Retrosigmoid approach for glycerin rhizotomy in the treatment of trigeminal neuralgia without overt arterial compression: updated case series

Restricted access

OBJECTIVE

Trigeminal neuralgia (TN) is a neuropathic pain disorder characterized by severe, lancinating facial pain that is commonly treated with neuropathic medication, percutaneous rhizotomy, and/or microvascular decompression (MVD). Patients who are not found to have distinct arterial compression during MVD present a management challenge. In 2013, the authors reported on a small case series of such patients in whom glycerin was injected intraoperatively into the cisternal segment of the trigeminal nerve. The objective of the authors’ present study was to report their updated experience with this technique to further validate this novel approach.

METHODS

The authors performed a retrospective analysis of data obtained in patients in whom glycerin was directly injected into the inferior third of the cisternal portion of the trigeminal nerve. Seventy-four patients, including 14 patients from the authors’ prior study, were identified, and demographic information, intraoperative findings, postoperative course, and complications were recorded. Fisher’s exact test, unpaired t-tests, and Kaplan-Meier survival curves using Mantel log-rank test were used to compare the 74 patients with a cohort of 476 patients who received standard MVD by the same surgeon.

RESULTS

The 74 patients who underwent MVD and glycerin injection had an average follow-up of 19.1 ± 18.0 months, and the male/female ratio was 1:2.9. In 33 patients (44.6%), a previous intervention for TN had failed. On average, patients had an improvement in the Barrow Neurological Institute Pain Intensity score from 4.1 ± 0.4 before surgery to 2.1 ± 1.2 after surgery. Pain improvement after the surgery was documented in 95.9% of patients. Thirteen patients (17.6%) developed burning pain following surgery. Five patients developed complications (6.7%), including incisional infection, facial palsy, CSF leak, and hearing deficit, all of which were minor.

CONCLUSIONS

Intraoperative injection of glycerin into the trigeminal nerve is a generally safe and potentially effective treatment for TN when no distinct site of arterial compression is identified during surgery or when decompression of the nerve is deemed to be inadequate.

ABBREVIATIONS BNI = Barrow Neurological Institute; MS = multiple sclerosis; MVD = microvascular decompression; TN = trigeminal neuralgia.

Article Information

Correspondence Michael Lim: Johns Hopkins Hospital, Baltimore, MD. mlim3@jhmi.edu.

INCLUDE WHEN CITING Published online March 8, 2019; DOI: 10.3171/2018.12.JNS182572.

Disclosures Dr. Bettegowda reports being a consultant for DePuy Synthes. Dr. Lim reports being a consultant for Aegenus, BMS, Regeneron, Oncorus, Boston Biomedical, Tocagen, SQZ Technologies, Stryker, and Baxter, and he has received research support from Arbor, Aegenus, Altor, BMS, Immunocellular, Celldex, Accuray, and DNAtrix.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Kaplan-Meier pain recurrence rate after treatment of patients who underwent MVD only and MVD+glycerin injection. No statistical significance was found (p = 0.08). Figure is available in color online only.

References

  • 1

    Adams CBKaye AHTeddy PJ: The treatment of trigeminal neuralgia by posterior fossa microsurgery. J Neurol Neurosurg Psychiatry 45:102010261982

  • 2

    Ashkan KMarsh H: Microvascular decompression for trigeminal neuralgia in the elderly: a review of the safety and efficacy. Neurosurgery 55:8408502004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Baechli HGratzl O: Microvascular decompression in trigeminal neuralgia with no vascular compression. Eur Surg Res 39:51572007

  • 4

    Bennett MHLunsford LD: Percutaneous retrogasserian glycerol rhizotomy for tic douloureux: Part 2. Results and implications of trigeminal evoked potential studies. Neurosurgery 14:4314351984

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Broggi GFerroli PFranzini APluderi MLa Mantia LMilanese C: Role of microvascular decompression in trigeminal neuralgia and multiple sclerosis. Lancet 354:187818791999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Broggi GFranzini ALasio GGiorgi CServello D: Long-term results of percutaneous retrogasserian thermorhizotomy for “essential” trigeminal neuralgia: considerations in 1000 consecutive patients. Neurosurgery 26:7837871990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Cheng JSLim DAChang EFBarbaro NM: A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery 10 (Suppl 1):25332014

  • 8

    Cheshire WP: Trigeminal neuralgia: diagnosis and treatment. Curr Neurol Neurosci Rep 5:79852005

