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Xu Y, El Ahmadieh TY, Nunez MA, Zhang Q, Liu Y, Fernandez-Miranda JC, Cohen-Gadol AA, Mao Y. Refining the Anatomy of Percutaneous Trigeminal Rhizotomy: A Cadaveric, Radiological, and Surgical Study. Oper Neurosurg (Hagerstown) 2023; 24:341-349. [PMID: 36716051 DOI: 10.1227/ons.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/06/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Percutaneous trigeminal rhizotomy (PTR) is a widely used procedure for trigeminal neuralgia. However, comprehensive analyses that combine anatomic, radiological, and surgical considerations are rare. OBJECTIVE To present high-quality anatomic dissections and radiological studies that highlight the technical nuances of this procedure. METHODS Six silicon-injected postmortem heads underwent PTR. The surgical corridors were dissected, and the neurovascular relationships were studied. In addition, 20 dried human skulls and 50 computed tomography angiography and MRI scans were collected to study the anatomic relationships for a customized puncture corridor. RESULTS The PTR corridor was divided into 3 segments: the buccal segment (length, 34.76 ± 7.20 mm), the inferior temporal fossa segment (length, 42.06 ± 6.92 mm), and the Meckel cave segment (length, 24.75 ± 3.34 mm). The puncture sagittal (α) and axial (β) angles measured in this study were 38.32° ± 4.62° and 19.13° ± 2.82°, respectively. The precondylar reference line coincided with the foramen ovale in 75% of the computed tomography angiography scans, and the postcondylar line coincided with the carotid canal in 70% of the computed tomography angiography scans; these lines serve as the intraoperative landmarks for PTR. The ovale-carotid-pterygoid triangle, delineated by drawing a line from the foramen ovale to the carotid canal and the lateral pterygoid plate, is a distinguished landmark to use for avoiding neurovascular injury during fluoroscopy. CONCLUSION Knowledge of the anatomic and radiological features of PTR is essential for a successful surgery, and a customized technical flow is a safe and effective way to access the foramen ovale.
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Affiliation(s)
- Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Neurosurgery, Stanford Hospital, Stanford, California, USA.,Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Shanghai, China
| | - Tarek Y El Ahmadieh
- Neurosurgical-Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Qi Zhang
- Department of Cerebrovascular Diseases, Brain Hospital Affiliated to Tongji University, Shanghai, China
| | - Yaohua Liu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Juan Carlos Fernandez-Miranda
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA.,The Neurosurgical Atlas , Carmel, Indiana, USA
| | - Aaron A Cohen-Gadol
- The Neurosurgical Atlas , Carmel, Indiana, USA.,Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences, Shanghai, China
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Cohen DT, Bragin I, Hwang R, Oselkin M. Cone Beam CT With Flat Panel Detector and Biplane Fluoroscopy-Guided Percutaneous Trigeminal Nerve Rhizotomy Using Three-Dimensional Needle Trajectory Planning. Cureus 2022; 14:e25538. [PMID: 35800834 PMCID: PMC9246451 DOI: 10.7759/cureus.25538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
Trigeminal-mediated pain disorders can be devastating for patients refractory to medical therapy. Gasserian ganglion blocks and percutaneous trigeminal rhizotomy have been used with success to treat these patients, however, serious complication risks include facial hematoma, cranial nerve palsy, and stroke. Cone beam CT, combined with fluoroscopy and needle navigation has been shown to decrease needle pass rates, procedure time, radiation exposure, and complications in multiple interventional radiology procedures, but hitherto has not been utilized for Gasserian ganglion interventions. Here, we present two cases of trigeminal-mediated pain successfully treated via cone beam CT combined fluoroscopy and needle navigation.
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Frameless navigation-guided percutaneous rhizotomy of the trigeminal nerve: an appraisal of the literature. Neurosurg Rev 2021; 45:405-410. [PMID: 34089414 DOI: 10.1007/s10143-021-01575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/16/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
Percutaneous rhizotomy is a cornerstone of trigeminal neuralgia treatment. The procedure is classically performed under intermittent fluoroscopic guidance. While frameless navigation has been advanced to overcome potential difficulties and risks of the technique, literature on the subject is limited, and a gap between actual use and published series is likely. We have assessed all available studies of percutaneous rhizotomy of the trigeminal nerve performed under frameless navigation. Technical and clinical data that has been reviewed included clinical outcome, type of navigation employed, type of rhizotomy performed, types and rate of complications, operative time, cannulation time, and cannulation rate. Reports are heterogeneous, and most of these aspects have been inconsistently described. Comparisons with non-guided procedures are mostly indirect. While no obvious disadvantages are apparent when employing navigation, the ability to draw conclusions is nonetheless limited. Navigation appears as an inviting adjunct to trigeminal rhizotomy, but publication of longer, rigorously evaluated series would be welcomed.
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Vance AZ, El Ahmadieh TY, Christian Z, Aoun SG, Barnett SL, White JA. Biplane Fluoroscopic-Guided Balloon Rhizotomy for Trigeminal Neuralgia: A Technical Note. Oper Neurosurg (Hagerstown) 2020; 18:295-301. [PMID: 31232436 DOI: 10.1093/ons/opz132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk. OBJECTIVE To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy. METHODS Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail. RESULTS The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided. CONCLUSION Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.
