New Trigeminal Stimulation Technique with Dorsal Root Ganglion Stimulation Electrode and Maxillary Fixation: Technique Description.

BACKGROUND: Trigeminal neuralgia is considered the worst pain a human being can experience. Initial treatment uses anticonvulsant sodium channel blockers, which relieve pain in approximately 70% of patients. In refractory cases, it is possible to perform ablative treatments, decompressive surgeries, and neuromodulatory techniques. METHODS: This report describes the treatment of a patient with refractory trigeminal neuralgia who continued to have a painful clinical presentation after four surgical procedures and three ablative procedures. The patient presented with severe pain (verbal numerical scale between 9 and 10), manifesting an evident suicidal ideation. A dorsal root ganglion (DRG) stimulation electrode was implanted in the trigeminal ganglion through intraoral puncture with maxillary fixation of the electrode, in order to minimize the chances of displacement. The test phase consisted of implanting a quadripolar electrode for DRG stimulation through puncture lateral to the buccal rim in a fluoroscopic coaxial view. The electrode was fixed to the skin and maintained for 5 days, during which the patient remained completely pain free. After the 5-day test period, the definitive stimulation electrode was implanted, this time with intraoral puncture and maxillary electrode fixation. RESULTS: The patient remains pain free in the 3-month follow-up, with no displacement of the electrode. CONCLUSIONS: The DRG electrode may be considered a therapeutic option in patients with severe trigeminal neuralgia. Controlled studies must be performed to determine the efficacy and safety of the method.

Cardiovascular response to Gasserian ganglion ablation on trigeminal neuralgia under local anesthesia: a retrospective single-blind case-control study.

OBJECTIVE: Radiofrequency thermocoagulation of Gasserian ganglion brings with it the difficult problem of how to provide adequate acesodyne therapy for patients in order to make the treatment more comfortable. In our study, we assess the safety and efficacy of lidocaine local anesthesia in the treatment of trigeminal neuralgia. METHODS: From January, 2017 to December, 2020, 80 patients in our hospital who were suffering from trigeminal neuralgia were treated with radiofrequency thermocoagulation through oval foramen. They were all enrolled in our study and randomly divided into a study group and a placebo group. In the study group an appropriate concentration of lidocaine was given outside and inside of the oval foramen after puncturing in place, while in the placebo group the same dose of normal saline was given in the same way. We then recorded the mean arterial pressure (MAP), heart rate (HR) and visual analogue scale (VAS) at different treatment temperatures. RESULTS: The values of MAP and HR in the study group were generally lower than those in the placebo group, and the difference was statistically significant. Additionally, the two groups showed a significant difference in MAP, HR, and VAS at different treatment temperatures. There were significant differences in MAP and VAS between the study group at the baseline as well as each time point thereafter, and the range of MAP and HR in the study group were lower than those in the placebo group. CONCLUSION: Reasonable lidocaine local anesthesia can provide analgesic effects and prevent hypertension and arrhythmia during Gasserian ganglion radiofrequency thermocoagulation for the treatment of trigeminal neuralgia.

Use of a Subtemporal Approach for a Salvage Placement of a Trigeminal Ganglion Stimulating Electrode for the Treatment of Trigeminal Neuropathic Pain.

BACKGROUND: Trigeminal ganglion stimulation can be effective for trigeminal neuralgia. For patients who respond well to neurostimulation delivered percutaneously through the foramen ovale but require extensive revision and removal of instrumentation, a subtemporal approach for stimulation of the trigeminal ganglion is an alternative option as a salvage procedure. CASE DESCRIPTION: We report on a 47-year-old woman who responded well to neurostimulation for trigeminal neuropathic pain over a 1-year period from 2008 to 2009. Her preoperative pain on the numerical rating scale (NRS) was between 7 and 8 out of 10, which decreased to 2 out of 10 postoperatively. However, she developed lead migration because of a motor vehicle accident. After revision surgeries to correct this, she continued to experience pain relief until 2011. At follow-up, signs of infection prompted removal of instrumentation and subsequent return of her pain. She continued to experience persistent and severe pain (NRS score 7 of 10), which was intractable to pharmacologic treatment over 5 years. She returned in 2016 to discuss neurosurgical options, and the original approach was ruled out because of her history of lead migration, erosion, and scarring. A subtemporal approach was pursued as a salvage option, which provided several advantages for this patient. CONCLUSIONS: The subtemporal approach for salvage placement of the trigeminal ganglion stimulating electrode was effective in this patient and minimized risks given her history of erosion and multiple operations. This suggests that the subtemporal approach is a viable salvage operation for trigeminal ganglion stimulation for trigeminal neuropathic pain.

