Efficacy and Safety of Awake CT-guided Percutaneous Balloon Compression of Trigeminal Ganglion for Trigeminal Neuralgia

Three-dimensional CT reconstruction-guided percutaneous balloon compression for trigeminal neuralgia

OBJECTIVE

To study the value of three-dimensional CT (3D-CT) reconstruction by comparing the surgical effects of C-arm and 3D-CT in the treatment of trigeminal neuralgia (TN) by percutaneous balloon compression (PBC).

METHODS

A total of 136 patients were included from May 2018 to February 2019. Among them, 65 patients underwent PBC treatment with 3D-CT and others with C-arm. During 3D-CT-guided operation, 3D-CT reconstruction software was used to analyze and measure the distances from the internal orifice of Foramen ovale (FO-I) and the external orifice of Foramen ovale (FO-E) to the top of the balloon (BT) and the petrous bone ridge (PR). The data, including the angle between the puncture needle direction and the zygomatic arch, petrous bone ridge, and slope, were used to assist the puncture and balloon plasty. Postoperative follow-up for more than five years was performed to evaluate the efficacy and pain recurrence.

RESULTS

The distance from FO-E to PR was (2.10 ± 0.16)cm, the average distance from FO-I to BT was (2.39 ± 0.07)cm, and the average angles between the puncture needle and zygomatic arch, slope, and petrous bone ridge were (56.19 ± 5.59)°, (69.12 ± 6.92)°, and (104.49 ± 6.46)°, respectively. One (1.5 %) patient in the 3D-CT group and three (4.2 %) patients in the C-arm group failed to receive PBC treatment because of failure of FO puncture (P = 0.032).In terms of postoperative pain improvement, 3D-CT group achieved better results than the C-arm group (P = 0.043). There were no significant differences in the rates of major complications and short-term recurrence (P = 0.926) between the two groups after surgery, but the five-year recurrence rate in the 3D-CT group was lower than that in the C-arm group (P = 0.032).

CONCLUSION

By guiding the angle and depth of puncture, the intraoperative application of 3D-CT reconstruction technology can improve the accuracy of foramen ovale puncture and alleviate postoperative pain, and also maintain long-term postoperative pain relief, which can be used as a potentially better guidance method to improve the surgical efficacy of PBC.

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.

Percutaneous balloon compression of trigeminal ganglion under conscious sedation local anesthesia for the treatment of primary trigeminal neuralgia-A prospective cohort study

Introduction

Trigeminal neuralgia is a debilitating condition that can significantly impair the quality of life of affected individuals. Percutaneous balloon compression (PBC) has been established as an effective treatment for this condition. However, the use of general anesthesia during the procedure poses challenges to achieving the desired degree of nerve damage without causing excessive numbness. In this study, we aimed to evaluate the feasibility and efficacy of performing PBC under conscious sedation of local anesthesia.

Methods

We improved the surgical procedure for PBC by administering intraganglionic lidocaine 0.2% with fine needle aspiration to achieve conscious sedation. This allowed the operator to determine the degree of nerve damage in real time through the tactile test. We conducted a clinical observation of 87 patients who underwent PBC under conscious sedation of local anesthesia. We evaluated the intraoperative blood pressure and heart rate changes, postoperative facial pain relief, and occurrence of complications such as severe facial numbness, irreversible keratitis, vision loss, and masticatory muscle weakness.

Results

All 87 patients achieved immediate relief of facial pain after undergoing PBC under conscious sedation of local anesthesia. The intraoperative blood pressure and heart rate changes were <20% of the baseline value. No patient experienced severe facial numbness or developed irreversible keratitis, vision loss, or masticatory muscle weakness.

Discussion

Our findings suggest that PBC under wide-awake local anesthesia is a safe and effective treatment for trigeminal neuralgia. The use of conscious sedation of local anesthesia during the procedure allows the operator to achieve the desired degree of nerve damage without causing excessive numbness. This can lead to long-term pain relief and improved quality of life for patients with trigeminal neuralgia.

Efficacy and safety of computed tomography-guided percutaneous balloon compression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia

Percutaneous balloon compression (PBC) of Gasserian ganglion has been popularly used to treat trigeminal neuralgia (TN), one of the most painful syndromes in human experience. Vertebrobasilar dolichoectasia (VBD) is a rare cause of TN and remains challenging to treat. To our knowledge, no study has reported the therapeutic outcome of PBC for VBD-related TN (VBD-TN). In this retrospective study, we collected and analyzed the medical records of all patients undergoing PBC procedure for VBD-TN under the guidance of CT plus three-dimensional reconstruction at the Pain Management Center of Beijing Tiantan Hospital from January 2017 to December 2022. All 23 patients (15 men and 8 women) had a substantial pain relief as modified Barrow Neurological Institute (BNI) I-IIIb immediately after procedure. The follow-up duration ranged from 2 to 63 months, and at the last follow-up visit, only 3 patients (13%) relapsed (BNI IV-V). The cumulative recurrence-free survival was 95%, 87%, and 74% within 1, 3, and 5 years, respectively. Patients' reported satisfactory rate was 100% as Likert scale 4-5 throughout the whole follow-up period, with no severe complications occurring. Our data revealed promising efficacy and safety of PBC procedure for treatment of VBD-TN, thus suggesting a valuable option for pain control in these rare cases of TN. However, there has been no supporting evidence that PBC treatment is a preferred option to other treatments.

