; p = 0.009; and HR 4.26, 95% CI 1.77-10.2; p = 0.001, respectively) compared to the MVD group. No significant differences were found in terms of quality of life and satisfaction with treatment. A higher incidence of complications was observed in the MVD group.

CONCLUSION

Concerning pain control and risk of pain recurrence, MVD is superior to RFR and SRS, but not in terms of quality of life, satisfaction with treatment, and safety profile.

Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis

Multiple sclerosis is a chronic inflammatory disease that affects the central nervous system and can cause various types of pain including ongoing extremity pain, Lhermitte's phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efficacy and can cause unpleasant side effects. The literature search was conducted across two databases, PubMed, and Google Scholar. Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews. The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids, muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine, lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.

Clinical observation of perioperative negative emotional changes in patients with percutaneous balloon compression for primary trigeminal neuralgia: A prospective cohort study

OBJECTIVE

To investigate the prevalence of negative emotions in trigeminal neuralgia (TN) patients, to identify risk factors associated with anxiety and depression, and further to explore the impact of percutaneous balloon compression (PBC) on anxiety and depression in TN patients during the perioperative period.

METHODS

400 patients with primary TN treated with PBC at our institution from November 2021 to April 2023 were included. We analyzed visual analogue scale (VAS) and the Hospital Anxiety and Depression Scale (HADS) scores. The patients' clinical data and short-term clinical outcomes were gathered and subjected to statistical analysis.

RESULTS

This study included a total of 400 patients diagnosed with primary TN. Patients who had high pain intensity (OR 1.20, 95 % CI 1.02-1.41; p = 0.025) or a history of multiple previous TN procedures (OR 1.49, 95 % CI 1.03-2.16; p = 0.036), were more prone to anxiety. Patients who were female (OR 1.59, 95 % CI 1.03-2.44; p = 0.036), had high pain intensity (OR 1.28, 95 % CI 1.08-1.52; p = 0.004) or had a history of multiple previous TN procedures (OR 1.48, 95 % CI 1.11-1.98; p = 0.008), were more likely to have depression. Significant improvements in anxiety and depressive symptoms were observed in patients who experienced pain relief after PBC (p < 0.001).

CONCLUSIONS

Female gender, high pain intensity, and a history of multiple prior TN procedures are associated risk factors for anxiety and depression in TN patients. PBC can provide patients with a high pain relief rate and significantly improve their anxiety and depression symptoms during the perioperative period.

Gamma Knife Stereotactic Radiosurgery for Trigeminal Neuralgia Secondary to Multiple Sclerosis: A Case-Control Study

BACKGROUND

The efficacy of stereotactic radiosurgery (SRS) for the relief of trigeminal neuralgia (TN) is well established. Much less is known, however, about the benefit of SRS for multiple sclerosis (MS)-related TN (MS-TN).

OBJECTIVE

To compare outcomes in patients who underwent SRS for MS-TN vs classical/idiopathic TN and identify relative risk factors for failure.

METHODS

We conducted a retrospective, case-control study of patients who underwent Gamma Knife radiosurgery at our center for MS-TN between October 2004 and November 2017. Cases were matched 1:1 to controls using a propensity score predicting MS probability using pretreatment variables. The final cohort consisted of 154 patients (77 cases and 77 controls). Baseline demographics, pain characteristics, and MRI features were collected before treatment. Pain evolution and complications were obtained at follow-up. Outcomes were analyzed using the Kaplan-Meir estimator and Cox regressions.

RESULTS

There was no statistically significant difference between both groups with regards to initial pain relief (modified Barrow National Institute IIIa or less), which was achieved in 77% of patients with MS and 69% of controls. In responders, 78% of patients with MS and 52% of controls eventually had recurrence. Pain recurred earlier in patients with MS (29 months) than in controls (75 months). Complications were similarly distributed in each group and consisted, in the MS group, of 3% of new bothersome facial hypoesthesia and 1% of new dysesthesia.

CONCLUSION

SRS is a safe and effective modality to achieve pain freedom in MS-TN. However, pain relief is significantly less durable than in matched controls without MS.