Trigeminal and sphenopalatine ganglion stimulation for intractable craniofacial pain--case series and literature review.

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.

Trigeminal Ganglion Stimulation.

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.

Perioperative pain in patients with trigeminal neuralgia undergoing radiofrequency thermocoagulation of the Gasserian ganglion.

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.

Cluster headache--acute and prophylactic therapy.

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.

A multiarray mapping method to minimize morbidity from thermocoagulation as treatment of refractory trigeminal neuralgia.

BACKGROUND: Conventional percutaneous thermocoagulation of postgasserian fibers has shown high success rates, with significant residual morbidity. METHODS: This communication summarizes conclusions of multiple publications on our computerized mapping method and technique, and presents new data on short- and long-term results on trigeminal pain, including an actuarial analysis, complications. RESULTS: In TTN, 97.4% of 75 procedures produced initial pain relief without medication. In all, 84.7% of appropriate verbal responses were achieved by proper location of the needle at the chosen target, requiring an average of 1.45 tracts per procedure. Needle tip was located between 1 and 15 mm below the sellar floor in 97.0% of procedures and in an angle of 40 degrees to 80 degrees regarding the clivus profile projection in 99.1%. A 93% reduction of corneal analgesia and a 100% suppression of major dysesthesias and cranial nerve palsies were found. CONCLUSION: We have shown a significant reduction of morbidity from percutaneous thermocoagulation of postgasserian fibers with similar short- and long-term results as those shown in 11 recently selected series. Strict adherence to all details of our new method and technique is essential. Future multiinstitutional studies are needed to confirm and enrich this small series.

Changes in systemic blood pressure and cardiac rhythm induced by therapeutic compression of the trigeminal ganglion.

Percutaneous compression of the trigeminal ganglion, which is currently being used for the control of trigeminal neuralgia, induces marked intraoperative elevations of the systemic blood pressure and heart rate changes, which may increase the risk of cardiovascular complications. We have analyzed the characteristics of the arterial hypertensive response and the cardiac rhythm changes induced by percutaneous compression of the trigeminal ganglion in 42 consecutive, unselected patients undergoing operations for essential trigeminal neuralgia under three different regimens of anesthesia. The first 22 patients (Group 1) underwent operations under brief general anesthesia without endotracheal intubation. The following 10 patients (Group 2) had general anesthesia with intubation and mechanical ventilation and received larger doses of hypnotic and analgesic agents. Finally, 10 more patients (Group 3), who had general anesthesia with intubation, underwent local anesthetic blockade of Meckel's cave (injection of 1 ml of 1% lidocaine) before ganglion compression. Foramen ovale puncture elicited bradycardia in the majority of the patients of Groups 2 and 3, but only four patients (18%) of Group 1 showed bradycardia. Ganglion compression caused marked tachycardia in all patients of Groups 1 and 2; about one-third of the patients also had extrasystoles. By contrast, patients of Group 3, who had local anesthetic blockade of Meckel's cave before ganglion compression, did not develop tachycardia or extrasystoles. Foramen ovale puncture elicited marked elevations of the systemic blood pressure in all patients. Ganglion compression further increased blood pressure, except in patients of Group 3, who had local anesthetic blockade of Meckel's cave.(ABSTRACT TRUNCATED AT 250 WORDS)

[Classification of trigeminal neuralgia and its effect on the results of surgical treatment]. / Die Klassifikation der Trigeminusneuralgie und ihr Einfluss auf die Ergebnisse der operativen Behandlung.

