Percutaneous Retrogasserian Glycerol Rhizotomy Research Articles

The Focus and New Progress of Percutaneous Balloon Compression for the Treatment of Trigeminal Neuralgia.

Trigeminal neuralgia is a condition confined to the trigeminal nerve, causing one or more branches of facial nerve pain. Surgical treatment options for trigeminal neuralgia include microvascular decompression(MVD), percutaneous balloon compression (PBC), radiofrequency thermocoagulation(RF), percutaneous retrogasserian glycerol rhizotomy(PRGR), gamma knife, etc. Of these treatments, PBC is increasingly being used by clinicians for trigeminal neuralgia. PBC is a simple surgical operation performed to treat trigeminal neuralgia. Owing to its advantages, PBC is favored by many clinicians. In this study, we aimed to emphasize the need to analyze the shape of the balloon, position, compression time, and pressure, as these factors can affect the efficacy of PBC. The relief of pain by balloon compression is related to the shape of the balloon on X-ray, which is the key to the operation. Owing to continued progress and advances in current imaging technologies, clinicians revealed that the precise positioning of the foramen ovale is no longer an intraoperative problem. Instead, the anatomy of Meckel’s cave and the shape of the balloon must be the focus to achieve the best treatment effect. For clinicians, PBC is simple and is associated with a short operation time. PBC also has other advantages, such as low cost and immediate postoperative pain relief. The recurrence rate of pain post-PBC is low, despite the occurrence of facial numbness post-op. However, this side effect is reversible and does not affect daily life of the patient. In fact, the patient can be discharged 1–2 days after surgery. Overall, PBC can be considered as one of the preferred surgical methods for the treatment of primary trigeminal neuralgia. In this paper, we explain the main points of PBC operation in detail in terms of Meckel’s cave, surgical procedure, complications, discussion of the focus and new progress, etc.

Percutaneous glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis: a long-term retrospective cohort study.

The prevalence of trigeminal neuralgia (TN) in patients with multiple sclerosis (MS-TN) is higher than in the general population (idiopathic TN [ITN]). Glycerol rhizotomy (GR) is a percutaneous lesioning surgery commonly performed for the treatment of medically refractory TN. While treatment for acute pain relief is excellent, long-term pain relief is poorer. The object of this study was to assess the efficacy of percutaneous retrogasserian GR for the treatment of MS-TN versus ITN. A retrospective chart review was performed, identifying 219 patients who had undergone 401 GR procedures from 1983 to 2018 at a single academic institution. All patients were diagnosed with medically refractory MS-TN (182 procedures) or ITN (219 procedures). The primary outcome measures of interest were immediate pain relief and time to pain recurrence following initial and repeat GR procedures. Secondary outcomes included medication usage and presence of periprocedural hypesthesia. The initial pain-free response rate was similar between groups (p = 0.726): MS-TN initial GR 89.6%; MS-TN repeat GR 91.9%; ITN initial GR 89.6%; ITN repeat GR 87.0%. The median time to recurrence after initial GR was similar between MS-TN (2.7 ± 1.3 years) and ITN (2.1 ± 0.6 years) patients (p = 0.87). However, there was a statistically significant difference in the time to recurrence after repeat GR between MS-TN (2.3 ± 0.5 years) and ITN patients (1.2 ± 0.2 years; p < 0.05). The presence of periprocedural hypesthesia was highly predictive of pain-free survival (p < 0.01). Patients with MS-TN achieve meaningful pain relief following GR, with an efficacy comparable to that following GR in patients with ITN. Initial and subsequent GR procedures are equally efficacious.

Efficacy of glycerol rhizotomy in trigeminal neuralgia: case-series

Treatment of trigeminal neurolagia by percutaneous retrogasserian glycerol rhizotomy was assessed in a series of 45 patients during the period from May 2008 through June 2012 with a follow up period ranging from 2 to 24 months postoperatively. All patients enrolled in the present study were considered medical failures before the procedure. Achievement of substantial pain relief was reported in 42 patients (93.3 %) and no further medical treatment was needed. Outcome also included reduction in facial sensation in 30 patients (66.7 %) and recurrence in 4 patients (8.9 %). Failure of treatment was seen in 3 patients (6.7 %).&#x0D; Conclusion: percutaneous retrogasserian glycerol rhizotomy offers safe and reliable relief of pain in patients with trigeminal neuralgia; low recurrence rate and long lasting reduction in facial sensations are the major disadvantages; nonetheless, it is by far, in our opinion, the method of choice in elderly particularly high risk patients.