A retrospective study to examine the association of different pear-shaped balloons with efficacy and postoperative complications in percutaneous balloon compression for trigeminal neuralgia

Percutaneous balloon compression is a safe and effective therapeutic modality for trigeminal neuralgia. It is widely recognized that the pear-shaped balloon is the key to the success of the procedure. This study aimed to analyze the effect of different pear-shaped balloons on the duration of the treatment outcome. In addition, the relationship between individual variables and the duration and severity of complications was analyzed. The clinical data and intraoperative radiographs of 132 patients with trigeminal neuralgia were reviewed. We classify pear-shaped balloons into type A, type B, and type C balloons depending on the size of their heads. The collected variables were correlated with prognosis by univariate and multivariate analyses. The efficiency of the procedure was 96.9%. There was no significant difference in pain relief rates between the different pear-shaped balloons. Median pain-free survival time was longer for type B and C balloons, which were significantly different from type A balloons. In addition, pain duration also was a risk factor for recurrence. There was no significant difference in the duration of numbness between the different types of pear-shaped balloons, but type C balloons resulted in longer-lasting masticatory muscle weakness. Duration of compression and balloon shape can also significantly influence the severity of complications. Different pear-shaped balloons have been shown to have a significant effect on the efficacy and complications of the PBC procedure, with type B balloons (head ratio: 10-20%) appearing to be the ideal pear shape. However, its clinical application remains to be validated.

Morphologic and Morphometric Measurements of the Foramen Ovale: Comparing Digitized Measurements Performed on Dried Human Crania With Computed Tomographic Imaging. An Observational Anatomic Study

The foramen ovale (FO) of the sphenoid bone is clinically important for the interventional treatment of trigeminal neuralgia. Percutaneous procedures applied to treat the chronic pain condition typically involve the cannulation of this oval-like foramen located at the base of the skull. Anatomic variations of the FO have been reported to contribute to difficulties in the cannulation of this structure. Computed tomography (CT) can help the surgeon improve the accuracy and safety of the intervention. However, even with navigation technology, unsuccessful cannulation of the FO has been reported. The aim of this observational anatomic study was to define morphometric and morphologic data of the FO and to investigate for potential differences between measurements taken on dried human crania and digitized measurements of the FO measured on CT images. One hundred eighteen FOs were evaluated. Twenty FOs underwent CT scanning. The mean length of the foramen was 7.41±1.3 mm on the left side and 7.57±1.07 mm on the right. The mean width of the foramen was 4.63±0.86 mm on the left side and 4.33±0.99 on the right. The mean area on the left side was 27.11±7.58 and 25.73±6.64 mm 2 on the right. No significant left-right differences were found for any of these dimensions. The most important conclusion that we can draw is that the measurements can indeed be performed on CT images to obtain an accurate picture of the morphology. Considering the surgical importance of the FO and taking into consideration the limitations this study added to scientific knowledge, this study was constructive as far as neurosurgeons and anatomists are concerned.

A review of literature and meta-analysis of one-puncture success rate in radiofrequency thermocoagulation with different guidance techniques for trigeminal neuralgia

OBJECTIVES

Radiofrequency thermocoagulation (RFT) is a type of Gasserian ganglion-level ablative intervention that is used for the treatment of trigeminal neuralgia. Guidance technologies are used to assist in the cannulation of the foramen ovale (FO) or foramen rotundum (FR) target. We conducted a systematic review to assess the value of different guidance technologies for RFT.

METHODS

We searched PubMed, Embase, the Cochrane database, Web of Science, and PROSPERO for studies published from January 2005 until December 2020. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and the nonrandomized studies of interventions-I tool were used to assess individual study characteristics and overall quality.

RESULTS

Our query identified 765 publications, and we were able to analyze 11 studies on patients suffering from trigeminal neuralgia. Only one study involved randomized controlled trials, whereas the others featured nonrandomized designs, predominantly before-and-after comparisons. Most of them were observational studies. A total of 222 participants were included, with a median number (range) of 20 (3-53) participants. The objective response rate (ORR) of the one-puncture success rate of RFT using puncture guidance for trigeminal neuralgia was 92% [95% CI (0.79-1), P < 0.001]. Statistically significant differences were observed in the cannulation and operation times between the guided and manual puncture groups (P < 0.001).

CONCLUSIONS

RFT with puncture guidance technology has an absolute advantage in puncturing the foramen ovale or foramen rotundum.

