Functional neurosurgery in Moldova. Percutaneus trigeminal ganglion compression

Abstract

Introduction: Trigeminal neuralgia (TN) is a clinical diagnosis characterized by facial pain within the distribution of the trigeminal nerve, predominantly unilateral, triggerable, paroxysmal, severe, electric shock, and is either predominantly episodic or constant. Clinical examination shows no trigeminal sensory disturbance and a normal neurological examination. Surgical treatment is recommended for patients with TN that is medically refractory, who are intolerant of medication or who prefer surgery as their primary treatment of this condition. Idiopathic trigeminal neuralgia has an incidence of 3-5/100000 cases. Since the description by Hartel in 1912 of transovale trigeminal rhizotomy a number of treatment options have been described. In patients unsuitable for microvascular decompression, selective interruption of the nociceptive fibers in most cases can provide pain relief. We present our experience on a case of TN treated in our clinic using C-arm guided rhizotomy. Methods: Subject - 56 year old woman diagnosed with idiopathic trigeminal neuralgia, drug resistant. Pharmacotherapy for 2 years, during pain episodes with Carbamazepine 400-800 mg/day. The patient was under neroleptanalgesia in the supine position. Placement of the stylet needle according to the Hartel’s landmarks. Under Rx control the needle entered at a point 2.5-3 cm lateral to the mouth’s commisure targeting the foramen ovale (FO) situated at the 90° intersection of the ipsilateral pupillary line with a point 3 cm in front of the tragus. A No. 4 Fogarty balloon catheter with cannula were introduced. After the insertion of the catheter under Rx control the balloon was expanded to a pear-shaped form with injection of a radio-opaque contrast and compression for 60-90s. No complications occurred. Results: Pain relief was acquired in matter of hours and recurrence produced at 3 years post interventional. Conclusion: We conclude that the balloon compression seems to be an effective method in the treatment of idiopathic trigeminal neuralgia. Careful advancement of the needle and catheter with the help of anatomic landmarks and radiological guidance may minimize the risk of technical problems and postsurgical morbidity. We also emphasize that the surgeon should make every possible effort to obtain the pear-shaped balloon with compression time (60-90s) for favorable results.