  • 9

    Devor MAmir RRappaport ZH: Pathophysiology of trigeminal neuralgia: the ignition hypothesis. Clin J Pain 18:4132002

  • 10

    Fujimaki TFukushima TMiyazaki S: Percutaneous retrogasserian glycerol injection in the management of trigeminal neuralgia: long-term follow-up results. J Neurosurg 73:2122161990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Goodwin CRYang JXBettegowda CHwang BJames CBiser A: Glycerol rhizotomy via a retrosigmoid approach as an alternative treatment for trigeminal neuralgia. Clin Neurol Neurosurg 115:245424562013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Gronseth GCruccu GAlksne JArgoff CBrainin MBurchiel K: Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 71:118311902008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Håkanson S: Trigeminal neuralgia treated by the injection of glycerol into the trigeminal cistern. Neurosurgery 9:6386461981

  • 14

    Hall GCCarroll DParry DMcQuay HJ: Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain 122:1561622006

  • 15

    Ishikawa MNishi SAoki TTakase TWada EOhwaki H: Operative findings in cases of trigeminal neuralgia without vascular compression: proposal of a different mechanism. J Clin Neurosci 9:2002042002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kondziolka DLunsford LD: Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: technique and expectations. Neurosurg Focus 18(5):E72005

  • 17

    Love SCoakham HB: Trigeminal neuralgia: pathology and pathogenesis. Brain 124:234723602001

  • 18

    Ma ZLi M: “Nerve combing” for trigeminal neuralgia without vascular compression: report of 10 cases. Clin J Pain 25:44472009

  • 19

    Merskey HBogduk N: Classification of Chronic Pain. Descriptors of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle: IASP Press1994

    • Export Citation
  • 20

    North RBKidd DHPiantadosi SCarson BS: Percutaneous retrogasserian glycerol rhizotomy. Predictors of success and failure in treatment of trigeminal neuralgia. J Neurosurg 72:8518561990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Oesman CMooij JJA: Long-term follow-up of microvascular decompression for trigeminal neuralgia. Skull Base 21:3133222011

  • 22

    Pollock BE: Percutaneous retrogasserian glycerol rhizotomy for patients with idiopathic trigeminal neuralgia: a prospective analysis of factors related to pain relief. J Neurosurg 102:2232282005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Rath SAKlein HJRichter HP: Findings and long-term results of subsequent operations after failed microvascular decompression for trigeminal neuralgia. Neurosurgery 39:9339401996

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Revuelta-Gutiérrez RLópez-González MASoto-Hernández JL: Surgical treatment of trigeminal neuralgia without vascular compression: 20 years of experience. Surg Neurol 66:32362006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Revuelta-Gutierrez RMartinez-Anda JJColl JBCampos-Romo APerez-Peña N: Efficacy and safety of root compression of trigeminal nerve for trigeminal neuralgia without evidence of vascular compression. World Neurosurg 80:3853892013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Sindou MPChiha MMertens P: Anatomical findings observed during microsurgical approaches of the cerebellopontine angle for vascular decompression in trigeminal neuralgia (350 cases). Stereotact Funct Neurosurg 63:2032071994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Slettebø HHirschberg HLindegaard KF: Long-term results after percutaneous retrogasserian glycerol rhizotomy in patients with trigeminal neuralgia. Acta Neurochir (Wien) 122:2312351993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Tatli MSatici OKanpolat YSindou M: Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. Acta Neurochir (Wien) 150:2432552008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Tölle TDukes ESadosky A: Patient burden of trigeminal neuralgia: results from a cross-sectional survey of health state impairment and treatment patterns in six European countries. Pain Pract 6:1531602006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Tyler-Kabara ECKassam ABHorowitz MHUrgo LHadjipanayis CLevy EI: Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 96:5275312002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Wu MFu XJi YDing WDeng DWang Y: Microvascular decompression for classical trigeminal neuralgia caused by venous compression: novel anatomic classifications and surgical strategy. World Neurosurg 113:e707e7132018

    • Search Google Scholar
    • Export Citation
  • 32

    Zakrzewska JMLopez BCKim SECoakham HB: Patient reports of satisfaction after microvascular decompression and partial sensory rhizotomy for trigeminal neuralgia. Neurosurgery 56:130413122005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 556 556 36
Full Text Views 69 69 5
PDF Downloads 47 47 0
EPUB Downloads 0 0 0

PubMed

Google Scholar