Clinical Efficacy of a Spiral CT-Guided Balloon Compression Day-Surgery Operation for the Treatment of Trigeminal Neuralgia

Objective

This study aimed to investigate the clinical efficacy of a balloon compression day-surgery operation under the guidance of spiral computed tomography (CT) three-dimensional (3D) reconstruction for the treatment of trigeminal neuralgia.

Methods

The clinical efficacy and related indexes of 380 patients with trigeminal neuralgia treated by a spiral CT-guided balloon compression day-surgery operation in the pain department of Beijing TianTan Hospital, from October 2017 to March 2021, were retrospectively analyzed.

Results

Five patients failed due to foramen ovale puncture or in placing the balloon; two patients had ineffective results after the operation and re-entered the hospital for secondary balloon compression. The initial effective rate of the operation in the 380 patients was 98.16%. All patients were discharged on the day of the operation, the average operation time was 26.46 ± 12.15 min, and the average interval from the completion of the operation to discharge was 2.67 ± 0.95 h. During the follow-up period (1-41 months), 12 patients had pain recurrence, and a Kaplan-Meier analysis revealed that the cumulative pain-free recurrence survival rate at 41 months after the operation was 80.64%. No complications related to foramen ovale puncture occurred.

Conclusion

The spiral CT-guided balloon compression day-surgery operation is safe, effective, and worthy of clinical promotion.

Internal neurolysis: 'nerve combing' for trigeminal neuralgia without neurovascular conflict - early UK outcomes

INTRODUCTION

Internal neurolysis (INL) is a surgical procedure where trigeminal nerve fibres are separated between the pons and porus trigeminus to relieve trigeminal neuralgia (TN). We report pain and functional outcomes to evaluate its safety and efficacy.

MATERIALS AND METHODS

Prospective cohort of all patients undergoing retrosigmoid craniotomy and INL between 2015 and 2017 at University Hospital Southampton. Patients with type I (6) or type II (2) refractory TN and no clear neurovascular conflict were offered INL as an alternative to partial sensory rhizotomy. Barrow Pain Intensity Scale (BNI) and Brief Pain Inventory Facial scores (BPI-Facial) were assessed. Minimum follow-up was 2 years'.

RESULTS

Eight patients (7F:1M) underwent INL. Two had MS. Pre-operatively, all had severe pain (BNI grade V) and the median BPI-Facial score was 115 (range 79-123).. There were no unexpected complications. On last follow-up, six (75%) had no pain (BNI grade I), while two (25%) had recurred (at 5 and 27 months). Median BPI-Facial score for all patients on the last follow-up was 20 (range 18-91) reflecting dramatically improved quality of life and activities.

CONCLUSIONS

INL is a potentially safe and effective treatment for refractory TN. Long-term efficacy is unknown, but early results are promising.

Robot-Assisted Percutaneous Balloon Compression for Trigeminal Neuralgia: Technique Description and Short-Term Clinical Results

Objective

Percutaneous balloon compression (PBC) is a minimally invasive treatment for trigeminal neuralgia (TG) with a favorable cost-effectiveness ratio, but this technique has a steep learning curve. This study presents our initial clinical experience of robot-assisted PBC using a neurosurgical robot on six consecutive patients with TG.

Methods

We fixed the patient's head with a skull clamp and connected it with the linkage arms of a Sinovation^® neurosurgical robot, which was then registered using four bone fiducials by the robotic pointer. The puncture needle was positioned at the entry point on the skin using a robotic arm and advanced to the target point after the skin had been incised with a pointed surgical blade. This procedure was repeated for a second trajectory. A balloon was then advanced and inflated using 0.3 ml of a contrast agent. Upon injection of 0.6 ml contrast agent, the ganglion was kept compressed for 120 s. After removal of the balloon and puncture needle, compression of the face was performed to achieve hemostasis.

Results

All patients achieved immediate pain relief following PBC. No permanent or severe complications were registered, and there was no pain recurrence in any of the patients during the follow-up period.

Conclusions

Despite requiring a longer time for preoperative preparation, robot-assisted PBC provided a high degree of accuracy and safety, and it can also shorten the learning curve for surgeons unfamiliar with PBC. Robot-assisted surgical approaches should be further developed and adopted for PBC.