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: an alternative technique

Background: One of the challenges faced by the modern-day NHS is workplace shortages, and experienced radiographers for intra-operative neurosurgical imaging is one such scenario. We describe our method for Percutaneous Retrogasserian Glycerol Rhizotomy (PRGR) using frameless neuronavigation which can be used effectively in such scenarios.Method: Stealth neuronavigation is used for needle placement within the foramen ovale and injection of glycerol, under sedation.Results: In our experience of ten procedures, it is accurate, safe and effective. Good results were obtained on all occasions. It can be repeated as often as necessary using the same Stealth® CT scan and reduces exposure for staff and patients, where repeated injections are required.Conclusion: This simple modification of PRGR technique is effective and safe provided the surgeon has previous experience in undertaking this procedure.

Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia.

BACKGROUND:Despite >30 years of clinical use, the literature is still sparse when it comes to comparisons between percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizolysis (PRGR) as treatments for trigeminal neuralgia.OBJECTIVE:To perform a retrospective cohort comparison between PBC and PRGR with regard to therapeutic effect, side effects, and complications.METHODS:Medical records and follow-up data from 124 primary PRGRs performed from 1986 to 2000 and 82 primary PBCs performed from 2000 to 2013 were reviewed. All patients had undergone clinical sensory testing and assessment of sensory thresholds. Analyses were performed to compare duration of pain relief, frequency of sensory disturbances, and side effects.RESULTS:Median duration of pain relief was 21 months after PRGR and 20 months after PBC. Both methods carried a high risk of hypesthesia/hypalgesia (P < .001) that was partly reversed with time. Decreased corneal sensibility was common after PRGR (P < .001) but not after PBC. Dysesthesia was more common after PRGR (23%) compared after PBC (4%; P < .001). Other side effects were noted but uncommon.CONCLUSION:PBC and PRGR are both effective as primary surgical treatment of trigeminal neuralgia. Both carry a risk of postoperative hypesthesia, but in this series, the side effect profile favored PBC. Furthermore, PBC is technically less challenging, whereas PRGR requires fewer resources. Between these 2 techniques, we propose PBC as the primary surgical technique for percutaneous treatment of trigeminal neuralgia on the basis of its lower incidence of dysesthesia, corneal hypesthesia, and technical failures.ABBREVIATIONS:MS, multiple sclerosisPBC, percutaneous balloon compressionPRGR, percutaneous retrogasserian glycerol rhizotomyTN, trigeminal neuralgia

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: A simple, safe, cost-effective procedure.

Trigeminal neuralgia (TN) is a condition that has been studied over decades and whose pathogenesis has still not been well defined. Various open and minimally invasive procedures are in vogue for the treatment of intractable TN. All these procedures have their complications and recurrence rates. Percutaneous retrogasserian glycerol rhizotomy (PRGR) is one of the minimally invasive procedures that have been popular for quite a long time. This paper is a prospective study analyzing the results of 93 patients with refractory TN who were treated with PRGR. There was an immediate pain relief in 96.8% of patients and long-term pain relief in 89.4% of patients, with a mean follow-up duration of 18.8 months. Recurrence of pain was seen in 10.4% of patients. The PRGR is a simple, safe, cost-effective procedure without any need for expensive equipment and with a good outcome that is compared to the other relatively more expensive open and minimally invasive procedures.

The role of percutaneous balloon compression in the treatment of trigeminal neuralgia recurring after other surgical procedures

Trigeminal neuralgia (TN) recurring after surgery can be difficult to treat. Treatment algorithms have not been standardized or universally accepted. Here we investigated the effectiveness of percutaneous balloon compression (PBC) in the treatment of patients with TN recurrence after other surgical techniques and analyzed the role of some clinical and operative factors in determining the prognosis. The records of 22 patients (13 M and 9 F) suffering recurrent TN after one (2 gamma knife surgery, 5 percutaneous radiofrequency rhizotomy, 6 percutaneous retrogasserian glycerol rhizotomy, 3 microvascular decompression) or more (6 patients) procedures and submitted to PBC at our institution from January 2003 to February 2012 were reviewed. Seven patients had TN related to multiple sclerosis (MS). Mean follow-up was 51.81 ± 26.63 months. 81.81 % of patients reported an acute pain relief. No major complication was observed after PBC. Eight patients (36.36 %) experienced pain recurrence and underwent one (five patients) or more (three patients) PBC. At the last follow-up, we obtained an excellent outcome (BNI I-II) in 16 patients out of 22 (72.72 %) and a good outcome (BNI III) in the remaining six. No patients had an uncontrolled pain. The lack of history of MS (p = 0.0174), the pear-like shape of the balloon at the operation (p = 0.0234) and a compression time <5 min (p < 0.05) were associated to higher pain-free survival. Considering these results PBC could be considered a useful technique for patients whose pain recurs after other procedures.

