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Background: Tumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions., Methods: Lateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections., Results: Changing the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit., Conclusions: This approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.

Percutaneous radiofrequency thermocoagulation (RFT) of the Gasserian ganglion is an effective treatment for primary trigeminal neuralgia (pTN). Currently Hartel anterior approach is the most commonly used method to access the Gasserian ganglion. However, this approach is associated with high recurrence rate and technical difficulties in certain patients with foramen ovale (FO) anatomical variations. In the present study, we assessed the feasibility of accessing the Gasserian ganglion through the FO from a mandibular angle under computed tomography (CT) and neuronavigation guidance.A total of 108 patients with TN were randomly divided into 2 groups (Group G and Group H) using a random number table. In Group H, Hartel anterior approach was used to puncture the FO; whereas in Group G, a percutaneous puncture through a mandibular angle was used to reach the FO. In both groups, procedures were guided by CT imaging and neuronavigation. The success rates, therapeutic effects, complications, and recurrence rates of the 2 groups were compared.The puncture success rates in Group H and Group G were 52/54 (96.30%) and 49/54 (90.74%), respectively (P = 0.24). The 2 procedural failures in Group H were rescued by using submandibular trajectory, and the 5 failures in Group G were successfully reapproached by Hartel method. Therapeutic effects as measured by Barrow Neurological Institute (BNI) pain scale (P = 0.03) and quality of life (QOL) scores (P = 0.04) were significantly better in Group G than those in Group H at 36 months posttreatment. Hematoma developed in 1/54 (1.85%) cases in Group H, and no cases of hematoma were observed in Group G (P = 0.33). In Group H, RFT resulted in injury to the unintended trigeminal nerve branches and motor fibers in 27/52 (51.92%) cases; in Group G, it resulted in the same type of injury in 7/49 cases (14.29%) (P < 0.01). In Group H, the 24- and 36-month recurrence rates were 12/51 (23.53%) and 20/51 (39.22%), respectively; in Group G, these recurrence rates were 7/49 (12.24%) and 9/49 (16.33%, P = 0.03), respectively.CT- and neuronavigation-guided puncture from a mandibular angle through the FO into the Gasserian ganglion can be safely and effectively used to deliver RFT for the treatment of pTN. This method may represent a viable option to treat TN in addition to Hartel approach., Competing Interests: The authors have no conflicts of interest to disclose.

Objectives: The authors describe a technique that includes a stereotactic approach in the preoperative plan in cases where the foramen ovale is difficult to access for radiofrequency thermocoagulation of the Gasserian ganglion., Methods: The study included 395 patients for whom three-dimensional computed tomographic reconstruction of the skull base, maxilla, and mandible was conducted before surgery. Accessibility of the foramen ovale was defined using numerical data from the three-dimensional computed tomographic reconstruction images. In those patients for whom accessibility of the foramen ovale was considered difficult, the authors used a stereotactic frame to design an individual operative plan. Adjustments of a single point of data,-that is, a change in X axis, Y axis, or an arc angle-were guided by radiographic fluoroscopy images. After verifying successful cannulation and electroneurophysiology, thermocoagulation targets-especially multiple targets recorded as data on the Z axis of the stereotactic approach-were identified and treated., Results: There were 24 patients who met the predetermined criteria for having a difficult-to-access foramen ovales-that is, they had at least two contributing factors and/or involvement of division V1 . Twenty-one of the 24 patients required a single satisfactory puncture; three patients required two to three punctures to successfully access the foramen ovale. There were no permanent complications from the procedure., Conclusions: The authors conclude that this stereotactic approach combined with three-dimensional computed tomographic reconstruction model can improve the accuracy, safety, and efficiency of percutaneous radiofrequency thermocoagulation in patients with trigeminal neuralgia for whom the foramen ovale is difficult to access., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Facial pain is often debilitating and can be characterized by a sharp, stabbing, burning, aching, and dysesthetic sensation. Specifically, trigeminal neuropathic pain (TNP), anesthesia dolorosa, and persistent idiopathic facial pain (PIFP) are difficult diseases to treat, can be quite debilitating and an effective, enduring treatment remains elusive., Methods: We retrospectively reviewed our early experience with stimulation involving the trigeminal and sphenopalatine ganglion stimulation for TNP, anesthesia dolorosa, and PIFP between 2010-2014 to assess the feasibility of implanting at these ganglionic sites. Seven patients received either trigeminal and/or sphenopalatine ganglion stimulation with or without peripheral nerve stimulation, having failed multiple alternative modalities of treatment. The treatments were tailored on the physical location of pain to ensure regional coverage with the stimulation., Results: Fluoroscopy or frameless stereotaxy was utilized to place the sphenopalatine and/or trigeminal ganglion stimulator. All patients were initially trialed before implantation. Trial leads implanted in the pterygopalatine fossa near the sphenopalatine ganglion were implanted via transpterygoid (lateral-medial, infrazygomatic) approach. Trial leads were implanted in the trigeminal ganglion via percutaneous Hartel approach, all of which resulted in masseter contraction. Patients who developed clinically significant pain improvement underwent implantation. The trigeminal ganglion stimulation permanent implants involved placing a grid electrode over Meckel's cave via subtemporal craniotomy, which offered a greater ability to stimulate subdivisions of the trigeminal nerve, without muscular (V3) side effects. Two of the seven overall patients did not respond well to the trial and were not implanted. Five patients reported pain relief with up to 24-month follow-up. Several of the sphenopalatine ganglion stimulation patients had pain relief without any paresthesias. There were no electrode migrations or post-surgical complications., Conclusions: Refractory facial pain may respond positively to ganglionic forms of stimulation. It appears safe and durable to implant electrodes in the pterygopalatine fossa via a lateral transpterygoid approach. Also, implantation of an electrode grid overlying Meckel's cave appears to be a feasible alternative to the Hartel approach. Further investigation is needed to evaluate the usefulness of these approaches for various facial pain conditions.

Objective: The aim of this study was to investigate whether antidromic conduction monitoring (ACM) can be utilized to map the trigeminal system under sedation as a potential substitute for subjective paresthesia description (SPD) during percutaneous ganglion radiofrequency thermocoagulation (PGRT)., Methods: Eighty-two patients with 152 pain divisions of trigeminal neuralgia (TN) were treated by computed tomography (CT)-guided PGRT. After the puncture needle entered the foramen ovale (FO), sensory and motor stimulation were applied to locate the pain division. And the corresponding voltage values were recorded by patients' SPD. In the following, the proper location was certified by ACM. The corresponding earliest waves and voltage values in the identified trigeminal branch were also recorded to outline a comparison between two methods., Results: The correlation of ACM and patients' SPD with voltage at ≤ 0.5 V was statistically significant (P < 0.05, r = 0.159; Spearman's rank correlation analysis). Although ACM and SPD showed weak correlation, as their interclass correlation coefficient was significant (F = 1.868, P < 0.01) with coefficient of internal consistency. Moreover, the two methods had consistency. Kruskal-Wallis test showed that ophthalmic (V1), maxillary (V2), and mandibular (V3) divisions had significant differences for test sensitivity (H = 15.945, P < 0.01). For comparison of sensitivities with ACM, V3 was most sensitive followed by V2 and then V1., Conclusion: ACM could potentially substitute for SPD of the paresthesias intra-operatively, enabling greater specificity and eliminating the need to interrupt the administration of anesthetic. These improvements would increase patient satisfaction and practitioner efficiency and accuracy., (© 2015 World Institute of Pain.)