Robot-assisted percutaneous balloon compression for trigeminal neuralgia- preliminary experiences

OBJECTIVES

This study aims to discuss the availability of robot-assisted percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) and share our preliminary experiences.

METHODS

Patients with TN who underwent robot-assisted PBC from June to September 2022 were enrolled. We designed a fixing plug for robot-assisted PBC, three-dimensional structured light registration was used, puncture trajectory was the line connects the medial third of inner and outer aperture of foramen ovale. Numerical Rating Scale (NRS), Barrow Neurological Institute (BNI) pain and numbness intensity score were used to evaluate the facial pain and numbness.

RESULTS

Eventually, nine patients were enrolled, the structured light registrations were successfully finished in all patients with a mean registration error of 0.68 mm. All the punctures of foramen ovales were successfully done one-time. Of note, the balloons were all got pear-shaped followed by 150 to 180 s compression. Though, postoperatively, all the patients complained of facial numbness and four patients suffered from transient masseter weakness, all patients got fully or mostly pain relief. It should be noted that is the numbness and weakness gradually relieved during follow-up.

CONCLUSION

Three-dimensional structured light registration and robot assisted PBC is an effective choice for patients with TN. Extension line between the medial third of the inner and outer aperture of foramen ovale might be a safe and effective puncture trajectory to this procedure.

Combination of Preoperative Multimodal Image Fusion and Intraoperative Dyna CT in Percutaneous Balloon Compression of Trigeminal Ganglion for Primary Trigeminal Neuralgia: Experience in 24 Patients

Objective

We retrospectively assessed the surgical results of PBC with preoperative multimodal image fusion and intraoperative Dyna Computed Tomography (CT) in 24 patients with primary trigeminal neuralgia (PTN) to explore a valuable aid for Percutaneous balloon compression (PBC).

Methods

We studied the data of 24 patients with PTN. All patients underwent PBC and were assessed with preoperative multimodal image fusion [computed tomography (CT) and magnetic resonance imaging (MRI)] and intraoperative Dyna CT in the Department of Neurosurgery of Zhuhai People’s Hospital between October 2020 and September 2021. Multimodal image fusion—three-dimensional (3D) reconstruction of CT and MRI data—was performed using 3D-Slicer software, and preoperative evaluation was performed according to the results of image fusion. Dyna CT was used to dynamically observe the position and shape of the metallic hollow introducer and Fogarty catheter and balloon during the operation to guide the operation in real time. We performed follow-up assessments each month and summarized the clinical characteristics, surgical effects, and complications in all patients.

Results

Surgery was successful for all patients; the patients reported immediate pain relief. Surgical complications included facial numbness in 24 patients (100%), mild masseter weakness in three (12.5%), herpes zoster in three (12.5%), and balloon rupture in one (4.2%). None of the patients had serious surgical complications. The mean follow-up time was 9.6 ± 2.7 months. During the follow-up period, 22 patients (91.7%) experienced no recurrence of pain, and two patients (8.3%) experienced recurrence of pain, of which one underwent secondary PBC surgery.

Conclusions

Preoperative multimodal image reconstruction can help fully evaluate PBC surgery, clarify the etiology, and predict the volume of contrast medium required during the operation. It provided important assistance for PBC treatment of trigeminal neuralgia patients when preoperative multimodal image fusion is combined with intraoperative Dyna CT.

The Molecular Basis and Pathophysiology of Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a complex orofacial pain syndrome characterized by the paroxysmal onset of pain attacks in the trigeminal distribution. The underlying mechanism for this debilitating condition is still not clearly understood. Decades of basic and clinical evidence support the demyelination hypothesis, where demyelination along the trigeminal afferent pathway is a major driver for TN pathogenesis and pathophysiology. Such pathological demyelination can be triggered by physical compression of the trigeminal ganglion or another primary demyelinating disease, such as multiple sclerosis. Further examination of TN patients and animal models has revealed significant molecular changes, channelopathies, and electrophysiological abnormalities in the affected trigeminal nerve. Interestingly, recent electrophysiological recordings and advanced functional neuroimaging data have shed new light on the global structural changes and the altered connectivity in the central pain-related circuits in TN patients. The current article aims to review the latest findings on the pathophysiology of TN and cross-examining them with the current surgical and pharmacologic management for TN patients. Understanding the underlying biology of TN could help scientists and clinicians to identify novel targets and improve treatments for this complex, debilitating disease.

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.