Trigeminal Neuralgia: Percutaneous Procedures

Abstract

Percutaneous destructive procedures include radiofrequency rhizotomy, glycerol rhizotomy, and trigeminal balloon compression. These procedures are best offered to patients who cannot undergo microvascular decompression or gamma knife radiosurgery or who fail the latter procedures. They are especially utilized in elderly patients in poor medical condition and in the treatment of trigeminal neuralgia associated with multiple sclerosis. All percutaneous destructive procedures cause injury to trigeminal rootlets. Under fluoroscopic guidance, a needle is inserted into the foramen ovale. In radiofrequency rhizotomy, an electrode that can deliver radiofrequency energy is advanced behind the ganglion into the painful trigeminal rootlets, causing thermal destruction of especially small myelinated fibers. In glycerol rhizotomy, glycerol in injected into the trigeminal cistern causing chemical injury to various trigeminal rootlets. In balloon compression, a #4 fogarty balloon is advanced into the porus trigeminus. When inflated, the balloon compresses the trigeminal rootlets against the dura, causing a mechanical injury to especially the large myelinated fibers. All percutaneous destructive procedures achieve a high rate of immediate initial pain relief and are associated with various rates of pain recurrence. Significant dysesthesia is the main potential complication that should be avoided by meticulous attention to details.