Percutaneous Retrogasserian Glycerol Rhizotomy Research Articles

Therapie und Prophylaxe von Gesichtsneuralgien und anderen Formen der Gesichtsschmerzen

Trigeminal neuralgia and postherpetic neuralgia are the most relevant neuralgiform facial pain syndromes. Trigeminal neuralgia is characterized by lancinating intensive pain attacks of very short duration, triggered by external cues,whereas postherpetic neuralgia consists predominantly of long-lasting burning pain. Sodium channel blocking drugs are first choice in treatment of trigeminal neuralgia, operative procedures encompass microvascular decompression,thermocoagulation and percutaneous retrogasserian glycerol rhizotomy. In the acute stage postherpetic neuralgia is treated antivirally and analgesically, in the chronic stage by tricyclic antidepressive substances. Other pain syndromes described encompass the Tolosa-Hunt-syndrome, cervicogenic headache, craniomandibular dysfunction syndrome, atypical facial pain and rarer syndromes. Therapeutic recommendations are based on evidence based medicine criteria (EBM).

791 Percutaneous Retrogasserian Glycerol Rhizotomy in the Management of Trigeminal Neuralgia Associated with Multiple Sclerosis

791 Percutaneous Retrogasserian Glycerol Rhizotomy in the Management of Trigeminal Neuralgia Associated with Multiple Sclerosis

791 Percutaneous Retrogasserian Glycerol Rhizotomy in the Management of Trigeminal Neuralgia Associated with Multiple Sclerosis

791 Percutaneous Retrogasserian Glycerol Rhizotomy in the Management of Trigeminal Neuralgia Associated with Multiple Sclerosis

Percutaneous Retrogasserian Glycerol Rhizotomy: Current Technique and Results

Despite the establishment of the vasculoneural compression as a frequent cause of trigeminal neuralgia, minimally invasive surgical techniques to treat medically refractory trigeminal neuralgia are needed in order to minimize the risks associated with craniotomy. Percutaneous retro gasserian glycerol rhizotomy (PRGR) is one of the alternative surgical treatments to microvascular decompression. Technical simplicity, less chance of trigeminal sensory loss, no need of intraoperative sensory testing, and no attempted deliberate destruction of the trigeminal nerve are advantages over other percutaneous trigeminal operations.

Sensory perception in patients with trigeminal neuralgia: effects of percutaneous retrogasserian glycerol rhizotomy.

We assessed thresholds for sensation of temperature and pressure and temporal summation of pain in the trigger area on the painful side and the contralateral nonpainful side in patients with trigeminal neuralgia previously treated with percutaneous retrogasserian glycerol rhizotomy (PRGR). Temperature and tactile thresholds were significantly increased on the painful side in both pain-free patients and patients with paroxysmal pain, but sensory loss was not more severe in patients with paroxysmal pain, except for increased warm thresholds. Abnormal temporal summation of pain (including progressive increase of pain intensity with radiation of pain and aftersensation) was present in the trigger area of patients with paroxysmal pain, but not in pain-free patients. Thus, relief of trigeminal neuralgia after PRGR involves normalization of abnormal temporal summation of pain, whereas sensory loss is less affected.

Long-Term Results after Glycerol Rhizotomy for Multiple Sclerosis-Related Trigeminal Neuralgia

Percutaneous retrogasserian glycerol rhizotomy (PRGR) was used during an 11-year interval in 53 patients with typical trigeminal neuralgia associated with multiple sclerosis. All patients had failed extensive medical trials prior to PRGR. Long-term (median follow-up, 36 months) complete pain relief (no further medication) was achieved in 29 (59%) of 49 evaluable patients. Eight patients (16%) had satisfactory pain control but required occasional medication. Twelve patients (25%) had initial unsatisfactory results with inadequate pain relief; nine underwent alternative surgical procedures. Sixteen patients (30%) subsequently required repeat glycerol rhizotomies to reachieve pain control. Twenty-seven patients (60% of 45 patients evaluated for this finding) retained normal trigeminal sensation after injection. Major trigeminal sensory loss developed in a single patient who had four glycerol rhizotomies over a 25-month interval. No patient developed deafferentation pain. We believe that PRGR is a low-morbidity, effective, and repeatable surgical procedure for the management of trigeminal neuralgia in the setting of multiple sclerosis.

