A technique to facilitate the cannulation of the foramen ovale for balloon compression

Neuronavigation-guided Percutaneous Rhizotomies to Trigeminal Neuralgia: A Systematic Review

OBJECTIVE

Neuronavigation improves intraoperative visualization of the cranial structures, which is valuable in percutaneous surgical treatments for patients with trigeminal neuralgia (TN) who are refractory to pharmacotherapy or reluctant to receive open surgery. The objective of this review was to evaluate the available neuronavigation-guided percutaneous surgical treatment modalities with cannulation of foramen ovale to TN, and their relative benefits and limitations.

METHODS

This review was conducted based on the PRISMA statement. An initial search was performed on electronic databases, followed by manual and reference searches. Study and patient characteristics, rhizotomy procedure and neuronavigation details, and treatment outcomes (initial pain relief and pain recurrence within 2 y, success rate of forman ovale cannulation, and complications) were evaluated. The risk of bias was assessed with a quality assessment based on the ROBINS-I tools.

RESULTS

Ten studies (491 operations, 403 participants) were analyzed. Three percutaneous trigeminal rhizotomy modalities identified were radiofrequency thermocoagulation rhizotomy (RFTR), percutaneous balloon compression, and glycerol rhizotomy. Intraoperative computed tomography and magnetic resonance imaging fusion-based RFTR had the highest initial pain relief rate of 97.0%. The success rate of foramen ovale cannulation ranged from 92.3% to 100% under neuronavigation. Facial hypoesthesia and masticatory muscle weakness were the most reported complications.

DISCUSSION

Neuronavigation-guided percutaneous trigeminal rhizotomies showed possible superior pain relief outcomes to that of conventional rhizotomies in TN, with the benefits of radiation reduction and lower complication development rates. The limitations of neuronavigation remain its high cost and limited availability. Higher-quality prospective studies and randomized clinical trials of neuronavigation-guided percutaneous trigeminal rhizotomy were lacking.

Foramen lacerum impingement of trigeminal nerve root as a rodent model for trigeminal neuralgia

Trigeminal neuralgia (TN) is a classic neuralgic pain condition with distinct clinical characteristics. Modeling TN in rodents is challenging. Recently, we found that a foramen in the rodent skull base, the foramen lacerum, provides direct access to the trigeminal nerve root. Using this access, we developed a foramen lacerum impingement of trigeminal nerve root (FLIT) model and observed distinct pain-like behaviors in rodents, including paroxysmal asymmetric facial grimaces, head tilt when eating, avoidance of solid chow, and lack of wood chewing. The FLIT model recapitulated key clinical features of TN, including lancinating pain-like behavior and dental pain-like behavior. Importantly, when compared with a trigeminal neuropathic pain model (infraorbital nerve chronic constriction injury [IoN-CCI]), the FLIT model was associated with significantly higher numbers of c-Fos-positive cells in the primary somatosensory cortex (S1), unraveling robust cortical activation in the FLIT model. On intravital 2-photon calcium imaging, synchronized S1 neural dynamics were present in the FLIT but not the IoN-CCI model, revealing differential implication of cortical activation in different pain models. Taken together, our results indicate that FLIT is a clinically relevant rodent model of TN that could facilitate pain research and therapeutics development.

Robot-Assisted Percutaneous Balloon Compression in Elderly Patients with Trigeminal Neuralgia

Objective

To investigate the clinical effects of percutaneous balloon compression (PBC) for trigeminal neuralgia in elderly patients with the assistance of a neurosurgical navigation and positioning planning system (referred to hereafter as the robot).

Methods

We performed a retrospective analysis of 11 patients with trigeminal neuralgia. Preoperative TOF MRA, T2WI-SPACE, and thin-slice CT scans were performed, and the volume of Meckel's Cave was calculated by multi-modal image fusion on a workstation. Surgical planning involved two paths. Path A was the actual puncture path, the target point was the anterior inner quadrant of the inner opening of the foramen ovale; Path B represented a virtual path for measurement, and was used to plan the depth of balloon placement. The foramen ovale puncture for path A was completed under the guidance of a robotic arm adapter, while path B was completed under lateral X-ray fluoroscopy with a DSA machine. The balloon was placed at a predetermined depth, and filled to a "pear" shape to complete the operation. Preliminary follow-up results were obtained by considering VAS score and BNI classification.

