Improving the Percutaneous Approach for the Management of Trigeminal Neuralgia

Abstract

Trigeminal neuralgia, a debilitating pain disorder affecting the trigeminal nerve distribution, is often treated through percutaneous procedures using the route of Härtel. Miscannulation and excessive attempts at traversing the foramen ovale can negatively affect surgical outcomes. Complications attributed to miscannulation include blindness, brainstem hematoma, temporal lobe hematoma, and carotid artery hemorrhage. Currently, there is disagreement regarding the best skin entry point for the percutaneous approach. However, identifying an optimum entry point for cannulation can decrease the number of attempts necessary for a successful cannulation and also decrease the amount of fluoroscopic radiation exposure for both the patient and the surgeon. Therefore, this cadaveric study assessed a total of 56 cadavers to identify the optimum skin entry point. Calvariae, brains, and trigeminal nerves were removed, and the foramina ovalae were exposed. A lumbar needle was inserted through each porous trigeminus and foramen ovale at varied angles. The cannulation procedure was “reversed” by inserting the needle from the interior of the cranium through the porous trigeminus, foramen ovale, and skin. The exit location of the needle relative to facial structures was assessed. The exit points from the facial skin, which would otherwise represent the optimal entry points for the percutaneous procedure, were recorded. The results of this study represent an improvement in the percutaneous approach for the management of trigeminal neuralgia.