Objective: Percutaneous treatments for trigeminal neuralgia are safe, simple, and effective for achieving good pain control. Procedural risks could be minimized by using noninvasive imaging techniques to improve the placement of the radiofrequency thermocoagulation probe into the trigeminal ganglion. Positioning of a probe is crucial to maximize pain relief and to minimize unwanted side effects, such as denervation in unaffected areas. This investigation examined the use of laser speckle imaging during probe placement in an animal model., Methods: This preclinical safety study used nonhuman primates, Macaca nemestrina (pigtail monkeys), to examine whether real-time imaging of blood flow in the face during the positioning of a coagulation probe could monitor the location and guide the positioning of the probe within the trigeminal ganglion., Results: Data from 6 experiments in 3 pigtail monkeys support the hypothesis that laser imaging is safe and improves the accuracy of probe placement., Conclusions: Noninvasive laser speckle imaging can be performed safely in nonhuman primates. Because improved probe placement may reduce morbidity associated with percutaneous rhizotomies, efficacy trials of laser speckle imaging should be conducted in humans.

Objective: To investigate curative effect and importance of radiofrequency thermocoagulation onsemilunar ganglion of aged patients with recurrent trigeminal neuralgia., Method: 112 cases with recurrent trigeminal neuralgia were performed with radiofrequency thermocoagulation on semilunar ganglion by puncture through skin under local anesthesia., Result: The maintaining effective duration in 112 cases was 7.3 ± 1.3 years after primary therapy. After the first thermocoagulation, 89.28% (100/112) patients got the relief from pain immediately, 8 (7.14%) cases also recieved the same effect after twice treatment. However two cases (2.6%) had no effects. The total effective rate was 98.21%. During five follow-up years, VAS scores, dose of carbamazepine and satisfaction were better than those before the treatment. The effective rate was still over 57.5% within three years after the treatment. The recurrent risk increased obviously from 40 months after the treatment by Kaplan-Meier method., Conclusion: Semilunar ganglion of radiofrequency thermocoagulation was an ideal option for old-age patients with trigeminal neuralgia. It can be performed repeatedly.

Background: Although microvascular decompression (MVD) has become the best surgical treatment for trigeminal neuralgia, it does not achieve 100% cure rate. Re-exploration of the posterior fossa may carry increased risk over first-time MVD and is not always successful, so other treatments are needed., Aims: In this study, we evaluate the effectiveness of the patients with recurrent trigeminal neuralgia after MVD treated with percutaneous balloon compression (PBC)., Methods: The clinical data of 52 recurrent trigeminal neuralgia patients after MVD who underwent PBC between November 2007 and March 2012 were retrospectively reviewed and analyzed., Results: After the PBC, 50 patients (96.2%) experienced immediate pain relief; 1 patient had occasional pain, and did not require medication; and 1 patient had no pain relief. The total efficiency was 98.1%. With a mean length of follow-up of 37.6 months, ranging from 12 to 64 months after surgery, 43 (82.7%) patients remained pain-free, 4 patients (7.7%) had mild recurrence, and 3 patients (5.8%) had severe recurrence. The mean time to recurrence was 25.1 months (5-60 months). PBC was repeated a second time in three patients, a third time in one patient. Postoperative complications included facial numbness in 51 patients (98.1%), masseter muscle weakness in 31 patients (59.6%), paresthesia in 5 patients (9.6%), and diplopia secondary to abducens nerve palsy in 1 patient (1.9%). None of the patients had serious surgical morbidities., Conclusions: PBC is a minimally invasive, safe and effective procedure which can be regarded as an optimized choice for recurrent trigeminal neuralgia after MVD.

Introduction: Trigeminal neuralgia is one of the most severe facial pain syndromes. The annual incidence varies between 4-13% and has a significant effect on patients' quality of life. When the pain cannot be controlled by pharmacological treatment, several different surgical options can be considered. The choice of technique will be based on observational studies and its application depends on the experience of each centre., Aims: To assess the effectiveness and level of evidence of pharmacological and surgical treatment in trigeminal neuralgia, and to analyse the current role of percutaneous techniques in the treatment of this pathology., Development: The initial treatment of trigeminal neuralgia is pharmacological and carbamazepine is the only drug with a sufficiently high level of evidence. The percutaneous surgical techniques are effective and easy to apply, but the tendency for relapses to appear means there is a preference for vascular microdecompression. Yet, there are no reports of comparative studies that determine the superiority of a technique with a good level of evidence. The three most commonly used percutaneous techniques, balloon compression, glycerol rhizotomy and thermocoagulation by radiofrequency, were reviewed. This last technique is the one that has undergone the greatest development in recent years, with the emergence of neurophysiological techniques that make it possible to optimise results., Conclusions: The selection of a surgical technique for use in trigeminal neuralgia does not have much backing from randomised clinical trials. The new procedures in the application of radiofrequency can improve the treatment prospects of this pathology.

Background: Airway management in patients undergoing neurosurgical interventions for trigeminal neuralgia can often prove difficult. This is because the patient's assistance is required during this neurosurgical intervention, and moreover, the site of puncture lies within the working area of the anesthesiologists. An obvious alternative for airway management is the use of a nasopharyngeally placed tube. The purpose of the present study was to objectify the gas exchange in patients during this new ventilation technique., Methods: In 5 patients, a tube with a 5 mm internal diameter was placed nasopharyngeally after induction of general anesthesia and ventilation was then manually assisted. The intraoperative partial pressure values of CO(2) (pvCO(2)) and O(2) (pvO(2)) in the venous blood were then compared with their respective patient's preoperative baseline pvCO(2) and pvO(2) levels. Blood pressure, heart rate, and SpO(2) were continuously and noninvasively monitored. During the entire surgical intervention, patients were ventilated with a fraction of inspired oxygen (FiO(2)) of 1.0 and a fresh gas flow of 18 L per minute., Results: All patients exhibited sufficient oxygenation during the entire procedure under manual ventilation. There were no excessive deviations in pvCO(2) from baseline levels. Furthermore, no incidents of hemodynamic instability occurred. Mean duration of the neurosurgical procedure was 54 minutes. Impairment of intraoperative verbal communication was not observed with the nasopharyngeal tube in situ., Conclusions: This preliminary study suggests that manually assisted ventilation with pure oxygen using a nasopharyngeally placed tube seems to be a sufficient airway management technique during thermal coagulation of the Gasserian ganglion.

Percutaneous balloon compression (PBC) of the trigeminal ganglion uses a differential injury of axons to interfere with the nerve's ability to transmit signals. In our experience, patients with lower divisional pain (V3) are often more difficult to control using PBC. We describe a modification to the PBC technique for patients with lower division (V3) pain, and present our experience to date.

