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      Personalized needle modification for CT-guided percutaneous infrazygomatic radiofrequency ablation of the maxillary nerve through the foramen rotundum in order to treat V2 trigeminal neuralgia

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          Background: The computed tomography (CT)-guided radiofrequency ablation (RFA) of the maxillary nerve (V2) via foramen rotundum (FR) approach has been reported to offer the highest rates of pain relief in V2 trigeminal neuralgia (TN). However, the access to FR may be obstructed by the greater wing of the sphenoid bone.

          Objectives: We report on an optimized CT-guided percutaneous infrazygomatic of maxillary nerve through the foramen rotundum (FR) to treat V2 trigeminal neuralgia (TN) using personalized RFA needles based on patient’s individual CT-image parameters.

          Patients and methods: 176 patients with isolated V2 TN were included. If the entry of the percutaneous needle into the FR canal was blocked by the greater wing of the sphenoid bone, straight RFA needles was bent at the tip with an angle α (the angle between the straight line from the external opening of FR to the skin entry point and the long axis of the FR canal). The maxillary nerve RFA was performed after confirmation with electrophysiological tests. Pain relief in the V2 territory and TN recurrence rate were followed for up to 60 months.

          Results: Fifty-two patients (29.55%) required needle bending. The maxillary nerve thermal RFA resulted in analgesia in the V2 territory without affecting the V1 or V3 zone. TN recurrence rate at 6, 12, 24, 36, 48 and 60 months was 2.55%, 7.64%, 17.20%, 24.41%, 30.28% and 33.77%, respectively.

          Conclusion: The personalized needle modification technique for maxillary nerve RFA through FR is safe and effective to treat V2 TN.

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          Most cited references 26

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          Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients.

          The objective of this study was to evaluate the effectiveness of percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR). The outcome of 1,600 patients with idiopathic trigeminal neuralgia after RF-TR was analyzed after a follow-up period of 1 to 25 years. A total of 1,600 patients with idiopathic trigeminal neuralgia underwent 2,138 percutaneous radiofrequency rhizotomy procedures between 1974 and 1999. Sixty-seven patients had bilateral idiopathic trigeminal neuralgia, and 36 of them were treated with bilateral RF-TR; 1,216 patients (76%) were successfully managed with a single procedure, and the remainder were treated with multiple procedures. Benzodiazepines and narcotic analgesics were used for anesthesia because patient cooperation during the procedures was essential so that the physician could create selective, controlled lesions. The average follow-up time was 68.1 +/- 66.4 months (range, 12-300 mo). Acute pain relief was accomplished in 97.6% of patients. Complete pain relief was achieved at 5 years in 57.7% of the patients who underwent a single procedure. Pain relief was reported in 92% of patients with a single procedure or with multiple procedures 5 years after the first rhizotomy was performed. At 10-year follow-up, 52.3% of the patients who underwent a single procedure and 94.2% of the patients who underwent multiple procedures had experienced pain relief; at 20-year follow-up, 41 and 100% of these patients, respectively, had experienced pain relief. No mortalities occurred. After the first procedure was performed, early pain recurrence (<6 mo) was observed in 123 patients (7.7%) and late pain recurrence was observed in 278 patients (17.4%). Complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1 %), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis of Cranial Nerves III and VI in 12 (0.8%). Permanent Cranial Nerve VI palsy was observed in two patients, cerebrospinal fluid leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one. Percutaneous, controlled RF-TR represents a minimally invasive, low-risk technique with a high rate of efficacy. The procedure may safely be repeated if pain recurs.
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            Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia.

            There are no randomized controlled trials comparing retrogasserian percutaneous radiofrequency thermocoagulation, glycerol rhizolysis, balloon compression of the gasserian ganglion, and stereotactic radiosurgery, nor are there systematic reviews using predefined quality criteria. The objective of this study was to systematically identify all of the studies reporting outcomes and complications of ablative techniques for treatment of trigeminal neuralgia, from the development of electronic databases, and to evaluate them with predefined quality criteria. Inclusion criteria for the outcome analysis included thorough demographic documentation, defined diagnostic and outcome criteria, a minimum of 30 patients treated and median/mean follow-up times of 12 months, not more than 20% of patients lost to follow-up monitoring, Kaplan-Meier actuarial analysis of individual procedures, less than 10% of patients retreated because of failure or early recurrence, and a minimal dose of 70 Gy for stereotactic radiosurgery. High-quality studies with no actuarial analysis were used for the evaluation of complications. Of 175 studies identified, 9 could be used to evaluate rates of complete pain relief on a yearly basis and 22 could be used to evaluate complications. In mixed series, radiofrequency thermocoagulation offered higher rates of complete pain relief, compared with glycerol rhizolysis and stereotactic radiosurgery, although it demonstrated the greatest number of complications. Radiofrequency thermocoagulation offers the highest rates of complete pain relief, although further data on balloon microcompression are required. It is essential that uniform outcome measures and actuarial methods be universally adopted for the reporting of surgical results. Randomized controlled trials are required to reliably evaluate new surgical techniques.
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              Treatment options in trigeminal neuralgia.

               Mark Obermann (2010)
              The incidence of trigeminal neuralgia (TN) is 4.3 per 100,000 persons per year, with a slightly higher incidence for women (5.9/100,000) compared with men (3.4/100,000). There is a lack of certainty regarding the aetiology and pathophysiology of TN. The treatment of TN can be very challenging despite the numerous options patients and physicians can choose from. This multitude of treatment options poses the question as to which treatment fits which patient best. The preferred medical treatment for TN consists of anticonvulsant drugs, muscle relaxants and neuroleptic agents. Large-scale placebo-controlled clinical trials are scarce. For patients refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife surgery and microvascular decompression are the most promising invasive treatment options.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                26 July 2019
                : 12
                : 2321-2329
                [1 ]Department of Anesthesiology and Pain Medical Center, First Affiliated Hospital of Jiaxing University , Jiaxing 314001, People’s Republic of China
                [2 ]Department of Anesthesiology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine , Shanghai 200020, People’s Republic of China
                Author notes
                Correspondence: Ming YaoDepartment of Anesthesiology and Pain Medical Center, First Affiliated Hospital of Jiaxing University , 1882 Zhonghuan South Road, Jiaxing314001, People’s Republic of China Email jxyaoming@ 123456163.com
                Langping LiDepartment of Anesthesiology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine , No.149 Chongqing South Road, Huangpu District, Shanghai200020, People’s Republic of China Email sunnycocoli@ 123456hotmail.com
                © 2019 Huang et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 6, Tables: 3, References: 28, Pages: 9
                Original Research


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