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ioCT-guided percutaneous radiofrequency ablation for trigeminal neuralgia: how I do it

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Abstract

Background

Percutaneous trigeminal nerve rhizotomy is usually performed by free-handed puncture of the foramen ovale under radiographic control with the patient kept semiconscious. The procedure has thus been reported to be highly uncomfortable for both the patient and surgeon. To our knowledge, this is the first description of a technique that includes precise navigated, CT-guided puncture of the foramen with the patient in general anesthesia and confirmation of needle placement by intraoperative CT.

Method

Radiofrequency ablation of the trigeminal nerve was guided by intraoperative CT navigation with neuromonitoring of trigeminal nerve function. The patient was kept under general anesthesia during the procedure.

Conclusion

CT-guided percutaneous trigeminal nerve rhizotomy is a safe and efficient treatment strategy for the management of trigeminal neuralgia without the need of the patient being in a semiconscious state.

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References

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Acknowledgements

We would like to thank our patients for providing their anonymous data, and the press and information center of the medical service of the German Armed Forces for the photo documentation of the operative procedure.

Author information

Correspondence to Sven Duda.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Informed consent was obtained from all patients whose treatment data were included in the paper or from their legal representatives

Additional information

Key points

1. Pre-operative MRI CISS and contrast-enhanced sequences are needed to decide on the pathogenesis of TGN and the preferred surgical procedure.

2. Thin-slice CT of the skull base may be helpful to study the anatomy of the foramens at the skull base of the middle cerebral fossa.

3. An intraoperative CT-scan is acquired for intraoperative neuronavigation and 3D modeling.

4. Härtel’s anatomical landmarks are used for plausibility control.

5. The distance of the electrode tip to the floor of the sella and the cilval line in the lateral X-ray projections (CT scout image) is used to determine the puncture of the correct portion of the trigeminal nerve.

6. The needle position is verified by another intraoperative CT scan.

7. Intraoperative neuromonitoring of the masseter muscle and trigeminal nerve SEPs allows additional quality control.

8. The patient is kept under general anesthesia during the entire procedure.

9. The puncture of adjacent foramens of the skull base and asystolia due to the trigemino-cardiac reflex are severe complications of the procedure.

10. Pre-operative application of parasympatholytic drugs should be considered to avoid cardiac complications.

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This article is part of the Topical Collection on Functional Neurosurgery - Pain

Electronic supplementary material

ioCT-guided percutaneous radiofrequency ablation of the trigeminal nerve is shown stepwise in a patient with TGN of the left trigeminal nerve (MP4 42,926 kb)

ESM 1

ioCT-guided percutaneous radiofrequency ablation of the trigeminal nerve is shown stepwise in a patient with TGN of the left trigeminal nerve (MP4 42,926 kb)

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Cite this article

Weßling, H., Duda, S. ioCT-guided percutaneous radiofrequency ablation for trigeminal neuralgia: how I do it. Acta Neurochir 161, 935–938 (2019). https://doi.org/10.1007/s00701-019-03859-8

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Keywords

  • Intraoperative computed tomography
  • Trigeminal neuralgia
  • Percutaneous rhizotomy
  • Radiofrequency thermocoagulation