Clinical Analysis of the Treatment of Primary Trigeminal Neuralgia by Percutaneous Balloon Compression

Purpose

To summarize the technical points and clinical effects of percutaneous balloon compression (PBC) in the treatment of primary trigeminal neuralgia.

Methods

The clinical data of 13 patients with trigeminal neuralgia who received PBC from April 2020 to July 2021 were retrospectively analyzed. VAS, VRS-4 and PPI were used to evaluate the postoperative pain relief. Different postoperative complications were analyzed.

Results

All patients had a smooth operation, the inflation volume of the balloon was 0.7 ml, the average compression time was 120 s, and there was no balloon rupture during the operation. On the day after operation, 12 patients (92.3%) had complete pain relief, and 1 patient (7.7%) was not satisfied with pain relief, but the pain disappeared 2 weeks after the operation. After operation, there were 12 patients with facial numbness in the affected side (92.3%), 3 patients with masseter muscle weakness (23.0%), 1 patient with herpes around the mouth (7.6%), and 1 patient with diplopia (7.6%).

Conclusion

PBC is an effective minimally invasive surgical method for the treatment of primary trigeminal neuralgia. It is suitable for the elderly and infirm people, those who cannot tolerate general anesthesia or are afraid of surgery, and patients who had undergone surgery but relapsed after surgery. However, it is necessary to pay attention to the serious facial numbness and postoperative masticatory weakness. These discomforts are generally relieved after half a year.

The Effect of Atropine on Trigeminocardiac Reflex-induced Hemodynamic Changes During Therapeutic Compression of the Trigeminal Ganglion

BACKGROUND

Percutaneous compression of the trigeminal ganglion (PCTG) can induce significant hemodynamic perturbations secondary to the trigeminocardiac reflex (TCR). The aim of this study was to investigate the effect of atropine pretreatment on hemodynamic responses during PCTG for trigeminal neuralgia.

MATERIALS AND METHODS

A total of 120 patients who received PCTG were randomly assigned to control and atropine groups that were pretreated with saline (n=60) and atropine 0.004 mg/kg intravenously (n=60), respectively. Heart rate (HR) and mean arterial pressure (MAP) were measured at 9 timepoints from before induction of anesthesia until the end of the PCTG procedure; the incidence of TCR was also observed.

RESULTS

HR was higher in the atropine compared with control group from the time of skin puncture with the PCTG needle until after the procedure was completed (P<0.05). MAP was also higher in the atropine compared with control group, but only at entry of the needle into the foramen ovale until 1 minute after trigeminal ganglion compression (P<0.05). HR was reduced in both groups during entry of the needle into the foramen ovale and during ganglion compression, but less so in the atropine compared with the control group (P<0.05). MAP increased during PCTG compared with baseline in both groups, but with a larger increase in the atropine group (P<0.05). Two and 52 cases in the control group, and 6 and 1 cases in the atropine group, exhibited a TCR during entry of the needle into the foramen ovale and at ganglion compression, respectively (P<0.05).

CONCLUSION

Pretreatment with atropine was effective in most patients at minimizing abrupt reduction in HR during PCTG.

Chinese expert consensus on minimally invasive interventional treatment of trigeminal neuralgia

BACKGROUND AND PURPOSE

Trigeminal neuralgia is a common condition that is associated with severe pain, which seriously affects the quality of life of patients. When the efficacy of drugs is not satisfactory or adverse drug reactions cannot be tolerated, minimally invasive interventional therapy has become an important treatment because of its simple operation, low risk, high repeatability and low cost. In recent years, minimally invasive interventional treatments, such as radiofrequency thermocoagulation (RF) of the trigeminal nerve and percutaneous microcompression (PMC), have been widely used in the clinic to relieve severe pain in many patients, however, some related problems remain to be addressed. The Pain Association of the Chinese Medical Association organizes and compiles the consensus of Chinese experts to standardize the development of minimally invasive interventional treatment of trigeminal neuralgia to provide a basis for its clinical promotion and application.

MATERIALS AND METHODS

The Pain Association of the Chinese Medical Association organizes the Chinese experts to compile a consensus. With reference to the evidence-based medicine (OCEBM) system and the actual situation of the profession, the Consensus Development Committee adopts the nominal group method to adjust the recommended level.

