|Year : 2019 | Volume
| Issue : 3 | Page : 136-140
Percutaneous balloon compression of Gasserian ganglion for idiopathic trigeminal neuralgia
Shivani Rastogi1, Anurag Agarwal1, Manjari Bansal1, Hitesh Patel2, Deepak Malviya1, Arvind Singh3
1 Department of Anesthesiology and Pain Medicine, Dr. Ram Manohar Lohiya Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Pain Physician, Livewell Pain Hospital, Ahmedabad, Gujarat, India
3 Department of Community Medicine, Dr. Ram Manohar Lohiya Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||02-Aug-2019|
|Date of Decision||09-Sep-2019|
|Date of Acceptance||06-Oct-2019|
|Date of Web Publication||5-Dec-2019|
Dr. Anurag Agarwal
Department of Anesthesiology and Pain Medicine, Dr. Ram Manohar Lohiya Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study was to evaluate the outcome and complication in patients with idiopathic trigeminal neuralgia (TN) posted for percutaneous balloon compression (PBC). Materials and Methods: The study included twenty patients of idiopathic TN presented in the outpatient department of pain clinic posted for PBC from the years 2016 to 2018. All patients were followed up for 6 months after the balloon compression of Gasserian ganglion. Out of the twenty patients, 40% were female and 60% were male. The mean age was 55.4 years (range: 37–70 years). These patients were on antineuropathic (carbamazepine, baclofen, and gabapentin) drugs with inadequate pain relief and 13 patients also had undergone radiofrequency ablation. PBC of Gasserian ganglion was planned by the technique described by Mullan and Lichtor in all patients. Visual Analog Score (VAS) and Barrow Neurological Intensity (BNI) score were compared pre and post procedure. Intraoperative and postoperative complications and side effects were analyzed retrospectively. Results: Eighteen out of twenty patients (90%) had excellent results with improvement in the VAS and BNI scores, which was statistically significant. The difference between the mean change in VAS and BNI scores for single nerve and multiple nerve roots was not statistically significant. Nearly 85% (17) of the patients had initial facial numbness, which improved in about 3 months. Only 10% of the patients had residual facial numbness, which was mild in nature and not bothersome to the patients. Masseter muscle weakness was present in seven (35%) patients. No patient reported corneal anesthesia or any other complications. Intraoperatively, four patients (20%) experienced moderate-to-severe bradycardia during entry to the foramen ovale and on inflation of the Fogarty balloon, which responded to injection atropine 0.6 mg intravenously stat. Conclusion: Hereby, we state that PBC is an effective and safe method with marked improvement in pain scores and improvement in quality of life of patients of idiopathic TN.
Keywords: Anesthesia dolorosa, percutaneous balloon compression, trigeminal neuralgia
|How to cite this article:|
Rastogi S, Agarwal A, Bansal M, Patel H, Malviya D, Singh A. Percutaneous balloon compression of Gasserian ganglion for idiopathic trigeminal neuralgia. Indian J Pain 2019;33:136-40
|How to cite this URL:|
Rastogi S, Agarwal A, Bansal M, Patel H, Malviya D, Singh A. Percutaneous balloon compression of Gasserian ganglion for idiopathic trigeminal neuralgia. Indian J Pain [serial online] 2019 [cited 2020 Jan 25];33:136-40. Available from: http://www.indianjpain.org/text.asp?2019/33/3/136/272381
| Introduction|| |
Trigeminal neuralgia (TN) is one of the worst painful syndromes experienced by humankind across the world, also known as tic douloureux. This pain has been known since ancient times which significantly affect the quality of life. TN is characterized by unilateral, strong, paroxysmal lancinating pain in the dermatomal distribution of trigeminal nerve. There is higher prevalence of TN in women, with a male-to-female proportion of 1:3. The maxillary and mandibular branches of the trigeminal nerve are the most affected branches. The most common age group affected is 37–67 years. The pain is evoked by nonpainful light stimuli such as talking, chewing, washing face, shaving, or even spontaneously, which may last for few seconds to several minutes.
The etiology may be either idiopathic or secondary to intracranial lesion such as tumor, infarction, and multiple sclerosis. In 2003, Burchiel classified TN on the basis of clinical features into Type I, which is predominantly episodic and sharp, and Type II, which is constant, dull, and burning in nature.
The pathophysiology is unclear. Based on clinical observations, there is compression of the nervous trigeminus near its origin at the brain stem, the so-called “root entry zone,” by the blood vessels. The local pressure causes demyelination that leads to abnormal depolarization resulting in ectopic impulse generation and TN.