Long-term results after percutaneous retrogasserian glycerol rhizotomy in patients with trigeminal neuralgia.

We have evaluated the long-term results of percutaneous retrogasserian glycerol rhizotomy (PRGR) in 60 patients with classical trigeminal neuralgia. Complete initial pain relief was achieved in 93% of the patients. Numbness was initially reported by 3/4 of the patients and at follow-up by 1/3, while long-lasting dysaesthesias were an important side effect in 38% of previously untreated patients. The half-life of the method was 47 months in our material, and this figure compares favourably with other previously reported series. The method carries a significant risk of long-lasting and troublesome sensory disturbances. Another disadvantage of the method, reported in the present long-term study, was the high incidence of recurrent neuralgia. We are unable to identify predictors of recurrent neuralgia after PRGR, although major recurrences were more common in patients with unchanged facial sensation postoperatively. In conclusion, PRGR offers safe and reliable relief of pain in patients with trigeminal neuralgia. In spite of the high incidence of recurrence and of long-lasting dysaesthesias it is, in our opinion, the method of choice in the elderly, and particularly suitable for patients at high risk.

Percutaneous retrogasserian glycerol rhizotomy

Eighty-five medically intractable trigeminal neuralgia patients treated by percutaneous retrogasserian glycerol rhizotomy (PRGR) were followed for 6 to 54 months. The median time to recurrence of symptoms refractory to medical therapy and requiring further intervention was 3 years (by Kaplan-Meier survival analysis). The median time to recurrence of symptoms requiring some form of medical treatment was 2 years. Following repeat PRGR for recurrent symptoms, the median time to recurrence was 1 year. Univariate log rank statistics and multivariate Cox proportional hazards modeling revealed significant associations between favorable outcome and female sex, absence of atypical features or associated cluster headache symptoms, success of prior carbamazepine therapy, duration of symptoms, and cerebrospinal fluid return during the procedure. A scoring system using prognostic factors has been developed based upon these findings. Assessment of published studies of PRGR and of other treatments for trigeminal neuralgia is made difficult by the variety of outcome measures employed and variable follow-up intervals. The present study attempts to address these issues by definition of endpoints, statistical analysis of the data, and identification of important prognostic factors in a manner useful to the clinician.

Current concepts concerning the etiology and treatment of trigeminal neuralgia.

Trigeminal neuralgia (tic douloureux) was first identified over three hundred years ago. Only recently have the causes of the disorder begun to be recognized and understood. The first attempts at treatment involved the neurotomy of peripheral branches of the trigeminal nerve. This procedure, along with neurectomy, ganglionectomy, rhizotomy, tractotomy, and injections of toxic substances into the ganglion and nerve branches were the main treatment modalities in years past. Although they exhibited marked success, they are fraught with complications, such as relapse, loss of facial sensation and motor control, infection, deafferentation pain, and a fairly high rate of mortality from the procedure. The current treatment modalities that result in a predictable success with minimal risk are microvascular decompression, percutaneous retrogasserian thermal rhizotomy, and percutaneous retrogasserian glycerol rhizotomy. Other procedures, such as balloon compression of the gasserian ganglion, cryotherapy, acupuncture, and drug therapy, are also being used with marked promise.

Peripheral glycerol injections in the treatment of idiopathic trigeminal neuralgia: A preliminary study

Thirteen patients with 17 nerves affected by trigeminal neuralgia underwent peripheral glycerol injections (PGI). Two nerves failed to respond to the treatment. The areas of 12 nerves have been pain free for between 6 and 26 months. Pain recurred in the areas of 6 nerves, 3–18 months following treatment. Three nerves were successfully reinjected. Decreased sensation was noticed in the area of 6 nerves. It appears that PGI can give comparable results to percutaneous retrogasserian glycerol rhizotomy with faster onset of pain relief and fewer complications. However, more clinical experience and longer follow-up periods are needed before definite conclusions can be reached.

Sensory disturbance following percutaneous retrogasserian glycerol rhizotomy.

