Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) has been an effective treatment modality for medically refractory trigeminal neuralgia. Our group has established a protocol for this procedure that includes intraoperative computed tomography (iCT) navigation. The depth of the puncture needle in our protocol was based on cadaveric studies, and anatomical localization was mainly by electric stimulation test. The limitation of the invisibility of the trigeminal cistern on CT imaging and bias from the patient’s subjective expression during neurophysiologic stimulation might affect the accuracy of the needle tip and the treatment effect.This study aimed to evaluate the feasibility and preliminary results of the application of magnetic resonance imaging (MRI) and iCT fusion imaging in RF-TR.
The study included 13 patients who received RF-TR with iCT navigation and with recurrence within 3 years. Repeated RF-TR was performed with real-time guidance by MRI and iCT fusion imaging.
A pain-free or partial satisfactory response was reported with 12 patients (92 %). There was a statistically significant difference in the depth of the needle tip before and after application of MRI and iCT fusion imaging.
This preliminary study demonstrated that the application of MRI and iCT fusion could help with anatomical localization of the trigeminal cistern intraoperatively. The improvement in neuronavigation provides a choice in the treatment of recurrent or persistent trigeminal neuralgia after previous intervention. Long-term follow-up of the result is necessary to evaluate the benefit in terms of durability of therapeutic efficacy.
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Financial support for this research was provided by Chang Gung Medical Institute (CMRPG6C0201). There is no personal or institutional financial interest in any drugs, materials, or devices described in the study.
Conflict of interest
The authors of this interesting article report their experience with MRI/iCT fusion in percutaneous radiofrequency (RF) lesion for trigeminal neuralgia (TGN). Direct puncture of the foramen ovale (FO) is a relatively simple procedure but there are at times anatomical difficulties and potential complications [1, 2] which have been extensively reported in the literature.
Neuronavigation (CT based) is currently used for direct puncture of the FO in several centres and there have been reports in the literature of an accuracy which is variable between 70 to 80 % and a cannulation time of 16 min .
The disadvantage of CT based neuronavigation is the lack of real-time image feed-back easily obtained with fluoroscopy. Both fluoroscopy and CT-based neuronavigation lack the capability to visualize the cisternal part of the nerve and correlate the needle position with the anatomy of the trigeminal ganglion.
The technique described by the authors is particularly attractive because it allows an anatomical planning based on MRI (visualization of the ganglion and cisternal part of the nerve) with added real-time navigation with iCT scan. This approach should minimize procedural complication and maximize clinical response targeting a selective area of the foramen ovale (v1 lateral third, v2 middle third and v3 medial third). Real-time neuronavigation with MRI/CT alongside functional imaging of the trigeminal ganglion (anatomical topography based on fMRI/DTI) will be possibly the future of percutaneous procedure, allowing better targeting and good long-term results.
Jibril Osman Farah
1. Spaziante R, Cappabianca P, Peca C, de Divitiis E (1988) Subarachnoid hemorrhage and “normal pressure hydrocephalus”: fatal complication of percutaneous microcompression of the gasserian ganglion. Case report Neurosurgery 22:148–151
2. Peris-Celda M, Graziano F, Russo V, Mericle RA, Ulm AJ (2013) Foramen ovale puncture, lesioning accuracy, and avoiding complications: microsurgical anatomy study with clinical implications. J Neurosurg 119:1176–1193
3. Lin MH, Lee MH, Wang TC, Cheng YK, Su CH, Chang CM, Yang JT (2011) Foramen ovale cannulation guided by intra-operative computed tomography with integrated neuronavigation for the treatment of trigeminal neuralgia. Acta Neurochir (Wien) 53:1593–1599
Electronic supplementary material
Below is the link to the electronic supplementary material.
This video shows the workflow of the procedure with neuronavigation based on MRI and iCT fusion image. We marked the trigeminal cistern on MRI and then the MRI and iCT fusion image was performed by BrainLab iPlan software. After image fusion, we could see the green mark on the intraoperative CT image. The foramen ovale and pterygoid plate were marked on image. After complete preoperative plan, the images were then sent to neuronavigation system to enable operator to perform the procedure with precise anatomical localization. (MPG 45410 kb)
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Chen, K., Lin, M.H., Tsai, Y. et al. Application of MRI and intraoperative CT fusion images with integrated neuronavigation in percutaneous radiofrequency trigeminal rhizotomy. Acta Neurochir 157, 1443–1448 (2015). https://doi.org/10.1007/s00701-015-2459-8
- Trigeminal neuralgia
- Percutaneous trigeminal rhizotomy
- Computed tomography
- Magnetic resonance image