Surgical Outcomes of Trigeminal Neuralgia in Patients With Multiple Sclerosis

Trigeminal neuralgia (TN) is relatively frequent in multiple sclerosis (MS) patients and can be extremely disabling. Surgical interventions are less effective for the treatment of MS-related TN compared with classic TN, and higher recurrence rates are observed. To evaluate initial pain-free response (IPFR), duration of pain-free intervals (PFIs), and factors predictive of outcome in different surgical modalities used to treat MS-related TN. A total of 96 MS patients underwent 277 procedures (range, 1-11 procedures per patient) to treat TN at our institution from 1995 to 2011. Of these, 89 percutaneous retrogasserian glycerol rhizotomies, 82 balloon compressions, 52 stereotactic radiosurgeries, 28 peripheral neurectomies, 15 percutaneous radiofrequency rhizotomies, and 10 microvascular decompressions were performed as upfront or repeat treatments. Bilateral pain was observed in 10% of patients during the course of disease. During the follow-up period (median, 5.7 years), recurrence of symptoms was seen in 66% of patients, and 181 procedures were performed for symptom recurrence. As an initial procedure, balloon compression had the highest IPFR (95%; P = .006) and median PFI (28 months; P = .05), followed by percutaneous retrogasserian glycerol rhizotomy (IPFR, 74%, P = .04; median PFI, 9 months; P = .05). In general, repeat procedures had lower effectiveness compared with initial procedures, with no statistically significant difference seen across the various treatment modalities. Treatment failure occurs in most of the MS-related TN patients independently of the type of treatment. However, balloon compression had the highest rate of IPFR and PFI compared with other modalities in the initial treatment of MS-related TN.

Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis

Among patients with multiple sclerosis (MS) there is a high incidence of trigeminal neuralgia (TN), and outcomes after treatment seem inferior to those in patients suffering from idiopathic TN. The goal of this study was to evaluate clinical outcomes in patients with MS-related TN after Gamma Knife surgery (GKS) and compare them with those obtained using percutaneous retrogasserian glycerol rhizotomy (PRGR). The authors retrospectively reviewed the charts of 45 patients with MS-related TN. The first procedure undertaken was GKS in 27 patients and PRGR in 18 patients. Pain had been present for a median of 60 months (range 12-276 months) in patients who underwent GKS and 48 months (range 12-240 months) in patients who underwent PRGR. The following outcome measures were assessed in both groups of patients: pain relief (using the Barrow Neurological Institute [BNI] Pain Scale), procedure-related morbidity, time to pain relief and recurrence, and subsequent procedures that were performed. The median duration of follow-up was 39 months (range 13-69 months) in the GKS group and 38 months (range 2-75 months) in the PRGR group. Reasonable pain control (BNI Pain Scale Scores I-IIIb) was noted in 22 patients (81.5%) who underwent GKS and in 18 patients (100%) who underwent PRGR. For patients who underwent GKS, the median time to pain relief was 6 months; for those who underwent PRGR, pain relief was immediate. In the GKS group 12 patients required subsequent procedures (3 patients for absence of response and 9 patients for pain recurrence), whereas in the PRGR group 6 patients required subsequent procedures (all for pain recurrence). As of the last follow-up, complete or reasonable pain control was finally achieved in 23 patients (85.2%) in the GKS group and in 16 patients (88.9%) in the PRGR group. The morbidity rate was 22.2% in the GKS group (all due to sensory loss and paresthesia) and 66.7% in the PRGR group (mostly hypalgesia, with 2 patients having corneal reflex loss and 1 patient suffering from meningitis). Both GKS and PRGR are satisfactory strategies for treating MS-related TN. Gamma Knife surgery has a lower rate of sensory and overall morbidity than PRGR, but requires a delay before pain relief occurs. The authors propose that patients with extreme pain in need of fast relief should undergo PRGR. For other patients, both management strategies can lead to satisfactory pain relief, and the choice should be made based on patient preference and expectations.