Objectives: The objective of this study was to examine the long-term outcome of percutaneous radiofrequency thermocoagulation (PRT) of the Gasserian ganglion for the 2nd division and multiple division trigeminal neuralgia (TN), compared to the isolated 3rd division TN., Methods: One hundred and forty-eight procedures performed in 89 patients with typical TN between April 2004 and September 2011 in a single pain center were retrospectively analyzed. Baseline characteristics of these patients, immediate outcome, duration pain-free, and complications were obtained from their medical records and questionnaires sent in June 2012. Duration pain-free was assessed by Kaplan-Meier analysis., Results: Of the 148 PRT of the Gasserian ganglion, 37 procedures were performed for isolated 2nd-division TN (V2 TN), 67 procedures were for both 2nd- and 3rd-division TN (V2 + V3 TN), and 38 procedures were for isolated 3rd-division TN (V3 TN). The remaining 6 procedures were performed for V1 + V2 TN and V1 + V2 + V3 TN. Immediate success rates of PRT for V2 TN, V2 + V3 TN, and V3 TN were 100%, 86.6%, and 100%, respectively, whereas the durations pain-free for V2 TN and V2 + V3 TN were significantly shorter than that for V3 TN (9, 12, and 36 months, respectively: P = 0.012)., Conclusion: For 2nd-division TN and multiple-division TN, less long-term pain relief after PRT of the Gasserian ganglion can be expected compared with that for isolated trigeminal 3rd-division neuralgia, even if immediate pain relief is achieved., (© 2014 World Institute of Pain.)

Trigeminal neuralgia (TN) is characterized by unilateral, lancinating, paroxysmal pain in the dermatomal distribution area of trigeminal nerve. Percutaneous balloon compression (PBC) of Gasserian ganglion is an effective, comparatively cheaper and simple therapeutic modality for treatment of TN. Compression secondary to PBC selectively injures the large myelinated A-alfa (afferent) fibers that mediate light touch and does not affect A-delta and C-fibres, which carry pain sensation. Balloon compression reduces the sensory neuronal input, thus turning off the trigger to the neuropathic trigeminal pain. In this current case series, we are sharing our experience with PBC of Gasserian Ganglion for the treatment of idiopathic TN in our patients at an academic university-based medical institution in India. During the period of August 2012 to October 2013, a total of twelve PBCs of Gasserian Ganglion were performed in eleven patients suffering from idiopathic TN. There were nine female patients and two male patients with the age range of 35-70 years (median age: 54 years). In all patients cannulation of foramen ovale was done successfully in the first attempt. In eight out of eleven (72.7%) patients ideal 'Pear-shaped' balloon visualization could be achieved. In the remaining three patients (27.3%), inflated balloon was 'Bullet-shaped'. In one patient final placement of Fogarty balloon was not satisfactory and it ruptured during inflation. This case was deferred for one week when it was completed successfully with 'Pear-shaped' balloon inflation. During the follow up period of 1-13 months, there have been no recurrences of TN. Eight out of eleven patients (72.7%) are completely off medicines (carbamazepine and baclofen) and other two patients are stable on very low doses of carbamazepine. All patients have reported marked improvement in quality of life. This case series shows that percutaneous balloon compression is a useful minimally invasive intervention for the treatment of trigeminal neuralgia.

Facial pain in the distribution of the trigeminal nerve, commonly identified as trigeminal neuralgia, should not be confused with trigeminal neuropathic pain. The latter is caused by an accidental and nonintentional nerve lesion. When the first-line pharmacological treatment fails to provide satisfactory pain relief, surgical treatment, such as microvascular decompression and neurodestructive interventions (radiofrequency or cryotherapy), is not indicated. The logical choice of technique becomes neuromodulation, but it may be challenging to perform in the facial area. Although the initial results of trigeminal ganglion stimulation were promising, they often were of short duration because of lead migration and inadequate stimulation coverage in the trigeminal nerve distribution. To ensure accurate placement and proper anchoring, a custom-made electrode was developed and produced, and its stereotactic implantation is guided by electromagnetic navigation. This technique has been used at our center for several years; the published results show at least 30% of pain relief in 75% of the patients and considerable reduction in medication use., (© 2016 S. Karger AG, Basel.)

Background: Percutaneous trigeminal rhizotomy (PTR) uses fluoroscopic guidance to cannulate the foramen ovale for the treatment of trigeminal neuralgia., Objective: To describe the use of a high-resolution biplane neuroangiosuite for PTR and retrospectively to assess the performance of this technique., Methods: From 1990 through 2010, 67 PTRs were performed in 51 patients at our institution; 47 used the c-arm in the operating room (OR) and 20 used the biplane angiosuite. Hospital charts were reviewed for demographics, symptomatology, operative time, number of cannulation attempts, fluoroscopy time and pain outcome. Two-tailed univariate analyses were performed to compare the OR and angiosuite groups., Results: In 20 of 67 PTRs, biplane fluoroscopic guidance in the angiosuite was used. Variations in type of PTR, fluoroscopy technique and follow-up time barred meaningful comparison of these variables between OR and biplane groups. However, the biplane group had significantly fewer mean cannulation attempts (1 vs 2.2, p<0.001)., Conclusions: High-resolution biplane neuroangiosuites offer a readily available alternative to ORs for PTR in the treatment of trigeminal neuralgia. Use of the biplane fluoroscopy machine was practical, safe and at least as effective as the use of the c-arm. It may also offer the advantages of a reduced number of cannulation attempts., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To build the radio-frequency thermocoagulation (RFT) interface under navigation including foramen ovale and trigeminal ganglion based on CT/MRI image fusion technology, to visualize the relationship between the trigeminal ganglion and the puncture needle, and to observe clinical effects of this method., Methods: CT and MRI data of 20 trigeminal neuralgia patients which were input into BrainLAB-iPlan navigation planning system, were aligned and merged, so that the 3-dimentional image fusion interface of CT and MRI for puncture was built. According to the image fusion interface, the pathways targeting the trigeminal ganglion were planned to assist trigeminal ganglion puncture and RFT. The treatment consequences were observed and compared with 20 patients under the RFT only with the direction of pre- and intra-operative CT., Results: In the group of CT/MRI image fusion cases, 3 cases had been predicted to be difficult because of unreachable ganglion through the foramen ovale pathway. The postoperative clinical examination proved that the ganglions of these 3 cases were only insufficiently damaged or undamaged. The other 17 cases proved better results, except 2 cases whose treatment was changed in operation. The valid rates for both image fusion navigation group and CT group were all above 95%., Conclusion: Navigation interface including both foramen ovale and trigeminal ganglion based on CT/MRI image fusion made visualization of the pathway targeting ganglion come true, which made the treatment more accurate and individual. Whether the pathway could reach the ganglion might distinguish the trouble cases from others.

