Computed tomography-guided percutaneous trigeminal tractotomy-nucleotomy.

Abstract

The destruction of the descending trigeminal tractus in the medulla is known as trigeminal tractotomy (TR), whereas the lesioning of the nucleus caudalis is known as trigeminal nucleotomy (NC). Trigeminal TR and/or NC procedures can be used in a large group of pain syndromes, such as glossopharyngeal, vagal, and geniculate neuralgias, atypical facial pain, craniofacial cancer pain, postherpetic neuralgias, and atypical forms of trigeminal neuralgia. In this study, anatomic and technical details of the procedure and the experience gained from 65 patients over the course of 20 years are discussed. Patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively (postoperative Day 1). The best results were obtained in the second-largest group (vagoglossopharyngeal neuralgia, n = 17) and in geniculate neuralgia (n = 4). Patients with atypical facial pain (n = 21; 13 women, eight men) accounted for the largest group to undergo computed tomography-guided TR-NC surgery; pain relief was achieved in 19 of these patients. In the third-largest group (craniofacial and oral cancer pain, n = 13), 11 of 13 patients were successfully treated with TR-NC. Four of five patients with failed trigeminal neuralgia were also effectively treated with TR-NC. We propose that computed tomography-guided TR-NC provides direct visualization of the target-electrode relation and can be considered a first-step procedure in patient management. In view of its high efficacy, low complication rate, and minimal invasiveness, computed tomography-guided trigeminal TR-NC is a safe and effective procedure in the treatment of intractable facial pain syndromes.