Comparison of percutaneous balloon compression and glycerol rhizotomy for the treatment of trigeminal neuralgia

The aim of this study was to compare percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizotomy (PRGR) in terms of effectiveness, complications, and technical aspects. Sixty-six consecutive PBC procedures were performed in 45 patients between January 2004 and December 2008, and 120 PRGR attempts were performed in 101 patients between January 2006 and December 2008. The PRGR procedures were not completed due to technical reasons in 19 cases. Five patients in the Balloon Compression Group and 9 patients in the Glycerol Group were lost to follow-up and were excluded from the study. The medical records and the intraoperative fluoroscopic images from the remaining cases were retrospectively examined, and the follow-up was completed with telephone contact, when necessary. The 2 groups were compared in terms of initial effect, duration of effect, and rates of complications as well as severity and type of complications. The rates for immediate pain relief were 87% for patients treated with glycerol injection and 85% for patients treated with balloon compression. The Kaplan-Meier plots for the 2 treatment modalities were similar. The 50% recurrence time was 21 months for the balloon procedure and 16 months for the glycerol procedure. When the groups were broken down by the "previous operations" criterion, the 50% recurrence time was 24 months for the Glycerol First Procedure Group, 6 months for the Balloon First Procedure Group, 8 months for the Glycerol Previous Procedures Group, and 21 months for the Balloon Previous Procedures Group. The rates of complications (excluding numbness) were 11% for PRGR and 23% for PBC, and this difference was statistically significant (chi-square test, p = 0.04). Both PRGR and PBC are effective techniques for the treatment of trigeminal neuralgia, with PRGR presenting some advantages in terms of milder and fewer complications and allowing lighter anesthesia without compromise of analgesia. For these reasons the authors consider PRGR as the first option for the treatment of trigeminal neuralgia in patients who are not suitable candidates or are not willing to undergo microvascular decompression, while PBC is reserved for patients in whom the effect of PRGR has proven to be short or difficult to repeat due to cisternal fibrosis.

Long-term outcomes of percutaneous retrogasserian glycerol rhizotomy in 3370 patients with trigeminal neuralgia

To assess the long-term outcomes of percutaneous retrogasserian glycerol rhizotomy (PRGR) in patients with medically unresponsive idiopathic trigeminal neuralgia. A total of 3370 patients undergoing PRGR between 1983 and 2003 in our hospital were followed up for 13.1 years (range 3-23 years), and the outcomes were investigated. Of the 3370 patients, 99.58% had complete initial pain relief. A total of 2750 patients were followed up when 112 died of unrelated causes and 508 were lost to follow up. Of the 2750 patients, 962 (35%) had pain recurrence at various intervals: 0.3% in 1 year; 21% in 1 to 5 years; 7% in 5 to 10 years; 4% in 10 to 15 years and 3% in 15 to 23 years. The major complication was facial numbness, among which hypesthesia outweighed hypalgesia. Most patients recovered within half a year, although 109 patients (3.96%) developed permanent mild hypesthesia. There was no anesthesia dolorosa or surgery related mortality in this series. PRGR is a minimally invasive and simple procedure yielding a favorable outcome for trigeminal neuralgia. The major complications of this procedure are reversible within various time intervals. It may serve as a first-line surgical modality for patients unresponsive to pharmacotherapy.

Does Egress of Cerebrospinal Fluid During Percutaneous Retrogasserian Glycerol Rhizotomy Influence Long Term Pain Relief?

