Browse

You are looking at 1 - 4 of 4 items for

  • Refine by Access: user x
  • By Author: Brown, Jeffrey A. x
Clear All
Full access

Jeffrey A. Brown and Julie G. Pilitsis

Object

Percutaneous balloon compression is an effective and technically simple method for treating trigeminal neuralgia (TN). Nevertheless, dysesthesias (10–20%) and masseter muscle weakness (66%) following the procedure have been noted. The purpose of this study was to evaluate the results of testing TN with percutaneousballoon compression aided by intraluminal pressure monitoring.

Methods

In this study the authors review the results and complications associated with percutaneous balloon compression by using intraluminal pressure monitoring data obtained in 65 procedures performed in 56 consecutive patients over 4 years. The mean patient age was 71 years (range 37–92 years), and the mean follow-up duration was 17 months (range 3–38 months). The mean intraluminal compression pressure was (1160 ± 62 mm Hg), and the mean duration of compression was 1.15 ± 0.27 minutes. The trigeminal depressor response was observed in 60 (92%) of 65 procedures, and initial pain relief occurred in 92% of patients. The recurrence rate in patients who had initial relief was 16% (nine of 56). The mean time until recurrence in patients who experienced pain relief after surgery was 13 months (range 3–23 months). Mild numbness immediately after surgery was observed in 83% of patients. At the most recent evaluation, 17% of patients reported persistent, nontroublesome numbness and none had moderate or severe numbness. Minor dysesthesia was present in two patients (4%). Mild masseter muscle weakness occurred in 24% of patients and resolved within a maximum period of 1 year. No patient experienced anesthesia dolorosa, corneal keratitis, or other cranial nerve deficits. These morbidity rates are lower than the incidence reported in the literature when pressure monitoring is not used.

Conclusions

These data show that by monitoring compression pressure and limiting the duration of compression, it is possible to reduce the incidence of dysesthesias, severe numbness, and masseter weakness after surgery without increasing the rate of recurrent pain in patients with classic TN.

Full access

Jeffrey A. Brown

In 1991 Tsubokawa and colleagues first published their landmark results from a series in which epidural motor cortex stimulation (MCS) was used in the treatment of eight patients with central and neuropathic pain. In ensuing studies authors have elaborated on the indications, technique, hypotheical mechanisms, and beneficial results of this treatment. Epidural MCS is effective for trigeminal neuropathy, lateral medullary and thalamic infarction, anesthesia dolorosa, postherpetic neuralgia, spinal cord injury, and limb stump pain. Postoperative outcomes are better when patients present with only mild or absent motor weakness in the region of pain and when there is pain in the trigeminal region. It is hypothesized that MCS is effective because it increases regional cerebral blood flow in the ipsilateral ventrolateral thalamus in which corticothalamic connections from the motor and premotor areas predominate. The extent of pain alleviation also correlates with the increase of blood flow in the cingulate gyrus. This suggests that stimulation reduces the suffering experienced by a patient with chronic pain. Procedure-related morbidity has included epidural hematoma, subdural effusion, gradual diminution of benefit, and painful stimulation. Although of concern, treatment-induced chronic seizure disorders have not occurred as a complication or in animal models of chronic cortical stimulation. Stimulation-induced pain relief occurs within minutes. There are no associated paresthesias or muscle contractions that confirm function. Pain relief may last for hours after electrical stimulation is discontinued. Motor cortex stimulation is an established therapy for the treatment of complex central and neuropathic pain syndromes that have proved refractory to medical treatment.

Full access

Topic Editor Jeffrey A. Brown

Full access

Jeffrey A. Brown, Christopher J. Chittum, David Sabol, and Jan J. Gouda

The technique of percutaneous balloon compression for treatment of trigeminal neuralgia is demonstrated by using embedded audiovisual kernels. A text-based description with linked images is also provided to accomodate varying computer hardware capabilities. A new needle system for guiding the balloon catheter to the entrance of Meckel's cave and a balloon pressure monitoring system for the procedure is described and demonstrated. Results from a series of 141 consecutive patients treated during the period between 1983 and 1995 indicate an initial success rate of 92%. Fifty-seven percent of patients have postoperative numbness, which is described as mild to moderate by 94% of them. Sixteen percent have ipsilateral masseter-pterygoid weakness after compression. The overall recurrence rate is 26%. A Kaplan-Meier survival curve indicates that 60% of patients are pain free 8 years after surgery without recurrence requiring reoperation. The recurrence rate does not significantly differ from patients with first division pain to patients without first division involvement. An absent corneal reflex has not occurred, nor has anesthesia dolorosa. Balloon compression injures the myelinated fibers that mediate the “trigger” to the lancinating pain of trigeminal neuralgia. Because the corneal reflex is mediated by unmyelinated fibers, selective, monitored compression of myelinated fibers should preserve the corneal reflex when first division pain is present.