Nineteen patients with tic douloureux were treated with glycerol injection in the trigeminal cistern. Facial sensibility was measured with an electrical stimulator one day before and one day after the glycerol treatment. The thresholds for perception and pain, and the maximal pain tolerance rose by about 50% (p less than 0.01, 0.01, and 0.001, respectively). The hypaesthesia and hypalgesia were most marked just below the eye, whereas the mandibular division showed only slight sensory impairment. In 13 patients a follow-up sensimetry study was done 1-7 months after surgery. Thirteen patients became completely free of pain and one almost completely free from pain (74%). Two had no pain relief. Twelve patients had no subjective complaints of the treatment. Three reported on dysaesthesiae (16%) over the previously painful area. Seven patients (37%) had subjective sensations of diminished or altered sensibility: numbness and hypalgesia in the face. Corneal hypaesthesia was recorded in ten patients (53%). Glycerol has a non-specific neurotoxic effect which is equal for tactile and nociceptive fibres. Sensory impairment may be a conditio sine qua non for a good clinical result.

Acute effect of anhydrous glycerol on peripheral nerve: an experimental study.

Percutaneous retrogasserian glycerol rhizotomy has shown encouraging results in the treatment of trigeminal neuralgia. An experimental study was undertaken using a rat sciatic nerve model to elucidate the mechanism of action of anhydrous glycerol and to study the acute changes which develop within one week. Extraneural glycerol was applied in 20 adult Wistar rats. Groups of five animals were sacrificed at days 1, 3, 5 and 7 respectively. The sciatic nerve of the opposite limb in the same animals was used as a control. The nerve were examined with light and electron microscopy including a morphometric study to assess the type of fibres affected. The specific pattern of involvement of larger and medium sized myelinated fibres with relative preservation of unmyelinated fibres was noted.

Percutaneous retrogasserian glycerol rhizotomy or radiofrequency thermocoagulation for treatment of trigeminal neuralgia?

Percutaneous retrogasserian glycerol rhizotomy or radiofrequency thermocoagulation for treatment of trigeminal neuralgia?

Five-and-a-half years' experience with percutaneous retrogasserian glycerol rhizotomy in treatment of trigeminal neuralgia.

The results of treating trigeminal neuralgia with percutaneous retroganglionic glycerol rhizotomy in 319 patients from an overall series of 394 patients with 459 operations carried out over a period of 5 1/2 years are reported. Idiopathic trigeminal neuralgia was the diagnosis in 252 patients. 34 patients had trigeminal neuralgia associated with multiple sclerosis. The remaining 33 patients suffered from symptomatic trigeminal neuralgia or atypical facial pain. 230 patients (91.3%) with idiopathic trigeminal neuralgia and 30 patients (88.2%) with multiple sclerosis reported complete freedom from pain. In 12 patients (4.8%) of those with tic douloureux and in 1 patient (2.9%) with multiple sclerosis, pain was alleviated, and the patients required a reduced pharmacotherapy. 10 patients (3.9%) and 3 patients (8.8%) were considered to be treatment failures. The rate of recurrences within the first 2 years was 10.9 and 40.0%, respectively. In the long-term, the rate of recurrences in patients with tic douloureux was 36.9%. 144 patients (45.1%) noticed a hypesthesia. 132 patients (41.4%) had hypalgesia following the procedure, and there was a decrease of symptoms in the long-term observation in 20.0% of the patients. 59 patients (18.5%) developed dysesthesia postoperatively which regressed only to an inappreciable extent in the long-term course. In 16 patients (5.0%) exclusively with a preexisting organic lesion or who had received surgical pretreatment, there was a loss of corneal sensation. The investigation showed on the one hand the effectiveness of the method, but on the other hand also the possibility of marked sensory disorder in selected cases.

Percutaneous retrogasserian glycerol rhizotomy for treatment of trigeminal neuralgia.