The treatment modalities according to the American Academy of Neurology and European Federation of Neurological Society guidelines on TN treatment start essentially with medications, and carbamazepine is considered to be the “Drug of Choice.” In patients not responding to medical treatment or when there are unacceptable side effects, interventional treatment is recommended which includes surgical microvascular decompression (MVD), stereotactic radiation by gamma knife, percutaneous balloon compression (PBC), percutaneous glycerol rhizolysis, percutaneous radiofrequency (Pulse radio frequency (PRF) and continuous radiofrequency), and Gasserian ganglion More Details stimulation or neuromodulator. Although MVD is the preferred and recommended treatment, it may not be suitable for older, debilitated patients. Moreover, MVD is also complicated with the risk of major surgical morbidity and mortality. Thus, percutaneous procedures are more commonly preferred and widely accepted treatment. PBC has emerged as an effective, safe, and economical treatment of TN.,,
| Materials and Methods|| |
The present retrospective study was conducted in the Department of Anesthesia and Pain Medicine at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India, from the years 2016 to 2018 and patients were followed up regularly for 6 months. All the demographic data and site of involvement, previous treatment, clinical presentation, intra-operative and postoperative complication, and treatment received during the follow-up period were collected and analyzed.
The data were collected on a predesigned schedule and entered into Microsoft Excel for subsequent analysis. Qualitative data were reported as proportions, and quantitative variables were analyzed using Chi-square tests. The difference between means of quantitative variables was tested for statistical significance using t-test, and correlation between two continuous variables was tested using Spearman's correlation. P < 0.05 was considered statistically significant.
Procedural details of percutaneous balloon compression
All patients planned for PBC were examined in detail regarding nerve involvement. Magnetic resonance imaging or computed tomography head was done to rule out secondary TN and treatment was initiated. Patients' informed consent was obtained after explaining the procedure. On the day of procedure, an 18G intravenous cannula was placed, and as per the American Society of Anesthesiologists standards, vital monitoring was attached.
All procedures were performed under deep sedation with C-arm fluoroscopic guidance. The patients were placed in supine position. C-arm fluoroscope was aligned to take a “modified submental view” to visualize the foramen ovale [Figure 1]. A 14G needle with a trocar was inserted into the foramen ovale after infiltrating with local anesthesia. The cannula was guided in “end on image” to reach the entry of the Meckels cave through the foramen ovale. Once the 14G needle was felt to be fixed at the walls of the foramen ovale and after checking in the lateral fluoroscopic view, advancement of the cannula was stopped and a 4-Fr catheter was gently threaded into the Meckels cave up to the clivus. After confirmation of the correct position of the balloon, the metallic guidewire of Fogarty balloon was removed and the balloon was inflated with 0.8–1 ml of water-soluble contrast dye and was kept inflated for 1.5 min [Figure 2]. After completion of the intervention, the Fogarty balloon was deflated and removed along with the cannula and manual pressure was applied for 5 min against the maxilla to stop any bleeding or cerebrospinal fluid drainage. A small dressing was applied on the skin, and the patients were transferred to postoperative room for observation. All patients were evaluated on postoperative days 1 and 7 and then monthly for 6 months. Patients' pain relief was assessed using the Visual Analog Scale (Sample- A for VAS) and Barrow Neurological Intensity (Sample- B for BNI) scores along with known side effects such as facial sensations, corneal reflex, and masseteric muscle power. All patients were followed up for 6 months by either reviewing medical records or through telephonic conversation.
Visual Analog Scale
| Results|| |
Out of the twenty patients, 18 (90%) had good relief and were regularly visiting the pain clinic. Two patients did not have much relief (BNI remained 4 and above); hence, they were referred for MVD. The demographic data [Table 1] show that 40% of the patients were female and 60% were male. The mean age was 55.4 years (range: 37–70 years). Nearly 85% of the patients had right-side involvement, and the duration of disease varied from 6 months to 12 years. Single-nerve involvement was less reported; V2 in 10%, V3 in 15%, V1 + V2 in 25%, V2 + V3 in 35%, and V1 + V2 + V3 in 15% of the patients.