To examine the effect of cerebrospinal fluid (CSF) flow during percutaneous retrogasserian glycerol rhizotomy (PRGR) on long term pain relief in patients with trigeminal neuralgia. Eighty-nine patients with trigeminal neuralgia underwent 102 PRGR procedures. PRGR was conducted under fluoroscopy. After the egress of CSF, anhydrous glycerol (0.3-0.4 cc) was injected in the sitting position. In the absence of CSF flow, 0.25 mL 2% lidocaine was injected to elicit hypesthesia in the affected side. Once hypesthesia was elicited glycerol was injected. Patients were grouped as A (CSF flow present) or B (CSF flow absent), according to the egress of CSF at the time of needle placement. Patients were followed up for the recurrence of pain (average duration of follow up, 62 months). CSF flow was present in 54 patients (60.6%) and absent in 35 patients (39.4%). Thirty patients (56.6%) of group A had excellent pain relief, 18 patients (33.3%) had good pain relief, and 6 patients (11.1%) had no pain relief. However, in the absence of CSF flow, 14 patients (40%) each had excellent and good pain relief, and 7 patients (20%) were treatment failures. The pain relief was comparable between the groups. The median time to recurrence of pain needing further injection was 66 months in group A and 63 months in group B (not significant). Presence of CSF flow during needle placement does not influence the success rate and duration of pain relief following PRGR.

Trigeminal Neuralgia

Trigeminal neuralgia (TN) is the most common facial neuralgia, and is considered to be one of the most painful conditions to affect patients. The rate of occurrence of TN in men and women is 2.5 and 5.7 per 100,000 per year respectively. TN is generally characterized by lancinating, unilateral, paroxysmal pain occurring in the distribution of the fifth cranial nerve. The diagnosis of TN is made clinically by excluding other possible causes of facial pain and is based on signs and symptoms from the patient history such as a trigger zone, typical unilateral lancinating paroxysms following neural disturbance, and a refractory period. Generally, TN can be diagnosed by the typical patient history, a negative neurologic exam, and response to a trial of carbamazepine. Imaging studies should be considered if the diagnosis is uncertain or neurologic abnormalities are noted. Most cases are caused by compression of the trigeminal nerve root, usually within a few millimeters of entry into the pons. In a few cases, TN is caused by a primary demyelinating disorder. The treatment modalities for the management of TN may be divided into medical, surgical, and gamma-knife radiosurgery. Generally, response to drug therapy is good, with over 80% of patients responding to some of the anticonvulsants. Percutaneous approaches to trigeminal gangliolysis are considered to have less associated risk and less cost than open surgical procedures. Three different techniques may be used to perform percutaneous destruction of the ganglion: percutaneous radiofrequency trigeminal gangliolysis (PRTG), percutaneous balloon microcompression (PBM), and percutaneous retrogasserian glycerol rhizotomy (PRGR). Open surgical procedures used in the treatment of TN include microvascular decompression of the trigeminal root and retrogasserian rhizotomy. Additionally, because both of these procedures have greater associated risks, morbidity, and mortality, they are customarily applied only to younger patients in good health. Stereotactic radiosurgery has been established as an alternative treatment for patients who do not respond to optimal medical management.

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: technique and expectations

In the management of trigeminal neuralgia (TN), physicians seek rapid and long-lasting pain relief, together with preservation of trigeminal nerve function. Percutaneous retrogasserian glycerol rhizotomy (PRGR) offers distinct advantages over other available procedures. The aim of this report was to provide details of the PRGR procedure and its expected outcome. The authors reviewed their experience with PRGR in 1174 patients to evaluate the procedural technique, results, and complications. Although it is clear that TN is not a static disorder but one characterized by remissions and recurrences, long-lasting pain relief was noted in 77% of patients, with 55% discontinuing all medications and 22% requiring some drug usage. The authors discuss the role of PRGR in their practice, along with other procedures such as microvascular decompression and gamma knife surgery, for idiopathic or multiple sclerosis-related TN. They conclude that PRGR had distinct advantages over other procedures, which include eliminating the need for intraoperative confirmatory sensory testing, and a lower risk of facial sensory loss.

Glycerol rhizotomy versus gamma knife radiosurgery for the treatment of trigeminal neuralgia: An analysis of patients treated at one institution