Objective: To report a case of patulous eustachian tube which occurred after percutaneous balloon microcompression of the Gasserian ganglion., Method: Retrospective case review., Results: A 41-year-old man was referred to our audiovestibular medicine department following episodes of autophony. These symptoms appeared two weeks after percutaneous balloon microcompression performed to treat severe trigeminal neuralgia secondary to multiple sclerosis. A diagnosis of patulous eustachian tube was indicated by clinical examination and tympanometry. The symptoms were present for less than six months and improved without any specific treatment., Conclusion: Percutaneous balloon microcompression is a procedure used for refractory trigeminal neuralgia that can cause transient sensory and motor deficits of any of the trigeminal nerve branches. It is proposed that injury to the mandibular division in this case caused temporary tensor veli palatini dysfunction with consequent patulous eustachian tube.

OBJECTIVES. A training model was designed for learners and young physicians to polish their skills in clinical practices of pinpointing and puncturing trigeminal ganglion. METHODS. A head model, on both cheeks of which the deep soft tissue was replaced by stuffed organosilicone and sponge while the superficial soft tissue, skin and the trigeminal ganglion were made of organic silicon rubber for an appearance of real human being, was made from a dried skull specimen and epoxy resin. Two physicians who had experiences in puncturing foramen ovale and trigeminal ganglion were selected to test the model, mainly for its appearance, X-ray permeability, handling of the puncture, and closure of the puncture sites. Four inexperienced physicians were selected afterwards to be trained combining Hartel's anterior facial approach with the new method of real-time observation on foramen ovale studied by us. RESULTS. Both appearance and texture of the model were extremely close to those of a real human. The fact that the skin, superficial soft tissue, deep muscles of the cheeks, and the trigeminal ganglion made of organic silicon rubber all had great elasticity resulted in quick closure and sealing of the puncture sites. The head model made of epoxy resin had similar X-ray permeability to a human skull specimen under fluoroscopy. The soft tissue was made of radiolucent material so that the training can be conducted with X-ray guidance. After repeated training, all the four young physicians were able to smoothly and successfully accomplish the puncture. CONCLUSION. This self-made model can substitute for cadaver specimen in training learners and young physicians on foramen ovale and trigeminal ganglion puncture. It is very helpful for fast learning and mastering this interventional operation skill, and the puncture accuracy can be improved significantly with our new method of real-time observation on foramen ovale.

Background: Microvascular decompression (MVD) is an established surgical therapy for patients with idiopathic trigeminal neuralgia (TN). The role of MVD in patients with definite or suspected multiple sclerosis (MS) remains controversial., Methods: During the period 2000-2012, 10 patients with medically refractory TN and ipsilateral brainstem T2 hyperintensity underwent MVD. In 5 patients, additional clinical features suspicious for MS were present, including prior optic neuritis (n = 2), multiple disseminated lesions (n = 3), and elevated immunoglobulin G index (n = 2). One patient had failed prior percutaneous surgery; 1 patient had Burchiel type 2 TN. Follow-up (median, 14 months) was censored at the time of additional surgery (n = 6) or last clinic visit (n = 4)., Results: Neurovascular compression was confirmed at surgery from the superior cerebellar artery (SCA) plus adjacent vein (n = 4), vein alone (n = 3), SCA alone (n = 2), and SCA plus anterior inferior cerebellar artery (n = 1). Initially after MVD, 8 patients (80%) were pain-free and subsequently tapered off medications for their facial pain. Pain recurred in 6 patients at a median of 4 months (range, 1-23 months). Actuarial rates of being pain-free off medications were 50% at 3 months and 15% at 2 years. In 6 patients, additional treatments were performed, including glycerol rhizotomy (n = 4), radiosurgery (n = 2), balloon compression (n = 2), and repeat MVD (n = 1). At last contact, 5 of the 6 patients who were retreated were pain-free., Conclusions: Facial pain outcomes after MVD in patients with suspected MS-related TN are poor compared with outcomes for patients with idiopathic TN. This study provides further support that many patients with MS-related TN have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal root, ganglion, or divisions., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aim: This prospective case-control study documents the level of radiation expected during percutaneous balloon compression of the Gasserian ganglion., Methods: Percutaneous balloon compression of the Gasserian ganglion is a minimally invasive treatment for trigeminal neuralgia resistant to medical treatment and an alternative to microvascular decompression. This operation requires the use of fluoroscopy to navigate the needle through the foramen ovale and to monitor balloon inflation and deflation. However, the level of radiation exposure for this technique has never been reported. Exposure data (fluoroscopy time in seconds and radiation dose in mGycm(2)) were collected during 17 procedures on 14 patients using the dose report provided by the digital interface of the fluoroscope., Results: The mean fluoroscopy time per patient was 62 s, ranging from 102.9 s to 44.9 s, and the mean radiation dose per patient was 1137.18 mGycm(2), ranging from 1738 mGycm(2) to 639.5 mGycm(2)., Conclusion: This quantification of the dose and duration of radiation during percutaneous compression of the trigeminal ganglion shows that the amount of radiation required to perform this operation is significant and makes lead-coated protection clothing and careful use of the fluoroscope mandatory.

Trigeminal neuralgia is the worst pain that human beings have ever experienced. Few researches have illustrated perioperative pain in patients with trigeminal neuralgia undergoing radiofrequency thermocoagulation (RFT) of the gasserian ganglion under local anesthesia. Because there are some undeniable drawbacks of using intravenous short-term anesthesia during the intervention repeatedly, some physicians keep patients awake throughout the puncture procedure, using local anesthesia. The purpose of this investigation was to examine perioperative pain in patients with trigeminal neuralgia undergoing RFT of the gasserian ganglion. Participants were 104 patients with classic trigeminal neuralgia. Worst pain intensity, mean pain intensity, quality of sleep, and analgesia satisfaction were evaluated for 24 hours before admission, 24 hours before operation, and 24 hours after operation. Intraoperative worst pain intensity was determined. Preoperative pain was serious, and preoperative sleep quality significantly and positively correlated with preoperative mean pain (r = 0.52; P = 0.00) and worst pain (r = 0.49; P = 0.00). Few patients (1.9%) responded to preoperative treatment, and the preoperative treatment obtained low analgesia satisfaction scores (3.9 [1.3]). Most patients experienced severe pain during cannulation under local anesthesia. No patients complained of pain during radiofrequency lesioning. The RFT of the gasserian ganglion alleviated pain obviously. Most patients (94.2%) responded to the operation, and the operation got high analgesia satisfaction scores (8.9 [0.7]). The results demonstrate that preoperative pain in patients with trigeminal neuralgia undergoing RFT of the gasserian ganglion is prevalent and undertreated and that intraoperative pain is severe under local anesthesia during cannulation.