RESULTS

Precise imaging positioning and guidance are the keys to ensuring the efficacy and safety of the procedures. RF and PMC are the most widely performed and effective treatments among minimally invasive interventional treatments for trigeminal neuralgia.

CONCLUSIONS

The pain degree of trigeminal neuralgia is severe, and a variety of minimally invasive intervention methods can effectively improve symptoms. Radiofrequency and percutaneous microcompression may be the first choice for minimally invasive interventional therapy.

Comparison of Effectiveness and Safety between Intraoperative 3D-CT-Guided and C-Arm-Guided Percutaneous Balloon Compression for Idiopathic Trigeminal Neuralgia: A Multi-Center Retrospective Study

Objectives

To compare 3D-CT-guided and C-arm-guided percutaneous balloon compression (PBC) in terms of effectiveness and safety.

Methods

The medical records and follow-up data of patients with idiopathic trigeminal neuralgia who underwent 3D-CT-guided or C-arm-guided PBCs in Beijing Tiantan Hospital and the Characteristic Medical Center of the Chinese People's Armed Police Force between February 2018 and March 2020 were retrospectively reviewed and analysed.

Results

A total of 291 patients were included. Among them, 212 patients underwent PBC treatment with 3D-CT and others with C-arm. One (0.5%) patient in 3D-CT group and 4 (5.1%) patients in C-arm group failed to receive PBC treatment because of failure of foramen ovale (FO) puncture (P=0.020). Among patients with successful attempts, 5 (2.4%) patients in the 3D-CT group and 11 (14.7%) patients in the C-arm group received more than one needle pass during the procedure (P < 0.001). The 3D-CT group required less time than the C-arm group for puncture (P < 0.001) and for the whole operation (P < 0.001). The groups shared similar initial relief rates (P=0.749) and similar recurrence-free survival during follow-ups for a median of 22 months (P=0.839). No puncture-related complications occurred in either group and the two groups had similar incidences of compression-related complications.

Conclusion

3D-CT facilitated FO puncture and improved success rate of PBC. The overall time efficiency of PBC was also increased with 3D-CT. Thus, 3D-CT is a potentially useful image guidance technology for treating idiopathic trigeminal neuralgia by PBC.

Comparison of first-time microvascular decompression with percutaneous surgery for trigeminal neuralgia: long-term outcomes and prognostic factors

Objective

Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and percutaneous procedures (glycerol rhizolysis; thermocoagulation; and balloon compression). Although the efficacy of each procedure has been documented, direct comparisons of their relative efficacies for TN are lacking. We aimed to directly compare long-term outcomes after first-time MVD with percutaneous surgery in primary (idiopathic and classical) TN and identify predictors of outcome.

Methods

We conducted a retrospective analysis of prospectively collected data on 185 patients undergoing MVD and 129 undergoing percutaneous surgery. Procedures were performed by one of two neurosurgeons in a single centre; an independent observer collected long-term follow-up data by interviews, using the same outcome measures for all procedures.

Results

MVD patients were younger than those undergoing percutaneous surgery (P <.001). MVD provided superior initial pain relief (P <.001): 87.0% had Barrow Neurological Institute class I or II pain scores after MVD compared with 67.2% after percutaneous surgery. The complication rate for percutaneous procedures was 35.7% and for MVDs was 24.9% (P =.04), including minor and transient complications. Kaplan-Meier analysis demonstrated that MVD provided longer pain relief than percutaneous procedures (P <.001); 25% of patients had recurrence at 96 months following MVD compared with 12 months after percutaneous surgery. Subgroup analysis showed that balloon compression provided more durable relief amongst percutaneous procedures. Multivariate analysis revealed that post-operative numbness and age were prognostic factors for percutaneous procedures (P =.03 and .01, respectively).

Conclusions

MVD provides better initial pain relief and longer durability of relief than percutaneous surgery, although carrying a small risk of major complications. Amongst percutaneous procedures, balloon compression gave the most durable relief from pain. Older age and post-operative numbness were predictors of good outcome from percutaneous surgery. These results can help clinicians to counsel patients with primary TN on neurosurgical treatment selection for pain relief.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04793-4.

Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Patients with Multiple Sclerosis: A Single-Center Retrospective Study and Literature Review

OBJECTIVE

Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is a challenging condition to manage that is treated with Gamma Knife radiosurgery (GKRS). The aim of this report is to assess the safety, efficacy, and durability of GKRS for the treatment of TN in patients with MS. Our findings are compared with those of the existing literature and discussed.

METHODS

We retrospectively reviewed all patients at our institution who underwent GKRS for the treatment of TN secondary to MS and had 1 or more years of follow-up. Preoperative and postoperative pain intensities and facial numbness were evaluated with the Barrow Neurological Institute scores. Durability of successful pain relief was statistically evaluated with Kaplan-Meier analysis. The prognostic role of perioperative factors was investigated and analyzed using Cox proportional hazards regression.

RESULTS

There were 29 patients with MS-TN who underwent GKRS at our institution. Two patients underwent bilateral treatment. Four patients underwent repeat GKRS for pain recurrence. The median period of follow-up assessment was 33 months. Rates of reasonable pain reduction at 1, 3, and 5 years were 70%, 57%, and 57% respectively. All patients who underwent repeat GKRS had durable pain reduction. No prognostic factor for successful pain reduction was found.

CONCLUSIONS

Our study shows that GKRS for the treatment of TN secondary to MS is a safe and effective procedure in controlling pain in the short term but often fails to provide long-term pain control. GKRS can be safely repeated to prolong the time of pain reduction.

Percutaneous Surgical Approaches in Multiple Sclerosis-Related Trigeminal Neuralgia: A Systematic Review and Meta-analysis

OBJECTIVE

The prevalence of trigeminal neuralgia (TN) in the setting of multiple sclerosis (MS) is reported to be 20-fold higher than in the general population. In these patients, TN can be medically refractory and often requires neurosurgical interventions. Ablative percutaneous approaches such as balloon compression (BC), glycerol rhizolysis (GR), and radiofrequency ablation (RF) can be used and often provide rapid pain relief. The aim of this meta-analysis was to compare the safety and efficacy profile of these approaches.

METHODS

This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted.

RESULTS

Five studies with 481 percutaneous approaches were included. No differences in terms of immediate pain relief were identified between BC and GR (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.52-1.71). BC was associated with statistically significant higher odds of postoperative mastication weakness compared to GR (OR: 8.58; 95% CI: 1.52-48.43). The rates of pain recurrence (OR: 1.19; 95% CI: 0.04-40.12), hypoesthesia (OR: 0.98; 95% CI: 0.51-1.87), and reduced corneal reflex (OR: 1.07; 95% CI: 0.18-6.17) were similar between BC and GR. In addition, no differences in terms of immediate pain relief (OR: 2.01; 95% CI: 0.77-5.27), pain recurrence (OR: 5.37; 95% CI: 0.30-97.43), and hypoesthesia (OR: 0.63; 95% CI: 0.02-17.66) were identified between RF and GR. The comparison between BC versus RF showed similar rates of immediate pain relief (OR: 0.50; 95% CI: 0.10-2.44), pain recurrence (OR: 1.04; 95% CI: 0-325.96), and hypoesthesia (OR: 2.63; 95%CI: 0.01-735.71).

CONCLUSIONS

No significant differences in the immediate pain relief rates between BC, GR, and RF in MS patients were found. However, BC was associated with a higher risk of postoperative mastication weakness compared with GR.

[Trigeminal neuralgia : Modern diagnostic workup and treatment]

The present article gives an update of relevant aspects in the diagnosis and therapy of trigeminal neuralgia from the neurological, neuroradiological and neurosurgical point of view. The diagnosis of trigeminal neuralgia is clinical, but high-quality imaging is mandatory to identify secondary causes and a neurovascular contact. New methods such as DTI (diffusion tensor imaging) allow a more differentiated assessment of the consequences of a vascular contact on the trigeminal nerve. Carbamazepine and oxcarbazepine continue to be first choice for the medical treatment, but have been supplemented by additional options such as pregabaline, lamotrigine, and onabotulinumtoxin A. In patients insufficiently responding to medical treatment, there are neurosurgical treatment options giving very good results. The best long-term results have been described for microvascular decompression, but percutaneous and radiosurgical treatments also are good options, especially in patients with an increased surgical risk profile, in secondary trigeminal neuralgia, and in case of recurrence after microvascular decompression.