Results

The foramen ovale was successfully punctured in all 11 patients and entered Meckel's Cave, the balloon was then filled to create a "pear shape". Immediate complete healing was achieved in 10 patients and delayed healing was achieved in one patient by the 5th postoperative day. No serious complications were identified that were related to surgery, and over a follow-up time of 1-12 months, there was no recurrence of pain, and a BNI numbness grade of 2-3 points. The appropriate ratio of the balloon inflated volume to the preoperative Meckel's Cave volume was approximately 1.7.

Conclusion

Preliminary clinical application and short-term follow-up showed that robot-assisted PBC surgery is a safe and effective surgical method for elderly patients with trigeminal neuralgia.

Clinical study on the treatment of primary trigeminal neuralgia by robot-assisted percutaneous balloon compression

Background

C-arm-guided percutaneous puncture balloon compression alone has risk factors of puncture failure, complications, and poor prognosis. Robot-assisted PBC can effectively increase the one-time puncture success rate and improve the safety of the procedure. However, evidence on the superiority of robot-assisted PBC over C-arm-guided PBC alone remains relatively limited.

Methods

Retrospective analysis The clinical data of 60 patients with trigeminal neuralgia aged 60 years or older in the Department of Neurosurgery of the Fourth Hospital of Harbin Medical University from January 2021 to October 2021. There were 29 males and 31 females, and the patients’ ages ranged from 60 to 79 years, with an average of 71.63 ± 5.12 years. Two groups were divided according to the surgical method, the C-arm guidance-only group (30 cases, n = 30) and the robot-assisted group (30 cases, n = 30). The success rate of first puncture, total operation time, number of “pear-shaped” balloons, number of C-arm x-ray scans, and immediate postoperative relief rate were recorded in both groups, and follow-up was performed to evaluate the postoperative results and complications. The overall evaluation of postoperative results and complications was performed.

Results

Intraoperative balloon compression was successfully completed in all 60 patients, and the first puncture success rate was higher in the robot-assisted group than in the simple C-arm group, with a significant difference between the two groups (P < 0.001). In terms of intraoperative balloon morphology, the number of “pear-shaped” balloons was higher in the PBC than in the C-arm-only PBC group, with a significant difference between the two groups (P < 0.005). The degree of immediate postoperative remission in the robotic group was 0 VAS score, which was not statistically significant in both groups (P > 0.05). By the final follow-up, the mean VAS score of the robot-assisted group was lower than that of the simple C-arm group, and both were statistically significant (P < 0.05); complications of masticatory muscle weakness or abnormal facial sensation occurred in both groups after surgery, but the number of cases in the robot-assisted group was less than that of the simple C-arm group.

Conclusion

Robot-assisted PBC is better than PBC with a C-arm x-ray machine in terms of first puncture success rate, number of intraoperative balloon “pear-shaped” cases, number of C-arm x-ray scans and short-term efficacy.

Robot-Assisted Percutaneous Balloon Compression for Trigeminal Neuralgia: Technique Description and Short-Term Clinical Results

Objective

Percutaneous balloon compression (PBC) is a minimally invasive treatment for trigeminal neuralgia (TG) with a favorable cost-effectiveness ratio, but this technique has a steep learning curve. This study presents our initial clinical experience of robot-assisted PBC using a neurosurgical robot on six consecutive patients with TG.

Methods

We fixed the patient's head with a skull clamp and connected it with the linkage arms of a Sinovation^® neurosurgical robot, which was then registered using four bone fiducials by the robotic pointer. The puncture needle was positioned at the entry point on the skin using a robotic arm and advanced to the target point after the skin had been incised with a pointed surgical blade. This procedure was repeated for a second trajectory. A balloon was then advanced and inflated using 0.3 ml of a contrast agent. Upon injection of 0.6 ml contrast agent, the ganglion was kept compressed for 120 s. After removal of the balloon and puncture needle, compression of the face was performed to achieve hemostasis.

Results

All patients achieved immediate pain relief following PBC. No permanent or severe complications were registered, and there was no pain recurrence in any of the patients during the follow-up period.

Conclusions

Despite requiring a longer time for preoperative preparation, robot-assisted PBC provided a high degree of accuracy and safety, and it can also shorten the learning curve for surgeons unfamiliar with PBC. Robot-assisted surgical approaches should be further developed and adopted for PBC.