Trigeminal neuralgia is the worst pain that human beings have ever experienced. Surgery might be the only solution for some patients because no other way can relieve their severe pain. They experience intolerable pain before operation and during radiofrequency thermocoagulation of the gasserian ganglion. The aim of the current study was to prospectively evaluate the preoperative and perioperative analgesic effects of preoperative single peripheral nerve block. Sixty patients with classic trigeminal neuralgia who were scheduled to undergo radiofrequency thermocoagulation of the gasserian ganglion were randomly divided into a control group (n = 30) and a nerve block group (n = 30). Patients in the nerve block group were treated with single peripheral nerve block using 1% lidocaine and betamethasone on the day of admission. Average pain, worst pain, quality of sleep, and analgesia satisfaction were evaluated before surgery. The incidence and intensity of perioperative episodic pain were determined before the needle reached the gasserian ganglion. Compared with the control group, a single peripheral nerve block significantly attenuated average pain (P < 0.01) and worst pain (P < 0.01), ameliorated the quality of sleep (P < 0.01), and increased analgesia satisfaction (P < 0.01). Moreover, patients in the nerve block group experienced a decrease in incidence (P < 0.01) and intensity (P < 0.01) of episodic pain during surgery as compared with the participants in the control group. These results demonstrate that a single peripheral nerve block may be an effective way to relieve preoperative and perioperative intolerable pain of trigeminal neuralgia.

Objective: The computerized freezing milling technique is derived from the virtual human project. It has been widely used in three-dimensional (3D) reconstruction of the human body and organs. With this technique, the study was undertaken to explore the 3D features and adjacent anatomic relationships of the sellar region for skull base surgery., Methods: Continuous thin sections on the coronary plane were performed with the computerized freezing milling technique using a human head specimen. The related structures were described in six sections. After segmenting, labeling, and extracting in serial sections, the 3D reconstruction of the sellar region was finished with Amira 4.1 software., Results: A total of 390 thin coronary sections were obtained. In six sections, the anatomic relationships of the pituitary gland, carotid artery, sphenoid sinus, and nerves are displayed. Three-dimensional images of the sellar region are video films that continuously and dynamically display anatomic structures in 3D space at different velocities. It can show that the cavernous segment of the internal carotid artery is located anterolateral to the sphenoid sinus and lateral to the pituitary gland. The optic nerve protrudes into the superolateral portion of the sphenoid sinus., Conclusions: The combination of coronary sectional anatomy and 3D reconstruction can display the anatomic characteristics of the sellar region. The 3D models are video films that continuously and dynamically display anatomic structures in 3D space at different velocities., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Although radiofrequency thermocoagulation is considered as a primary treatment for most patients with trigeminal neuralgia, neuronavigator-guided percutaneous radiofrequency thermocoagulation has been rarely reported. The object of this study was to assess the clinical value of neuronavigator-guided percutaneous radiofrequency thermocoagulation in the treatment of trigeminal neuralgia., Methods: The radiofrequency thermocoagulation was performed in 100 cases of trigeminal neuralgia. The patients were positioned supine or sitting, under Hartel's technique (reported by Sweet and Wepsic J Neurosurg 40:143-156, 1974), by anterior lateral facial approaches. The Gasserian ganglions were acupunctured, assisted by intraoperative CT scanning (3-digital reconstruction) and electrophysiology in order to accurately locate target., Results: The needles located in oval foramen at the first puncture, the direction and position could be defined according to the electrophysiology examination. The pain alleviated immediately after operation. There occurred no serious complication and other nerve injury in all patients despite face numbness only., Conclusions: 3D-CT and electrophysiology Gasser's ganglion locations can raise the success rate of puncture, enhance the safety and reduce the incidence of complication, showing high academic value and its promising future.

Objectives: The objective of this case is to report the rare complication of a meningitis after an invasive treatment of the trigeminal ganglion., Methods: In this case report, two cases of meningitis due to oral streptococci are reported and a review of literature is presented., Results and Discussion: This complication should be recognized as early as possible to prevent deterioration of the situation. Meningitis must be suspected when a patient reports headache and fever within days after an invasive treatment of the trigeminal ganglion.

We present a case of a rare tumor--melanotic schwannoma of trigeminal nerve root and gasserian ganglion. Differential diagnosis between metastatic melanoma and melanotic schwannoma (MS) is associated with serious difficulties and high responsibility. Metastatic melanoma is a high grade tumor while most MS are benign lesions with good outcome. By the date 105 cases of these tumors are described in the world literature, 3 of them originated from trigeminal nerve root and gasserian ganglion. MS predominantly occur in relatively young patients, they are characterized by presence of Carney's complex and psammomatous bodies and absence of primary focus. MS and metastatic melanoma have similar appearance on MRI due to presence of melanin granules. Indirect signs evident for MS include cystic structure and dumbbell-shaped growth. Metastatic melanoma of cranial nerves is more typical in people older than 40, primary focus in the face in the zone of innervation of affected nerve is common. In case of absence of the listed features differential diagnosis is based on immunohistochemical analysis and electron microscopy of tissue samples.

Purpose: Percutaneous ganglion balloon compression (PBC) is a minimally invasive procedure for treatment of trigeminal neuralgia., Materials and Methods: Twenty-seven (19 female and 8 male) patients, who presented with classical symptoms of trigeminal neuralgia, were included. Age ranged from 34 to 91 years (median 62 years), 33 procedures were performed. Duration of the symptoms ranged from 1 year to 30 years (median 5 years)., Results: After the procedure, pain relief was reported in 25 (93%) patients. In two patients, the pain remained the same. The pain free period ranged from 2 to 74 months (median 15 months). A mean duration of analgesia was longer in patients with ideal pear shape of balloon at the time of the procedure compared to nonideal shape (P = 0.01). No major complications occurred in our group of patients., Conclusions: Percutaneous trigeminal ganglion balloon compression is a safe, simple, and effective method for temporary pain relief in a selective group of trigeminal neuralgia patients.

Aim: Surgical approaches to Meckel's cave (MC) are often technically difficult and sometimes associated with postoperative morbidity. The relationship of surgical landmarks to relevant anatomy is important. Therefore, we attempted to delineate quantitatively their anatomy and the relationships between MC and surrounding structures., Material and Methods: With the aid of a surgical microscope, MC and its contents were studied in 15 formalin-fixed cadaver head specimens. Measurements were made and their relationships were observed., Results: The distance from the zygomatic arch and the lateral end of the petrous ridge to MC was 26.5 and 34.4 mm, respectively. The distance from the arcuate eminence, the facial nerve hiatus, and the foramen spinosum to MC was 16.6, 12.8 and 7.46 mm respectively. The TG lay 5.81 mm posterior to the foramen ovale. The distance from the abducens, trochlear and oculomotor nerves to the trigeminal ganglion was 1.87, 5.53 and 6.57 mm respectively. The distance from the posterior and the anterior walls of the sigmoid sinus to the trigeminal porus was 43.6 and 33.1 mm respectively. The trigeminal porus was on average 7.19 mm from the anterior wall of the internal acoustic meatus., Conclusion: The anatomical landmarks as presented herein regarding MC may be used for a safer skull base approach to the region.