Percutaneous Balloon Compression for Trigeminal Neuralgia Because of Pontine Cavernous Angioma

BACKGROUND

A cavernous malformation (CM) with trigeminal neuralgia (TN) is relatively rare. We report a patient who presented with TN caused by a CM in the cerebellopontine angle.

CASE DESCRIPTION

A 37-year-old man presented with a history of episodic, shock-like, right facial pain of 2 months' duration. Neurologic examination revealed diminished sensation in the distribution of the right trigeminal nerve. Magnetic resonance imaging showed an ipsilateral minimally enhancing lesion affecting the trigeminal nerve with characteristics of a CM and evidence of hemorrhage in the cerebellopontine angle. The patient underwent percutaneous balloon compression (PBC) of the Gasserian ganglion for trigeminal ganglia. The patient's pain improved significantly after completion of this microsurgical method.

CONCLUSIONS

CMs can damage the trigeminal nerve and cause TN. PBC of the Gasserian ganglion can be undertaken safely and can relieve pain caused by TN caused by CM in the cerebellopontine angle.

Effect of Training on Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia: A Long-Term, Retrospective Comparison of Staff Neurosurgeon and Trainee Complications and Efficacy

OBJECTIVE

The role of trainee involvement in lesioning procedures for trigeminal neuralgia (TN) has not yet been investigated in reported studies. The objective of the present study was to compare the complications and efficacy of percutaneous glycerol rhizotomy (GR) when performed by staff neurosurgeons and trainees.

METHODS

A retrospective medical record analysis of 165 patients with medically refractory TN who had undergone 293 GR procedures by either a staff attending (n = 156) or trainee (n = 137) from 2007 to 2018 was performed. The data were analyzed with respect to procedure time, fluoroscopy time and radiation exposure, complication rates and outcomes.

RESULTS

No difference was found in procedure duration between the teaching and nonteaching cases and only a nonsignificant trend was found toward a longer fluoroscopy time for the latter. The initial response rates to GR were equal for staff attending (88.7%) and trainee (87.2%) cases (P = 0.708). Similarly, no statistically significant difference (P = 0.48) was found between the median time to recurrence for the staff attending cases (1.6 ± 0.3 years) compared with that of the trainee cases (1.7 ± 0.3 years). The overall incidence of complications was low (7.5%). The occurrence of facial hypoesthesia correlated with the amount of glycerol injected (P < 0.01).

CONCLUSIONS

GR for the treatment of TN can safely be performed by senior residents and fellows under supervision.

Myelin sheath structure and regeneration in peripheral nerve injury repair

Afferent and efferent nerve fibers cannot be distinguished based on the axonal diameter or the presence of the Remark bundle. The compaction of the myelin sheath involves 2 steps: 1) The distance between the 2 layers of cell membranes in the double-bilayer decreases; 2) the adjacent double-bilayers close to form MDL. The expression of MBP is positively correlated with the formation of the MDL. Anchoring of the myelin sheath by lipophilin particles might be required for the formation of a compacted myelin sheath. The abnormalities in nerve fiber structure observed in autologous nerve grafts do not appear to be related to either MBP or lipophilin, so further research is needed to determine their causes.

Observing the structure and regeneration of the myelin sheath in peripheral nerves following injury and during repair would help in understanding the pathogenesis and treatment of neurological diseases caused by an abnormal myelin sheath. In the present study, transmission electron microscopy, immunofluorescence staining, and transcriptome analyses were used to investigate the structure and regeneration of the myelin sheath after end-to-end anastomosis, autologous nerve transplantation, and nerve tube transplantation in a rat model of sciatic nerve injury, with normal optic nerve, oculomotor nerve, sciatic nerve, and Schwann cells used as controls. The results suggested that the double-bilayer was the structural unit that constituted the myelin sheath. The major feature during regeneration was the compaction of the myelin sheath, wherein the distance between the 2 layers of cell membrane in the double-bilayer became shorter and the adjacent double-bilayers tightly closed together and formed the major dense line. The expression level of myelin basic protein was positively correlated with the formation of the major dense line, and the compacted myelin sheath could not be formed without the anchoring of the lipophilin particles to the myelin sheath.