The treatment of trigeminal neuralgia by percutaneous retrogasserian glycerol rhizotomy was assessed in a series of 58 patients with a follow-up period ranging from 2 to 40 months postoperatively. All patients were considered medical failures prior to the procedure. Idiopathic trigeminal neuralgia was the diagnosis in 54 patients, and four patients had trigeminal neuralgia associated with multiple sclerosis. Forty-two patients (72%) reported complete relief from the procedure and are taking no medications. Four patients (7%) are much improved and require only minimal drug therapy. Twelve patients (21%) were considered treatment failures. The recurrence rate after initial relief of symptoms was 11%. Ten patients (17%) noticed a mild decrease in facial sensation following the procedure, and one additional patient had a profound sensory loss including loss of corneal reflex. The authors conclude that, while percutaneous retrogasserian glycerol rhizotomy may be useful in the treatment of trigeminal neuralgia, more clinical series and documentation of recurrence rate and complications are needed before any firm conclusions can be reached as to the efficacy of this therapy.

Percutaneous retrogasserian glycerol rhizotomy for tic douloureux: Part 2. Results nd implications of trigeminal evoked potential studies.

Trigeminal evoked potentials were recorded before and 6 weeks after a percutaneous retrogasserian glycerol rhizotomy was performed in 22 patients with tic douloureux. The latency of the trigeminal evoked potential (TEP) N20 peak and the sensory threshold to electrical stimulation of the maxillary gum were measured in each patient. The N20 latency differences between normal and affected sides for each patient were reduced after glycerol injection. Sensory thresholds were significantly different between the normal and the affected sides both before and after rhizotomy. These results were interpreted to indicate that glycerol more specifically affects the damaged myelinated axons implicated in the pathogenesis of trigeminal neuralgia. Of the 22 patients, 82% were either pain-free or significantly improved after operation. Postoperative normal N20 latencies were associated with pain relief in most cases. Our preliminary experience suggests that recurrent pain is more likely to develop in those patients whose postoperative TEP remains abnormal, especially if the abnormality cannot be ascribed to a prior surgical deafferentiation procedure. In addition to providing insight into the mechanism of pain relief, TEP measurements may help to predict the likelihood of long term relief after percutaneous retrogasserian glycerol rhizotomy.

Percutaneous retrogasserian glycerol rhizotomy for tic douloureux: Part 1. Technique and results in 112 patients.

The technique and results of treatment of tic douloureux by percutaneous retrogasserian glycerol rhizotomy ( PRGR ) were assessed in a series of 112 patients. All patients were refractory to or intolerant of medical therapy. Many of these patients had recurrent pain despite such surgical treatment as microvascular decompression (21%) or one or more percutaneous radiofrequency thermal rhizotomies (19%). The follow-up duration after glycerol rhizotomy ranged from 4 to 28 months. At the final assessment, 67% had complete pain relief; 23% were improved, with pan relieved by minimal drug therapy; and 10% had poor results with unsatisfactory pain relief even with medications. Before the final assessment, 19 patients required a second PRGR because of an initially suboptimal injection (10%) or recurrent pain (16.9%). Seventy-three per cent had no demonstrable change in facial sensation after operation. H akanson 's original procedure based on anatomic verification by cisternography provided precise localization, required no intraoperative stimulation or lesion generators, and allowed varied anesthetic options during operation. In contrast to thermal rhizotomy, PRGR offers patients relief of painful tic douloureux without altering facial sensation in most cases.

Percutaneous Retrogasserian Glycerol Rhizotomy for Tic Douloureux: Part 1 Technique and Results in 112 Patients

Abstract The technique and results of treatment of tic douloureux by percutaneous retrogasserian glycerol rhizotomy (PRGR) were assessed in a series of 112 patients. All patients were refractory to or intolerant of medical therapy, Many of these patients had recurrent pain despite such surgical treatment as microvascular decompression (21%) or one or more percutaneous radiofrequency thermal rhizotomies (19%). The follow-up duration after glycerol rhizotomy ranged from 4 to 28 months. At the final assessment, 67% had complete pain relief; 23% were improved, with pain relieved by minimal drug therapy; and 10% had poor results with unsatisfactory pain relief even with medications. Before the final assessment, 19 patients required a second PRGR because of an initially suboptimal injection (10%) or recurrent pain (16.9%). Seventy-three per cent had no demonstrable change in facial sensation after operation. Hakanson's original procedure based on anatomic verification by cisternography provided precise localization. required no intraoperative stimulation or lesion generators, and allowed varied anesthetic options during operation. In contrast to thermal rhizotomy. PRGR offers patients relief of painful tic douloureux without altering facial sensation in most cases.