The trigeminal neuralgia has to be differentiated from the trigeminal neuropathy in respect of pain character and etiology. The neuralgia is characterized by paroxysmal pain evoked by trigger stimuli. The most frequent cause of this type of pain is a parapontine vascular compression of the trigeminal root without neurological deficits. The symptoms of neuropathy are some sensory loss associated with continuous pain resulting from peripheral damage of the trigeminal nerve. This distinction alleviates the indication for specific operative procedures and is more precise than the subdivision in typical and atypical neuralgia. The results of neurovascular decompression and thermorhizotomy can be much improved if neuropathic pain syndromes are excluded from operation. Out of 180 patients suffering from trigeminal neuralgia 94% were pain-free after neurovascular decompression and 96% of 144 patients following thermorhizotomy. For the treatment of continuous neuropathic pain augmentative electrostimulation of the Gasserian Ganglion via implanted electrodes is recommended.

Stimulation of internal capsule, thalamic sensory nucleus (VPM) and cerebral cortex inhibited deafferentation hyperactivity provoked after gasserian ganglionectomy in cat.

Facilitation of the opiate-mediated system provides relief of excess pain but not of deafferentation pain. Influence on neuronal hyper-activity, which was provoked after the deafferentation of the peripheral trigeminal nerve (deafferentation hyperactivity; DH), by stimulation of the internal capsule (IC), VPM nucleus of the thalamus and by the cerebral sensorimotor cortex, was examined. This experiment demonstrates that a suppressive effect is exerted on the sustained neuronal hyperactivity, which was proved to have a close relationship with deafferentation pain. In the preliminary experiment, it was confirmed that DH was provoked by coagulation of unilateral (left side) Gasserian ganglion in 29 adult cats, who were allowed to survive up to 72 days. DH, sustained high amplitude discharge without any stimuli on the face or neck, was detected in the subnucleus caudalis of the spinal trigeminal nucleus (STNcd) of the denervated side. DH was never suppressed by facilitation of the opiate-mediated system. 87 of 113 neurones identified in the STNcd of the denervated side showed DH in another 18 cats. In 30 of 55 neurones examined, DH was conspicuously suppressed by the stimulation of contralateral (right) side, 11 of 29 neurones by ipsilateral IC. Five of 13 neurones were suppressed by contralateral VPM stimulation, 2 of 3 neurones by ipsilateral stimulation. Stimulation of cortical area, SM1 of MS1, in other 15 cats, considerably suppressed DH in STNcd. Microinjection of wheat-germ-agglutinin in the cerebral cortex revealed in direct projection of the descending fibre from MS1 to STNcd and brain stem reticular formation via IC.(ABSTRACT TRUNCATED AT 250 WORDS)

Suppression of pain in trigeminal neuropathy by electric stimulation of the gasserian ganglion.

Lesions of the peripheral part of the trigeminal nerve may cause trigeminal neuropathy associated with severe pain. Such pain usually does not respond to carbamazepine and analgesics, and it is continuous and lacks the characteristic paroxysmal character of tic douloureux. These patients often present with complex changes of facial sensibility in the form of dysesthesia, hyperalgesia, and allodynia. The pain sometimes responds favorably to transcutaneous nerve stimulation, but direct stimulation of the trigeminal ganglion and rootlets via an implanted electrode provides a greater likelihood of pain relief. Fourteen patients diagnosed as having painful trigeminal neuropathy received implants of a gasserian ganglion-stimulating electrode. The mean follow-up period is 4 years (range, 1 to 7 years). Eleven of the patients have retained the pain-relieving effect, and 1 had pain disappear without further stimulation. Eight of the patients estimated their pain relief to be complete or very good. There were no serious complications, but in several of the patients the electrode had to be exchanged because the insulation of the lead wires broke. For the selection of patients for permanent electrode implantation, a method has been developed for trial stimulation via a percutaneous electrode introduced into the trigeminal cistern. Temporary trial stimulation can be performed for several days. It is concluded that stimulation of the trigeminal ganglion and rootlets with the aid of an implanted electrode may effectively relieve certain forms of trigeminal pain that are otherwise extremely difficult to manage.