Skip to main content

Advertisement

SpringerLink
Log in

Efficiency and Efficacy of Real-Time Fluoroscopic Image-Guided Percutaneous Gasserian Glycerol Rhizotomy (PGGR), for Intractable Cases of Trigeminal Neuralgia

  • Clinical Paper
  • Published:
Journal of Maxillofacial and Oral Surgery Aims and scope Submit manuscript

Abstract

Aim & Objectives

To evaluate the ease, efficiency, effectiveness, and associated complications of the technique of percutaneous Gasserian glycerol rhizotomy (PGGR) under real-time fluoroscopic image guidance, for management of severe and refractory cases of primary trigeminal neuralgia, in medical compromised patients. To also assess the long-term efficacy and the necessity, if any, for repeat procedures to salvage recurrences.

Study Design & Setting

In a prospective study conducted at a single institution over a period of three years, 25 cases of Idiopathic Trigeminal Neuralgia refractory to conservative modalities of treatment including medication were managed with PGGR under real-time fluoroscopic image guidance. All the 25 patients included in this study were known surgical risks for relatively invasive treatment procedures, owing to factors such as advanced age and/or presence of co-morbidities.

Material & Methods

In order to minimize the risks related to the conventional techniques of Trigeminal root rhizotomy based on cutaneous landmarks alone, and to eliminate the need for frequent repositioning of the needle/cannula, we adopted a technique of real-time fluoroscopic image-guided negotiation of a 22 gauge (0.7 mm dia), 10-cm-long spinal nerve block needle through the foramen ovale, to reach the trigeminal cistern within the Meckel’s cave. The efficiency of the technique was assessed in terms of time taken, effort, and ease in performing it. Associated intra- and post-procedural complications were recorded. The immediate and long-term effectiveness of the procedure was evaluated by analysing the degree and duration of pain control achieved, time to recurrence, and the necessity for repeat procedures.

Results & Conclusion

There were nil intra- or post-procedural complications encountered, and no failures associated with this procedure. Real-time fluoroscopic imaging enabled easy, quick, and successful negotiation of the nerve-block needle through the Foramen Ovale, so as to reach the Trigeminal cistern within the Meckel’s cave, within 11 min on an average. An immediate and long lasting post-procedural pain relief was achieved in all the patients. During the follow-up period of 36 months, recurrence of pain was observed in six cases, the mean timing of the recurrence being 26 months or more. Five of these cases were manageable with medication alone, and only one required a repeat procedure. These results indicate that PGGR under real-time fluoroscopic image guidance is a safe, simple, time-efficient, convenient, efficacious, reliable, and minimally invasive means of treating refractory and intractable cases of trigeminal neuralgia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Headache Classification Committee of the International Headache Society (IHS) (2018) The international classification of headache disorders, 3rd edition. Cephalagia 38:1–211

    Article  Google Scholar 

  2. Maarbjerg S, Wolfram F, Gozalov A, Olesen J, Bendtsen L (2015) Association between neurovascular contact and clinical characteristics in classical trigeminal neuralgia: a prospective clinical study using 3.0 Tesla MRI. Cephalalgia 35:1077–1084

    Article  Google Scholar 

  3. Devor M, Amir R, Rappaport ZH (2002) Pathophysiology of trigeminal neuralgia: the ignition hypothesis. Clin J Pain 18:4–13

    Article  Google Scholar 

  4. Cohen-Gadol AA (2011) Microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm: nuances of the technique based on experiences with 100 patients and review of the literature. Clin Neurol Neurosurg 113:844–853

    Article  Google Scholar 

  5. Sheehan JP, Ray DK, Monteith S, Yen CP, Lesnick J, Kersh R et al (2010) Gamma Knife radiosurgery for trigeminal neuralgia: the impact of magnetic resonance imaging-detected vascular impingement of the affected nerve. Clin Artic J Neurosurg 113:53–58

    Article  Google Scholar 

  6. Verheul JB, Hanssens PEJ, Lie ST, Leenstra S, Piersma H, Beute GN (2010) Gamma Knife surgery for trigeminal neuralgia: a review of 450 consecutive cases. Clin Artic J Neurosurg 113(Suppl):160–167

    Article  Google Scholar 

  7. Koopman JS, de Vries LM, Dieleman JP, Huygen FJ, Stricker BH, Sturkenboom MC (2011) A nationwide study of three invasive treatments for trigeminal neuralgia. Pain 152:507–513

    Article  Google Scholar 

  8. Cheng JS, Lim DA, Chang EF et al (2014) A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery 10(Suppl 1):25–33

    Google Scholar 

  9. Montano N, Papacci F, Cioni B, Di Bonaventura R, Meglio M (2012) Percutaneous balloon compression for the treatment of trigeminal neuralgia in patients with multiple sclerosis. Analysis of the potentially prognostic factors. Acta Neurochir (Wien) 154:779–783

    Article  Google Scholar 

  10. Bender MT, Bettegowda C (2016) Percutaneous procedures for the treatment of trigeminal neuralgia. Neurosurg Clin N Am 27:277–295

    Article  Google Scholar 

  11. Pickett GE, Bisnaire D, Ferguson GG (2005) Percutaneous retrogasserian glycerol rhizotomy in the treatment of tic douloureux associated with multiple sclerosis. Neurosurgery 56:537–545

    Google Scholar 

  12. Kouzounias K, Lind G, Schechtmann G, Winter J, Linderoth B (2010) Comparison of percutaneous balloon compression and glycerol rhizotomy for the treatment of trigeminal neuralgia. J Neurosurg 113:486–492

    Article  Google Scholar 

  13. Håkenson S (1981) Trigeminal neuralgia treated by the injection of glycerol into the trigeminal cistern. Neurosurgery 9:638–646