Patients with higher preoperative VAS scores showed lower score on the VAS after the procedure. However, the correlation between these two variables was weak (Spearman's rho = −0.089) [Graph 1]. Patients with higher preoperative BNI scores showed higher changes in BNI scores after the procedure, and the correlation between these two variables was strong (Spearman's rho = 0.792) [Graph 2]. The mean change in VAS score was 5.00 ± 2.92 for single-nerve root involvement and 5.73 ± 1.75 for multiple nerve root involvement. The difference in the mean VAS change between these groups was statistically nonsignificant (P = 0.501) [Table 2]. The mean change in BNI score was 2.20 ± 1.30 for single-nerve root involvement and 2.27 ± 1.33 for multiple nerve root involvement. The difference in mean BNI change between these groups was statistically nonsignificant (P = 0.924) [Table 3]. During PBC, four (20%) patients experienced moderate-to-severe bradycardia (heart rate <40/min) in spite of pre-atropinization with 0.4-mg atropine. All these patients responded favorably with bolus dose of injection atropine 0.6 mg intravenously. Post procedure, 85% of the patients (17) reported facial numbness immediately after the procedure, and 35% of the patients (7) reported masseteric muscle weakness which gradually improved over time. No incidence of loss of corneal reflex or diplopia was reported. Nearly 15% of the patients (3) had herpes labialis immediately in the postprocedural period [Table 4].
|Table 3: Changes in Barrow Neurological Intensity score for single nerve and multiple nerves|
Click here to view
| Discussion|| |
TN or tic douloureux is a neuropathic pain syndrome. TN is characterized by unilateral, strong, paroxysmal lancinating pain in the dermatomal distribution of trigeminal nerve. The pain is evoked by nonpainful light stimuli such as talking, chewing, washing face, shaving, or even spontaneously and may last for few seconds to several minutes. The etiology may be either idiopathic or secondary to intracranial lesion such as tumor, infarction, and multiple sclerosis. Medical treatment has good control initially, but, later, drug intolerance and ineffectiveness of the medical treatment may ensue. Although neurosurgical MVD is considered to be the first-line choice, it is associated with risk. PBC of Gasserian ganglion causes anatomic injury to the Gasserian ganglion neurons, which is different from that caused by thermal or chemical injury. PBC causes a compression which selectively injures the large myelinated A-alpha and Beta fibers (afferent) that mediate light touch and does not affect A-delta and C fibers which carry pain sensation. Percutaneous procedures are well-defined, minimally invasive, low-cost, and safe and effective procedures., MVD is preferred in younger patients, but if patients are not willing or deemed unfit for surgery, PBC can be a good choice.,
Regarding the demographic data, the mean age was 55.4 years (range: 37–70 years). Nearly 85% of the patients had right-side involvement. Single-nerve involvement was less reported; V2 and V3 components were more affected. De Toledo et al. in 2016 and Park et al. in 2008 also reported right-sided predominance in patients in the age group of 37–67 years and V2 and V3 components were the most common presentation in their study.
Through reviewing literature reports, Ying in 2017 and Park et al. in 2015 also reported excellent pain relief in 92% of patients with good satisfaction during follow-up.
Postoperative side effects included facial numbness in 85% of patients, which improved in about 3 months. Only 10% of patients had residual numbness which was mild in nature and not bothersome to the patients. Mild masseteric muscle weakness was present in seven (35%) patients, but none of the patients complained any difficulty in masticatory functions. Three (15%) patients reported herpes labialis simplex eruptions, which were treated with topical acyclovir and resolved in 1 week without any sequelae. No patient reported corneal anesthesia. On follow up the quality of life was better with mild post-operative hypoesthesia. Our results are comparable with those of Du et al. in 2015 who published their results in which patients had postprocedural morbidity such as facial numbness, masseter muscle weakness, and paresthesia. They also reported no incidence of corneal anesthesia or any other serious complication.
Patients with higher preoperative VAS scores showed lower VAS scores after the procedures, but the correlation between the two variables was weak. The higher preoperative BNI scores improved after the procedures and the correlation between these two variables was strong. The mean change in VAS score was 5.00 + 2.92 for single-nerve root involvement and 5.73 for multiple nerve root involvement, but the difference in mean VAS score was not significant. In addition, the mean changes in BNI score for single-nerve root involvement or multiple nerve root were not statistically significant. Du in 2015 also published improvement in postoperative BNI in 97% of patients.
| Conclusion|| |
Thus, to conclude, the percutaneous balloon procedure has an advantage of being a minimally invasive, safe, and effective procedure with minimal side effects. Improved quality of life was observed in patients with decrease in BNI and VAS score.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]