Introduction: Neurotrophic ulceration (NTU) in the trigeminal nerve sensitive area is rare. It may be caused by a lesion anywhere on the trigeminal nerve's trajectory. The diagnosis is usually clinical, but other diagnoses, particularly neoplastic, must be ruled out first. The physiopathology and treatment of NTU remain controversial. We report a severe case of NTU and describe the main features of this poorly documented disease., Observation: A 67-year-old female patient consulted in the dermatology department for a progressive ulceration of the nose ala and the right upper lip, having developed over the two previous years. She had undergone two thermocoagulations of the right Gasserian ganglion for facial neuralgia 3 years before. The diagnosis of NTU, initially ruled out because of biopsies suggesting verrucous carcinoma, was finally retained because of the clinical presentation and anamnesis. Treatment consisted in surgical excision and primary reconstruction using a forehead flap. The diagnosis was confirmed after histopathological examination of the surgical specimen. A recurrence was noted 2 years postoperatively, then the patient was lost to follow-up., Discussion: The physiopathology of NTUs is badly documented. The cutaneous ulcerations look like facial neoplasms but the clinical findings (unilateral and paranasal location; lesion of the trigeminal nerve; local trauma; psychological instability) suggest neurotrophic ulceration. The histopathological examination, sometimes difficult, reveals non-specific chronic inflammatory ulceration. There is no consensus on treatment. The psychological profile may be a risk factor for recurrences and must be taken into account., (Copyright © 2011. Published by Elsevier Masson SAS.)

Purpose: To determine the effect of lamellar transection surgery on the nerve fiber density (NFD) and pattern of nerve regeneration in the cornea of thy1-YFP transgenic mice., Methods: Wide-field stereo fluorescence microscopy was used to obtain serial images of nerves in live thy1-YFP mice, which express a fluorescent protein in their axons. NFD (mm/mm(2)) was calculated from maximum intensity projection images as the total length of fibers within the area of the contour in which nerves were traced. Whole-mount confocal microscopy was performed to analyze the arrangement of nerves and the types of regenerating fibers., Results: NFD in normal corneas was 35.3 ± 1.8 mm/mm(2). Stereo fluorescence microscopy revealed the presence of a subbasal hairpin nerve layer and an intrastromal nerve trunk layer. After surgery, regenerative sprouting was observed from transected distal ends of intrastromal nerve trunks. NFD also increased, with this increase being maximal between 4 and 6 weeks after surgery. NFD approximated baseline values at 6 weeks and did not change any further at 8 weeks. Regenerated nerves did not readopt the normal corneal nerve arrangement. A dense interlacing network of regenerated nerves was present in the corneal bed. Branches from this network traversed the flap to innervate the epithelium. Immunofluorescence staining revealed that regenerating fronds contained peptidergic nociceptive fibers (positive for calcitonin gene-related peptide and substance P) and myelinated non-nociceptive fibers (positive for neurofilament 200)., Conclusions: Although corneal NFD recovers to normal levels by 8 weeks after nerve transection, the arrangement of regenerated nerves is abnormal.

Background: Surgical interventions are used for trigeminal neuralgia when drug treatment fails. Surgical treatments divide into two main categories, ablative (destructive) or non-ablative. These treatments can be done at three different sites: peripherally, at the Gasserian ganglion level, and within the posterior fossa of the skull., Objectives: To assess the efficacy of neurosurgical interventions for classical trigeminal neuralgia in terms of pain relief, quality of life and any harms. To determine if there are defined subgroups of patients more likely to benefit., Search Strategy: We searched the Cochrane Neuromuscular Disease Group Specialized Register, (13 May 2010), CENTRAL (issue 2, 2010 part of the Cochrane Library), Health Technology Assessment (HTA) Database, NHS Economic Evaluation Database (NHSEED) and Database of Abstracts of Reviews of Effects (DARE) (issue 4, 2010 (HTA, NHSEED and DARE are part of the Cochrane Library)), MEDLINE (January 1966 to May 2010) and EMBASE (January 1980 to May 2010) with no language exclusion., Selection Criteria: Randomised controlled trials and quasi-randomised controlled trials of neurosurgical interventions used in the treatment of classical trigeminal neuralgia., Data Collection and Analysis: Two authors independently assessed trial quality and extracted data. We contacted authors for clarification and missing information whenever possible., Main Results: Eleven studies involving 496 participants met some of the inclusion criteria stated in the protocol. One hundred and eighty patients in five studies had peripheral interventions, 229 patients in five studies had percutaneous interventions applied to the Gasserian ganglion, and 87 patients in one study underwent two modalities of stereotactic radiosurgery (Gamma Knife) treatment. No studies addressing microvascular decompression (which is the only non-ablative procedure) met the inclusion criteria. All but two of the identified studies had a high to medium risk of bias because of either missing data or methodological inconsistency. It was not possible to undertake meta-analysis because of differences in the intervention modalities and variable outcome measures. Three studies had sufficient outcome data for analysis. One trial, which involved 40 participants, compared two techniques of radiofrequency thermocoagulation (RFT) of the Gasserian ganglion at six months. Pulsed RFT resulted in return of pain in all participants by three months. When this group were converted to conventional (continuous) treatment these participants achieved pain control comparable to the group that had received conventional treatment from the outset. Sensory changes were common in the continuous treatment group. In another trial, of 87 participants, investigators compared radiation treatment to the trigeminal nerve at one or two isocentres in the posterior fossa. There were insufficient data to determine if one technique was superior to another. Two isocentres increased the incidence of sensory loss. Increased age and prior surgery were predictors for poorer pain relief. Relapses were nonsignificantly reduced with two isocentres (risk ratio (RR) 0.72, 95% confidence intervaI (CI) 0.30 to 1.71). A third study compared two techniques for RFT in 54 participants for 10 to 54 months. Both techniques produced pain relief (not significantly in favour of neuronavigation (RR 0.70, 95% CI 0.46 to 1.04) but relief was more sustained and side effects fewer if a neuronavigation system was used. The remaining eight studies did not report outcomes as predetermined in our protocol., Authors' Conclusions: There is very low quality evidence for the efficacy of most neurosurgical procedures for trigeminal neuralgia because of the poor quality of the trials. All procedures produced variable pain relief, but many resulted in sensory side effects. There were no studies of microvascular decompression which observational data suggests gives the longest pain relief. There is little evidence to help comparative decision making about the best surgical procedure. Well designed studies are urgently needed.

Cluster headache (CH) pain is the most severe of the primary headache syndromes. It is characterized by periodic attacks of strictly unilateral pain associated with ipsilateral cranial autonomic symptoms. The majority of patients have episodic CH, with cluster periods that typically occur in a circannual rhythm, while 10% suffer from the chronic form, with no significant remissions between cluster periods. Sumatriptan injection or oxygen inhalation is the first-line therapy for acute CH attacks, with the majority of patients responding to either treatment. The calcium channel blocker verapamil is the drug of choice for CH prevention. Other drugs that may be used for this purpose include lithium carbonate, topiramate, valproic acid, gabapentin, and baclofen. Transitional prophylaxis, most commonly using corticosteroids, helps to control the attacks at the beginning of a cluster period. Peripheral neural blockade is effective for short-term pain control. Recently, the therapeutic options for refractory CH patients have expanded with the emergence of both peripheral (mostly occipital nerve) and central (hypothalamic) neurostimulation. With the emergence of these novel treatments, the role of ablative surgery in CH has declined., (© 2011 American Headache Society.)