    Article  Google Scholar 

  14. Linderoth B, Lind G (2012) Retrogasserian glycerol rhizolysis in trigeminal neuralgia. In: Quin˜ones- Hinojosa A (ed) Schmidek and Sweet’s Operative neurosurgical techniques. Phila Saunders Chapter, vol 123, pp 1393–1408

  15. King JS, Jewett DL, Sundberg HR (1972) Differential blockade of cat dorsal root C fibers by various chloride solutions. J Neurosurg 36:569–583

    Article  CAS  Google Scholar 

  16. Bennett MH, Lunsford LD (1984) Percutaneous retrogasserian glycerol rhizotomy for tic douloureux. Part 2: results and implications of trigeminal evoked potential studies. Neurosurgery 14:431–435

    Article  CAS  Google Scholar 

  17. Lunsford LD, Bennett MH, Martinez AJ (1985) Experimental trigeminal glycerol injection: Electrophysiologic and morphologic effects. Arch Neurol 42:146–149

    Article  CAS  Google Scholar 

  18. Koizuka S, Saito S, Tobe M, Sekimoto K, Obata H, Koyama Y (2010) Percutaneous radiofrequency mandibular nerve rhizotomy guided by high-speed real time computed tomography fluoroscopy. Anesth Analg 111:763–767

    Article  Google Scholar 

  19. Xu SJ, Zhang WH, Chen T, Wu CY, Zhou MD (2006) Neuronavigator-guided percutaneous radiofrequency thermocoagulation in the treatment of intractable trigeminal neuralgia. Chin Med J (Engl) 119:1528–1535

    Article  Google Scholar 

  20. Besi E, Boniface DR, Cregg R, Zakrzewska JM (2015) Comparison of tolerability and adverse symptoms in oxcarbazapine and carbamazepine in the treatment of trigeminal neuralgia and neuralgiform headches using the Liverpool Adverse Events Profile (AEP). J Headache Pain 16:563

    Article  CAS  Google Scholar 

  21. Tatli M, Satici O, Kanpolat Y et al (2008) Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. Acta Neurochir (Wien) 150:243–255

    Article  CAS  Google Scholar 

  22. Rappaport ZH, Devor M (1994) Trigeminal neuralgia : the role of self-sustaining discharge in the trigeminal ganglion. Pain 56:127–138

    Article  Google Scholar 

  23. Bendtsen JM, Zakrzewska JA, Braschinsky M, Di Stefano G, Donnet A, Eide PK et al (2019) European academy of neurology guideline on trigeminal neuralgia. Eur J Neurol 26:831–849

    Article  CAS  Google Scholar 

  24. Heinskou T, Maarbjerg S, Rochat P, Wolfram F, Jensen RH, Bendtsen L (2015) Trigeminal neuralgia–a coherent cross-specialty management program. J Headache Pain 16:66

    Article  Google Scholar 

  25. Yuan M, Zhou HY, Xiao ZL, Wang W, Li X-L, Chen S-J et al (2016) Efficacy and safety of gabapentin vs carbamazepine in the treatment of trigeminal neuralgia: a meta-analysis. Pain Pract 16:1083–1091

    Article  Google Scholar 

  26. Zakrzewska JM, Coakham HB (2012) Microvascular decompression for trigeminal neuralgia: update. Curr Opin Neurol 25:296–301

    Article  Google Scholar 

  27. Maarbjerg S, Di Stefano G, Bendtsen L, Cruccu G (2017) Trigeminal neuralgia—diagnosis and treatment. Cephalalgia 37:648–657

    Article  Google Scholar 

  28. Egan RA, Pless M, Shults WT (2001) Monocular blindness as a complication of trigeminal radiofrequency rhizotomy. Am J Ophthalmol 131:237–240

    Article  CAS  Google Scholar 

  29. Savas A, Sayin M (2010) Subarachnoid bleeding into the superior cerebellopontine cistern after radiofrequency trigeminal rhizotomy: case report. Acta Neurochir (Wien) 152:561–562

    Article  Google Scholar 

  30. Arrese I, Lobato RD, Alén JF, Lagares A, Miranda P (2005) Acute subdural and intratemporal hematoma as a complication of percutaneous compression of the gasserian ganglion for trigeminal neuralgia. Neurocirugia (Astur) 16:177–182

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The author of this article has not received any research grant, remuneration, or speaker honorarium from any company or committee whatsoever, and neither owns any stock in any company.

Funding

This study was not funded by any organization/society.

Author information

Authors and Affiliations

  1. Classified Specialist (Oral & Maxillofacial Surgery), Commanding Officer 33 CDU and 33 Corps Dental Adviser, Indian Army, West Bengal, India

    Priya Jeyaraj

Authors
  1. Priya Jeyaraj
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Priya Jeyaraj.

Ethics declarations

Conflict of interest

The author declares that she does not have any conflict of interest.

Ethical approval

This article does not contain any new studies with human participants or animals performed by the author.

Informed consent

Written informed consent was obtained from all the individual participants in this study, including the parents of the Minors.

Human Participants and/or Animals

All procedures performed on the patients (human participants) involved were in accordance with the ethical standards of the institution and/or national research committee, as well as with the 1964 Helsinki Declaration and its later amendments and comparable ethical standards.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jeyaraj, P. Efficiency and Efficacy of Real-Time Fluoroscopic Image-Guided Percutaneous Gasserian Glycerol Rhizotomy (PGGR), for Intractable Cases of Trigeminal Neuralgia. J. Maxillofac. Oral Surg. 21, 1053–1064 (2022). https://doi.org/10.1007/s12663-021-01682-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12663-021-01682-2

Keywords

Search

Navigation