Medically refractory trigeminal neuralgia (TN) has been treated with a variety of minimally invasive techniques, all of which have been compared with microvascular decompression. For patients not considered good surgical candidates, percutaneous retrogasserian glycerol rhizotomy (GR) and gamma knife (GK) radiosurgery are two minimally invasive techniques in common practice worldwide and used routinely at Jefferson Hospital for Neuroscience. Using a common pain scale outcomes questionnaire, we sought to analyze efficacies and morbidities of both treatments. Between June 1994 and December 2002, 79 patients were treated with GR and 109 patients underwent GK for the treatment of TN. GR was performed with fluoroscopic guidance as an overnight inpatient procedure. GK was performed using a single 4-mm shot positioned at the root exit zone of the trigeminal nerve. Radiation doses of 70-90 Gy prescribed to the 100% isodose line were used. Treatment outcomes including pain response, pain recurrence, treatment failure, treatment-related side effects, and overall patient satisfaction with GK and GR were compared using a common outcomes scale. Using the Barrow Neurologic Institute pain scale, patients were asked to define their level of pain both before and after treatment: I, no pain and no pain medication required; I, occasional pain not requiring medication; IIIa, no pain and pain medication used; IIIb, some pain adequately controlled with medication; IV, some pain not adequately controlled with medication; and V, severe pain with no relief with medication. We used posttreatment scores of I, II, IIIa, and IIIb to identify treatment success, whereas scores of IV and V were considered treatment failure. Results were compiled from respondents and analyzed using SAS software. Statistical comparisons used log-rank test, univariate and multivariate logistic regression, Fisher's exact test, and Wilcoxon test with significance established at p < 0.05. There were 63 evaluable GK patients and 36 evaluable GR patients. The median follow-up time was 34 and 29 months for the GR and GK groups, respectively. The median age was 69 and 70 years and the median number of years with TN pain was 6 and 7 years in the GR and GK groups, respectively. Thirty-one GR (86%) and 58 GK (92%) patients achieved a successful treatment outcome (p = 0.49). The median time to pain relief was < or = 24 h in the GR group and 3 weeks in the GK group (p < 0.001, ordinal logistic regression). Nineteen GR and 26 GK patients experienced pain recurrence or pain never relieved (p = 0.30). The median time to pain recurrence was 5 and 8 months in the GR and GK groups, respectively (p = 0.22). At last follow-up, however, a statistically significant greater number of GR vs. GK patients had failed treatment. Twelve or 33% of GR patients, whereas 8 or 13% of GK patients, had BNI scores of 4 or 5 (p = 0.019, Fisher's exact test). When both initial and late treatment failures were combined, the overall rate of treatment failures was 39% in the GR group and 24% in the GK group (p = 0.023, log-rank). More GR patients developed facial numbness and facial numbness morbidity than GK patients: 19 GR (54%) and 17 GK patients (30%) developed new facial numbness and 12 GR and 7 GK patients reported either somewhat or very bothersome facial numbness (p = 0.018). On multivariate analysis, only treatment with GK and severity of pain before treatment significantly predicted treatment response. GK patients were more likely to have a lower pain score at last follow-up than were GR patients (p = 0.005, OR = 4.3), and patients with pretreatment pain scores of 5 were more likely to have lower posttreatment pain scores than patients with pretreatment pain scores of 4 and lower (p = 0.003, OR = 4.0). Despite greater facial numbness morbidity and a higher failure rate, GR provided more immediate pain relief than GK. GR therefore should be considered in patients with disabling trigeminal pain requiring urgent pain relief. For all other patients, GK provides better long-term pain relief with less treatment-related morbidity, and should therefore be considered the preferred treatment for patients with medically refractory trigeminal neuralgia who are not suitable candidates for microvascular nerve decompression.

In-training Liaison

Patients with multiple sclerosis (MS) have a relatively high incidence of tic douloureux (TD) and often do not tolerate medical therapy well. The minimally invasive nature of percutaneous retrogasserian glycerol rhizotomy (PRGR) renders it ideal for first-line surgical treatment of TD. We sought to ascertain the benefits of PRGR in patients with MS and to determine whether hypalgesia after PRGR correlates with efficacy. We assessed 97 glycerol procedures performed in 53 patients followed prospectively for treatment of TD associated with MS. Factors assessed included degree of pain relief, postoperative hypalgesia, procedural morbidity, medication use, time to pain recurrence, and number and type of subsequent procedures. Complete pain relief was obtained in 78% of patients after the initial glycerol injection, and partial relief was obtained in 13% of patients. Long-term follow-up (mean, 81 mo) demonstrated a recurrence rate of 59%, with a mean time to recurrence of 17 months. Actuarial recurrence rates were 50% at 12 months and 60% at 24 months. Twenty-four patients underwent a second or subsequent PRGR for recurrent pain and achieved similar rates of pain relief and time to recurrence. Facial sensory loss was associated with a higher likelihood of pain relief (P < 0.05), with longer time to pain recurrence (P < 0.05), and with decreased use of medication after surgery (P < 0.01.) PRGR is an effective, low-morbidity surgical procedure in the management of TD complicating MS. The presence of facial sensory loss after PRGR is associated with prolonged efficacy.