In a retrospective study of 206 patients diagnosed with trigeminal neuralgia (TN), we examined the results of percutaneous balloon compression (PBC) of the Gasserian ganglion performed by the same surgeon from September 1991 to November 2005. In these patients, 230 procedures were done. All patients had clinical follow-up for a minimum of 3 years while being evaluated for any recurrence of the symptoms. Initial pain relief was complete in 214 operated patients (93%) while in 16 operated patients (7%) it was not. From those, nine patients had another PBC performed immediately with eight of them becoming pain free while the remaining seven patients opted for medical treatment. From that last group, we found that six patients ended up experiencing resolution of their symptoms. In total, only 2 patients (1%) from the original 206 did not improve initially, while 99% had an excellent response. After a 3-year follow-up, only 35 patients (15%) had developed recurrent symptoms. In the majority of cases, the recurrence occurred between 2 and 3 year intervals (16 patients). There was no mortality. The low cost, low morbidity, low recurrence rate and high positive results make this procedure a valid option in the treatment of trigeminal neuralgia refractory to medical treatment.

Background: Endonasal and infrazygomatic pterygopalatine ganglion (PPG) block for facial pain provides pain relief in a broader area than expected on anatomic grounds. The aim of this study was to search for neural structures in the pterygopalatine fossa (PPF) that could explain unexpected pain relief after PPG blockage., Methods: The neural PPF content was explored through human cadaver study and nerve-specific staining. Five human PPF specimens were dissected as whole-mount preparations with the aid of an operation microscope and stained for acetylcholinesterase. One of these specimens was partially sectioned and analyzed through nitric oxide synthase (NOS) immunohistochemistry., Results: A previously unknown nerve was identified. The nerve runs between the PPG and the ophthalmic nerve and was identified in all five specimens. NOS-containing nerve fibers were present but did not occupy the complete nerve area., Conclusion: Because it is likely that the nerve contains sensory fibers, our findings may provide an anatomic basis for unexplained pain relief in the ophthalmic area after PPG blockage.

Background: Stereotactic radiosurgery is an attractive option for elderly patients and those who do not tolerate the more invasive surgical procedures available for trigeminal neuralgia (TN). In the majority of the studies, the target location was designated as the proximal nerve at the root entry zone (REZ). The purpose of this article was to evaluate the efficacy of and complications associated with X-knife stereotactic radiosurgery on the trigeminal ganglion (TG) for TN., Patients and Methods: 40 patients with typical idiopathic TN were treated with X-knife. The maximum radiation dose was 70 Gy. A 4-mm collimator and a 9-arc technique were employed. Treatment was focused at the TG., Results: At the last follow-up (mean follow-up period: 7.9 months, range: 1-19 months), pain relief for all patients was excellent in 16 (40%), good in 17 (42.5%), for a total success rate of 82.8%. The mean time to initial relief was 12.5 days ranging from immediate in onset (<24 h) to 2 months. One patient (3.0%) experienced some recurrent pain. 3 patients (7.5%) experienced noticeable subjective facial numbness. Hearing impairment was found in 1 patient (2.5%), and ulceration of the temporal skin was seen in 2 patients (5%)., Conclusion: Similar to other TN radiosurgery reports, X-knife stereotactic radiosurgery for TN provides effective pain relief with a low complication rate., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Puncture of the ganglion Gasseri through the foramen ovale and subsequent thermocoagulation, balloon compression, or glycerin injection is a well-established technique to treat trigeminal neuralgia. However, direct puncture of the foramen is sometimes difficult. Here, the authors present a simple technique of improved biplane fluoroscopic control for insertion of the needle into the foramen ovale., Methods: The authors evaluated an alternative oblique X-ray trajectory for the correct placement of a needle into the foramen ovale on cadaveric skull models. After determination of the ideal X-ray trajectory, 13 subsequent patients suffering from trigeminal neuralgia were subjected to intraforaminal needle placement with application of the alternative X-ray trajectory., Results: An oblique projection with the X-ray tube (mean rotation 20.9° and angulations 28°) aligned coaxially to the inserted needle is proposed. On cadaver skull models, this oblique trajectory appeared to be ideal for visualization of the correct needle position. In the 13 patients, an immediate needle insertion into the foramen ovale was achieved under this direct oblique fluoroscopic control. No complications were observed., Conclusions: Experimentally and clinically, the new projection demonstrated three distinct advantages over the standard submental projection: Firstly, the foramen ovale can be better visualized independent of the patient's position. Secondly, needle correction or insertion can be performed much easier because of the direct fluoroscopic control. Thirdly, the correct needle position in the foramen ovale is more reliably determined than with the submental projection due to projection geometry. Further studies are needed to give evidence that the needle insertion into the foramen ovale is easier achieved with the coaxial projection than with the standard technique.

Objectives: There are controversies about the use of local anesthetics during balloon compression for trigeminal neuralgia (TN) as a protective factor for cardiovascular events. The objective of this study was to investigate cardiovascular parameters (blood pressure and heart rate [HR]) of patients that underwent trigeminal balloon compression with local anesthetics compared to a control group (placebo)., Methods: This is a randomized controlled study; 55 patients were randomized into two groups: study (deep sedation and trigeminal block with 0.8-mL lidocaine 2%) and control group (deep sedation and trigeminal injection of 0.8-mL saline). Blood pressure and HR were measured in five distinct moments: preoperative, during puncture for local anesthesia/placebo, during puncture with the catheter, during balloon compression, and final evaluation. Statistical analysis was performed with Pearson's chi (2) and McNemar tests and the analysis of variance for repetitive measures., Results: The means of systolic and diastolic blood pressures (SBP and DBP, respectively) were higher in the control group when compared to the study group at the evaluation during puncture with the catheter (p < 0.001) and balloon compression (p < 0.001 and p = 0.018 for DBP and SBP, respectively). There was an increase in the HR in the control group during the procedure (p = 0.017)., Conclusion: The use of local anesthetics during the trigeminal balloon compression for TN can have a preventive role for the risk of cardiovascular events.

Background: We performed a comparative study of the retrogasserian zone (RGZ) with the dorsal root entry zone (DREZ) target to determine effective gamma knife radiosurgery (GKRS) technique in patients with medically refractory trigeminal neuralgia (TN)., Methods: We retrospectively reviewed the records of 39 patients with refractory TN undergoing GKRS between April 2005 and October 2008. Until October 2007, DREZ was used as the primary target point. Since November 2007, RGZ has been targeted, located anterior to DREZ. The pain outcome of patient, pain recurrence, and treatment-related complications were evaluated., Findings: Using the Barrow Neurologic Index (BNI) pain score, 15 (93.8%) RGZ and 20 (87.0%) DREZ cases achieved treatment success (BNI pain score I-IIIb) (p = 0.631). Seven (43.8%) RGZ and four (17.4%) DREZ patients reported complete pain relief without medications (BNI pain score I). The time to a response after the GKRS was significantly shorter in the RGZ group (mean 4.1 weeks) than in the DREZ group (mean 6.4 weeks) (p = 0.044). The total complication rate (25.0%) in the RGZ group was similar to the DREZ group (26.1%); however, frequency of bothersome facial numbness and dry eye syndrome was lower in the RGZ group (0%, 0%) compared to the DREZ group (13.1%, 8.7%) (p = 0.255 and 0.503)., Conclusions: The RGZ targeting technique in the GKRS for TN had a better treatment success, with fewer bothersome complications compared to the DREZ target.

