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An alternative projection for fluoroscopic-guided needle insertion in the foramen ovale: technical note

  • Technical Note
  • Published:
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Abstract

Purpose

Puncture of the ganglion Gasseri through the foramen ovale and subsequent thermocoagulation, balloon compression, or glycerin injection is a well-established technique to treat trigeminal neuralgia. However, direct puncture of the foramen is sometimes difficult. Here, the authors present a simple technique of improved biplane fluoroscopic control for insertion of the needle into the foramen ovale.

Methods

The authors evaluated an alternative oblique X-ray trajectory for the correct placement of a needle into the foramen ovale on cadaveric skull models. After determination of the ideal X-ray trajectory, 13 subsequent patients suffering from trigeminal neuralgia were subjected to intraforaminal needle placement with application of the alternative X-ray trajectory.

Results

An oblique projection with the X-ray tube (mean rotation 20.9° and angulations 28°) aligned coaxially to the inserted needle is proposed. On cadaver skull models, this oblique trajectory appeared to be ideal for visualization of the correct needle position. In the 13 patients, an immediate needle insertion into the foramen ovale was achieved under this direct oblique fluoroscopic control. No complications were observed.

Conclusions

Experimentally and clinically, the new projection demonstrated three distinct advantages over the standard submental projection: Firstly, the foramen ovale can be better visualized independent of the patient's position. Secondly, needle correction or insertion can be performed much easier because of the direct fluoroscopic control. Thirdly, the correct needle position in the foramen ovale is more reliably determined than with the submental projection due to projection geometry. Further studies are needed to give evidence that the needle insertion into the foramen ovale is easier achieved with the coaxial projection than with the standard technique.

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Acknowledgement

The authors gratefully acknowledge Mr. S. Kindel's expert support in illustration of this publication.

Disclosure

The authors have nothing to disclose in association with this study.

Author information

Authors and Affiliations

  1. Klinik für Neurochirurgie, Universitaetsmedizin, Johannes Gutenberg Universitaet, Mainz, Germany

    Peter Grunert, Martin Glaser & Joachim Oertel

  2. Neurochirurgische Klinik, Universitätsspital, Zürich, Schwitzerland

    Ralf Kockro

  3. Institut für Neuroradiologie, Universitaetsmedizin, Johannes Gutenberg Universitaet, Mainz, Germany

    Stephan Boor

  4. Neurochirurgische Klinik und Poliklinik, Universitaetsmedizin, Johannes Gutenberg Universität, Langenbeckstrasse 1, 55131, Mainz, Germany

    Peter Grunert & Joachim Oertel

Authors
  1. Peter Grunert
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  2. Martin Glaser
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  3. Ralf Kockro
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  4. Stephan Boor
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  5. Joachim Oertel
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Corresponding authors

Correspondence to Peter Grunert or Joachim Oertel.

Additional information

Comment

This paper provides values for performing coaxial fluoroscopic control of electrode trajectory: mean rotation angulation of 21° with SD of 6.0 and mean forward angulation of 28° with SD of 8.4. Of course coaxial fluoroscopic needs a transparent head-holder/rest and no X-ray obstacle on the way. This method does help to find foramen ovale (F.O.), especially in those patients in whom pterygoid processes are abnormally developed, or with hypoplastic F. O. or F.O. modified by local pathology.

The oblique trajectory of X-ray control does not exempt from performing a lateral view to check location of the electrode tip before starting neurophysiological testing. According to our experience, electrode tip should be at the (retrogasserian) triangular plexus, that is—regarding bony landmarks—at the cross-section between petrous upper ridge and clivus (Sindou M., Keravel Y. (1979) Thermocoagulation percutanée du trijumeau dans le traitement de la névralgie faciale essentielle. Résultat en fonction du siège de la thermolésion. Neurochirurgie 25: 166–172).

Thereafter electrophysiological testing is mandatory to assure selective location of electrode tip in the fibers corresponding to the trigger-zone and the pain territory (Sindou M., Fobe J. L., Berthier E., Vial C. (1994) Facial motor responses evoked by direct electrical stimulation of the trigeminal root. Localizing values for radiofrequency thermorhizotomy. Acta Neurochirurgica 128: 57–67; Sindou M. (1999) Neurophysiological navigation in the trigeminal nerve: use of masticatory responses and facial motor responses evoked by electrical stimulation of the trigeminal Rootlets for RF—thermorhizotomy guidance. Stereotact Funct Neurosurg72: 1117–1121; Sindou M., Tatli M.(2009) Traitement de la névralgie trigéminale par thermorhizotomie. Neurochirurgie 55: 203–210).

Authors should be acknowledged for the practical usefulness of their work. Their paper should incite neurosurgeons to use coaxial fluoroscopic control for targetting F. O., not only for performing procedures for treating trigeminal neuralgia, but also for inserting electrodes in the temporomesial cisternal spaces, and evenmore for performing percutaneous biopsies in the Meckel cave, posterior part of the cavernous sinus upper petro-clival region (Sindou M., Chavez J.M., Saint-Pierre G., JOUVET A. (1997) Percutaneous biopsy of cavernous sinus tumors through the foramen ovale. Neurosurgery 40: 106–111).

Doctor Marc SINDOU, M.D., D. Sc

University of Lyon, France

This work was not presented earlier nor is it under evaluation for publication elsewhere.

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Grunert, P., Glaser, M., Kockro, R. et al. An alternative projection for fluoroscopic-guided needle insertion in the foramen ovale: technical note. Acta Neurochir 152, 1785–1792 (2010). https://doi.org/10.1007/s00701-010-0700-z

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  • DOI: https://doi.org/10.1007/s00701-010-0700-z

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