Percutaneous retrogasserian glycerol rhizotomy for patients with idiopathic trigeminal neuralgia: a prospective analysis of factors related to pain relief

The goal of this study was to analyze prospectively factors associated with facial pain outcomes after percutaneous retrogasserian glycerol rhizotomy (PRGR) for patients with medically unresponsive idiopathic trigeminal neuralgia. Between July 1999 and December 2003, 98 patients underwent PRGR in the manner described by Håkanson. The mean patient age was 72.1 years and the average pain duration prior to PRGR was 8.6 years. Fifty patients (51%) had previously undergone surgery. In six patients (6%), the trigeminal cistern could not be defined and the procedure was aborted; six patients were lost to follow-up review. An excellent facial pain outcome was defined as the absence of facial pain without medications. Thirty-two (35%) of 92 patients either received no benefit (17 patients) or experienced recurrent pain (15 patients) and required additional surgery at a mean of 7.5 months after PRGR; the mean duration of follow-up review in the other 60 patients was 28.7 months (range 3-52 months). Including patients who did not receive a glycerol injection, the 1- and 3-year chances of an excellent facial pain outcome were 61 and 50%, respectively. A multivariate analysis of clinical and surgical factors showed that the facial pain exhibited on glycerol injection correlated with excellent facial pain outcomes (relative risk [RR] = 1.02; 95% confidence interval [CI] 0.26-1.77; p < 0.01), whereas patients who experienced any constant pain less frequently had excellent outcomes (RR = 1.13; 95% CI 0.06-2.20; p = 0.04). Forty-six patients (53%) experienced either mild numbness/parathesias (39 patients) or dysesthesias (seven patients). New trigeminal deficits after PRGR were associated with excellent facial pain outcomes (RR = 1.25; 95% CI 0.56-1.93; p < 0.001). Percutaneous retrogasserian glycerol rhizotomy remains a good operation for patients with medically unresponsive trigeminal neuralgia who are considered poor candidates for posterior fossa exploration. Predictive factors for success include patients without any constant facial pain, patients with immediate facial pain during glycerol injection, and patients with new trigeminal deficits after PRGR.

Effect of cerebrospinal fluid return on success rate of percutaneous retrogasserian glycerol rhizotomy

Trigeminal neuralgia is a painful syndrome, which has been commonly treated with percutaneous retrogasserian glycerol rhizotomy (PRGR). This study was performed to evaluate the effect of cerebrospinal fluid (CSF) return on the success rate of PRGR. In this retrospective, nonrandomized, observational case series, 100 cases underwent 140 PRGRs under fluoroscopic guidance and were followed up for 6 to 36 months. The results were compared in the presence or absence of CSF return before PRGR. The PRGR was successful in 115 procedures (82.1%). CSF return was present in 84 procedures (60%) and, among these, 76 PRGRs (90.5%) produced pain relief. More than 1 year of pain relief without medications was present in 60 of 84 procedures (71.4%). CSF return before PRGR was absent in 56 procedures (40%) and success resulted in 39 procedures (69.6%). Pain relief for more than 1 year without medications was present in 19 procedures (33.9%). The success rate and duration of pain relief was greater in the presence of CSF return compared with absence of CSF return (P < .005). The incidence of complications such as facial dysesthesia (40%), corneal anesthesia (2.8%), herpes simplex (3.5%), and nonbacterial meningitis (0.7%) was not significantly different in 2 groups ( P > .05). The presence of CSF is an important factor in determining the success rate and duration of pain relief of PRGR.

754 Percutaneous Retrogasserian Glycerol Rhizotomy for Patients with Idiopathic Trigeminal Neuralgia: A Prospective Analysis of Factors Related to Pain Relief

754 Percutaneous Retrogasserian Glycerol Rhizotomy for Patients with Idiopathic Trigeminal Neuralgia: A Prospective Analysis of Factors Related to Pain Relief

754 Percutaneous Retrogasserian Glycerol Rhizotomy for Patients with Idiopathic Trigeminal Neuralgia: A Prospective Analysis of Factors Related to Pain Relief

754 Percutaneous Retrogasserian Glycerol Rhizotomy for Patients with Idiopathic Trigeminal Neuralgia: A Prospective Analysis of Factors Related to Pain Relief