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Affiliation(s)
- Awais Z Vance
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zachary Christian
- Department of Neurological Surgery, The University of Texas Southwestern, School of Medicine, Dallas, Texas
| | - Salah G Aoun
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel L Barnett
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan A White
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
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Electrophysiological Monitoring During Percutaneous Trigeminal Nerve Ganglion Block. J Neurosurg Anesthesiol 2018; 31:448-449. [PMID: 30024422 DOI: 10.1097/ana.0000000000000526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ren Z, Wang S, Xu K, Mokin M, Zhao Y, Cao Y, Wang J, Qiu H, Agazzi S, van Loveren H, Zhao J. The working road map in a neurosurgical Hybrid Angio-Surgical suite------ development and practice of a neurosurgical Hybrid Angio-Surgical suite. Chin Neurosurg J 2018; 4:7. [PMID: 32922868 PMCID: PMC7393899 DOI: 10.1186/s41016-017-0108-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background The concept of a Hybrid Angio-Surgical Suite (HASS) has emerged as a solution to the complexity of cerebrovascular surgery and the need for immediate intraoperative feedback. When to use it, what cases are suitable for its use, who can use it and how to use it remain debatable. Objective Provide the information regarding the application of the HASS for hospital, neurosurgeon and interventionalist. Methods We review the literatures of case reports and studies on the use of the hybrid angio-sugical suite along with application of HASS in our own practice. Results Indications for using HASS on different types of cerebral vascular disease, including cerebral aneurysm, AVM, DAVF, carotid and vertebral stenosis/occlusion, are addressed. The application of HASS for other non-cerebral vascular diseases, such as trauma, spine and skullbase cases, is reviewed and discussed. Conclusion HASS has made many surgical procedures safer and many difficult or previously untreatable conditions much more tractable and cost-effective. Other than used in cerebral vascular disease, HASS has much more applications, such as trauma, spine and other neurosurgical diseases.
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Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606 USA
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100050 China
| | - Kaya Xu
- Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606 USA.,Department of Neurosurgery, Guiyang Medical University, Guiyang, 550004 China
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606 USA
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100050 China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100050 China
| | - Jia Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100050 China
| | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606 USA
| | - Harry van Loveren
- Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, FL 33606 USA
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
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Chopko BW. Percutaneous thoracolumbar decompression combined with percutaneous pedicle screw fixation and fusion: a method for treating spinal degenerative pain in a biplane angiography suite with the avoidance of general anesthesia. JOURNAL OF SPINE SURGERY 2016; 2:122-7. [PMID: 27683708 DOI: 10.21037/jss.2016.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia. METHODS The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material. RESULTS In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks). DISCUSSION The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.
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Easwer HVI, Chatterjee N, Thomas A, Santhosh K, Raman KT, Sridhar R. Usefulness of flat detector CT (FD-CT) with biplane fluoroscopy for complication avoidance during radiofrequency thermal rhizotomy for trigeminal neuralgia. J Neurointerv Surg 2015; 8:830-3. [PMID: 26186933 DOI: 10.1136/neurintsurg-2015-011738] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/29/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Trigeminal neuralgia (TN) is characterized by episodes of shooting pain in the areas innervated by one or more divisions of the trigeminal nerve. The initial treatment of TN is with drugs but the increased frequency and intensity of the neuralgic episodes often force the patient to seek alternative therapies. Microvascular decompression (MVD) and radiofrequency thermal lesioning of trigeminal rootlets (RFTR) offer close to the best results for TN. MVD has the disadvantage of being an open surgical procedure with its attendant risks and longer hospital stay, whereas RFTR is a short, 'day-care' procedure. However this latter procedure involves positioning of the RF needle in the area behind the trigeminal ganglion through the foramen ovale, which can pose significant challenges. OBJECTIVE To use the fluoroscopic support of a biplane catheter laboratory to access the foramen, and flat detector CT to confirm the location of the tip of the RF needle in the optimal position. METHODS Fifty-three patients with TN underwent RFTR under local anesthesia with conscious sedation. RESULTS All patients reported pain relief with hypesthesia over the offending trigeminal division. In seven patients the needle tip required repositioning according to the CT images. Two patients each had loss of corneal reflex and abducens nerve palsy after the procedure. No other complications were seen. CONCLUSIONS The superior view in two planes coupled with the anatomical confirmation of the position of the needle tip in the Meckel's cave during the rhizotomy reduces the need for multiple passages of the needle to access the foramen ovale and achieves accurate needle tip positioning. The technique increases the safety and precision of such treatments and helps to manage potential complications.
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Affiliation(s)
- Hariharan Venkat Iyer Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Nilay Chatterjee
- Department of Anesthesia and ICU, Khoula Hospital, Muscat, Sultanate of Oman
| | - Ajith Thomas
- Division of Neurosurgery, Section of Cerebrovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kannath Santhosh
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Kapilamoorthy Tirur Raman
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Rupa Sridhar
- Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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