Objective: In this paper, a technique to place a probe at the trigeminal ganglion using a stereotactic frame and intraoperative computed tomography (CT) scans is described., Method: The procedure is performed on the CT table using a stereotactic frame. After the coordinates have been obtained and then adjusted, the target is probed using the frame. In this study, intraoperative scans were obtained to confirm the accuracy of probe placement. After successful stimulation studies, radiofrequency lesions were made. Thirty-two procedures were performed on 26 patients., Results: Twenty patients were free of pain at a follow-up which lasted a median of 30 months. There was no permanent complication from the procedure., Conclusions: The technique is straightforward, accurate and safe. It also enables the surgeon to obtain intraoperative confirmation of accurate probe placement on CT images., (2010 S. Karger AG, Basel.)

We report the case of a woman with short-lasting unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) whose severe headache attacks ceased after percutaneous balloon compression of the Gasserian ganglion. The patient remains pain free after 10-year follow-up. This may be the first literature report of SUNCT in Chile.

Although surgical ablative procedures can be effective in the management of chronic pain of malignant and non-malignant origin, they are often disregarded as treatment options due to the fact that in the past these procedures were associated with high complication rates. The complications include the development of new neurological deficits and in cases of long-term follow-up, the occurrence of the old or new pain syndromes by deafferentation. On the other hand there exist many less invasive, e.g. neuromodulatory procedures or non-invasive measures (systemic oral or transdermal opioids) which are able to considerably reduce chronic pain. Nevertheless, there remain certain very restricted indications for the use of neuroablative procedures for the treatment of chronic pain even today.

Introduction: Although Gasserian ganglion block is an established treatment for trigeminal neuralgia, the foramen ovale cannot always be clearly visualized by classical X-ray radiography. We present a new method for percutaneous radio-frequency thermocoagulation of the Gasserian ganglion, in which computed tomography (CT) fluoroscopy is used to guide needle placement., Methods: In the present study, 15 patients with trigeminal neuralgia underwent percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy., Results: Trigeminal neuralgia was improved in all patients after treatment without any severe complications. Moderate dysesthesia occurred in only one case., Conclusion: CT fluoroscopy-guided percutaneous radio-frequency thermocoagulation of the Gasserian ganglion was safe, quick, and effective for patients with intractable idiopathic trigeminal neuralgia.

Trigeminal neuralgia is a common cause of facial pain. It has a significant impact on the quality of life and the socioeconomic functioning of the patient. The aim of this review is to provide recommendations for medical management of trigeminal neuralgia based on current evidence. Based upon the analyses of the literature combined with experience in pain management, symptoms, assessment, differential diagnosis, and treatment possibilities of trigeminal neuralgia are described and discussed. Recommendations for pain management are given and are displayed in a clinical practice algorithm. Treatment should be multidisciplinary. Various treatment options and their risks should be discussed with the patient. The first treatment of choice is carbamazepine or oxcarbazepine. In younger patients, the first choice of invasive treatment is probably microvascular decompression. For elderly patients, radiofrequency treatment of Gasserian ganglion is recommended and the technique is described in detail.

Objectives/hypothesis: We describe our cadaveric dissections and clinical findings that address anterior and ventral limitations imposed by the trigeminal nerve. Particularly, we identify the trigeminal caroticodural fold, the vestment of dura that traverses the space between the nerve and the internal carotid artery. We address the effect of mobilization of this fold to optimize access in Kawase's space when approaching the clivus and posterior fossa., Methods: Histological study and cadaveric dissections were performed to examine this regional anatomy. Our clinical series (2002 to 2007) includes 30 patients who underwent anterior petrosectomy as part of more complex approaches for lesions of the skull base., Results: Histological and dissection specimens showed a dense fibrous confluence lateral to the trigeminal ganglion and portions of the trigeminal nerve that we called the trigeminal caroticodural fold. This fold was prominent in 18 patients, ill-defined in six, and absent in six patients. Incision of the trigeminal caroticodural fold permitted between 1 mm and 3 mm of additional exposure for drilling in Kawase's space without direct trauma to V(3)., Conclusions: Our study highlights the existence of a dural tethering of the trigeminal nerve and ganglion relevant to surgical exposure of Kawase's space. The regional dural anatomy that contributes to the trigeminal caroticodural fold is complex with subtle variances. We suggest that identification of this fold and its sharp dissection allows mobilization of the trigeminal ganglion and nerve without violation of V(3), and ultimately can improve the transpetrosal access to the upper clivus and posterior fossa via this corridor. Laryngoscope, 2009.

Objective: To introduce a novel surgical technique for the dissection of the greater superficial petrosal nerve (GSPN) in the middle fossa approach., Methods: Interdural temporal elevation was performed with a front-to-back technique to preserve the GSPN in 12 sides of 6 injected cadaveric heads dissected through a middle fossa approach., Results: The GSPN emerged from the facial hiatus in a shallow bony groove proximally, ran into a deeper sphenopetrosal groove, and eventually reached the mandibular nerve. With front-to-back dissection, this nerve was easily identified at the posterior border of the mandibular nerve. Dissection from front to back minimized the retraction force applied to the proximal part of the GSPN, which was preserved in all specimens., Conclusion: The temporal dura can be elevated safely with a front-to-back technique to preserve the GSPN and to help maintain the physiological integrity of the facial nerve.

Background: The purpose of this study was to call attention to the subtemporal approach directed through the petrous apex to the IAM. We studied the microsurgical anatomy of the middle floor to delineate a reliable angle between the GSPN and the IAM to precisely localize and expose the IAM from above. A new technique for the elevation of middle fossa floor in an anterior-to-posterior direction has also been examined in cadaveric dissections and performed in surgery., Methods: The microsurgical anatomy of the middle fossa floor was studied in 10 adult cadaveric heads (20 sides) after meatal drilling on the middle fossa. Five latex-injected specimens were dissected in a stepwise manner to further define the microsurgical anatomy of the middle fossa approach. The middle fossa approach is illustrated in a patient for the decompression of the facial nerve to demonstrate the surgical technique and limitations of bone removal., Results: Elevation of middle fossa dura in an anterior-to-posterior direction leads to early identification of the GSPN, where the nerve passes under V3. The most reliable and easily appreciated angle to be used in localizing the IAM is between the IAM and the long axis of the GSPN, which is approximately 61 degrees . Beginning drilling the meatus medially at the petrous ridge is safer than beginning laterally, where the facial and vestibulocochlear nerves become more superficial. The cochlea anteromedially, vestibule posterolaterally, and superior semicircular canal posteriorly significantly limit the bone removal at the lateral part of the IAM., Conclusions: The surgical technique for the middle fossa approach which includes an anterior-to-posterior elevation of middle fossa dura starting from the foramen ovale and uses the angle between the IAM and the long axis of the GSPN to localize the meatus from above may be an alternative to previously proposed surgical methods.