Surgical Treatment for Spasticity: Selective Dorsal Rhizotomy ­ Technique and Literature Review

Spasticity is amotor disorder that leads to a resistance to passive jointmovement. Cerebral palsy is the most important cause of spasticity and can be caused by several factors, including multiple gestations, alcoholism, infections, hemorrhages, drowning, and traumatic brain injuries, among others. There aremany scales that help tomeasure andmonitor the degree of impairment of these patients. The initial treatment should focus on the causal factor, such as tumors, inflammation, degenerative diseases, hydrocephalus, etc. Subsequently, the treatment of spastic musculature includes oral or intrathecal myorelaxants, spinal cord electrostimulation, neurotomies, Lissauer tract lesion, dentatotomy and selective dorsal rhizotomy. The latter is a safetechnique, possibleto beperformed inmost centers with neurosurgical support, and it is effective in the treatment of severe spasticity. In this article, the authors describe the surgical technique and conduct a review the literature.

Neurectomy of C2 for the Treatment of Occipital Neuralgia: Case Report

Occipital neuralgia (ON) is an uncommon cause of headache, and it is characterized by a stabbing paroxysmal pain that radiates to the occipital region. The present study includes a review of the literature and a case report. The etiology of this pathology can vary from traumas, infections, compressions of nerves or vertebrae, skull base surgeries, to degenerative changes and congenital anomalies. However, most of the time, the etiology is considered idiopathic. The diagnosis is essentially clinical. However, it is crucial that other types of primary headache are excluded. The treatment for ON may be based on nerve blocks, medications or surgeries. Neurectomy of the second spinal nerve is among the surgical techniques available.

Critérios de elegibilidade e efeitos da rizotomia dorsal seletiva sobre a função motora e marcha de crianças e adolescentes com paralisia cerebral: revisão sistemática / Eligibility criteria and effects of selective dorsal rhizotomy on the motor function and gait of children and adolescents with cerebral palsy: a systematic review

INTRODUÇÃO: A espasticidade pode ser considerada como uma das mais impactantes alterações secundárias à paralisia cerebral. Nos últimos anos, a Rizotomia Dorsal Seletiva (RDS) tem sido destacada como um procedimento cirúrgico eficaz para o tratamento da espasticidade dos membros inferiores de crianças com paralisia cerebral. OBJETIVOS: Verificar por meio de uma revisão sistemática da literatura os efeitos em médio e longo prazo, da RDS sobre a função motora grossa e a marcha em crianças e adolescentes com paralisia cerebral. Além de averiguar se existe um consenso na literatura sobre os critérios de indicação da RDS. MÉTODOS: Uma pesquisa foi realizada na rede internacional nos bancos de dados de acordo com os seguintes critérios de inclusão: (1) desenho: estudos envolvendo o acompanhamento pós-operatório longitudinal; (2) população: crianças e adolescentes com paralisia cerebral espástica; (3) intervenção: RDS; (4) grupo controle com intervenção diferente ou sem intervenção; (5) desfecho: melhora da função motora, melhora da espasticidade e desempenho da marcha. RESULTADOS: Foi encontrado um total de seis artigos que preencheram os critérios de inclusão e foram utilizados nesta revisão. Nos estudos analisados, foram observadas melhoras significativas na variável cinemática da marcha com diminuição da espasticidade no grupo RDS. CONCLUSÃO: A RDS diminui a espasticidade com efeitos positivos sobre a função motora grossa e a marcha de crianças e adolescentes com paralisia cerebral, porém estudos adicionais são necessários para esclarecer a eficácia da RDS aplicada em grupos musculares de membros inferiores.

INTRODUCTION: Spasticity can be considered one of the most striking alterations secondary to cerebral palsy. In recent years, Selective Dorsal Rhizotomy (SDR) has been highlighted as an effective surgical procedure for the treatment of lower limb spasticity in children with cerebral palsy. OBJECTIVES: To verify through a systematic review of the literature the medium and long-term effects of SDR on gross motor function and gait in children and adolescents with cerebral palsy. Secondarily, to verify if there is a consensus in the literature on the criteria to indicate SDR. METHODS: A search was performed in the international network databases according to the following inclusion criteria: (1) design: studies involving longitudinal postoperative follow-up; (2) population: children and adolescents with spastic cerebral palsy; (3) intervention: SDR; (4) control group with different intervention or without intervention; (5) outcome: improvement of motor function, improvement of spasticity and gait performance. RESULTS: A total of six articles were found that met the inclusion criteria and were used in this review. In the studies analyzed, significant improvements were observed in the kinematic gait variable with decreased spasticity in the SDR group. CONCLUSION: SDR decreases spasticity with positive effects on gross motor function and gait of children and adolescents with cerebral palsy, but additional studies are needed to elucidate the efficacy of RDS applied to lower limb muscle groups.

Gamma knife radiosurgery for trigeminal neuralgia: first case series from Latin America / Radiocirurgia por gamma knife para tratamento da neuralgia do trigêmeo: primeira série de casos na América Latina

ABSTRACT Gamma Knife® radiosurgery (GKRS) for trigeminal neuralgia is an effective treatment with at least a 50% reduction of pain in 75-95% of patients. Objective: To present the first series of patients treated for trigeminal neuralgia using GKRS in Latin America. Methods: Retrospective analysis. Analysis consisted of time to improvement of symptoms, best Barrow Neurological Institute scale (BNI) score after procedure, time without pain, time to recurrence and post-procedural hypoesthesia. Results: Nineteen cases of classical trigeminal neuralgia were analyzed and three cases of symptomatic trigeminal neuralgia were described. Mean time from symptom onset to radiosurgery was 99.6 months, and 78.9% of patients had undergone invasive procedures before treatment. Patients were followed for a mean of 21.7 months. BNI I was achieved in 36.8%, IIIa in 21.1%, IIIb in 21.1%, IV in 5.3% and V in 15.7%. New hypoesthesia developed in 12.1% patients, which was associated with achieving BNI I after the procedure (p < 0.05). Time from diagnosis to GKRS was higher in patients who failed to achieve BNI I (143 vs. 76 months). The distance from the root entry zone in patients who achieved BNI I was greater than patients who did not (1.94 vs. 1.14 mm). Mean distance from the root entry zone in patients with new hypoesthesia was 2.85 mm vs. 1.06 mm (p = 0.06). Conclusion: Clinical response to GKRS is related to the time between diagnosis and procedure, thus its indication should be considered early in the management of these patients.

RESUMO A radiocirurgia por Gamma Knife (GKRS) para neuralgia do trigêmeo é um tratamento comprovado, com redução de pelo menos 50% da dor em 75-95% dos casos. Objetivo: Apresentar a primeira série de pacientes tratados por neuralgia do trigêmeo com GKRS na America Latina. Métodos: Análise retrospectiva. A análise consistiu no tempo até melhora do sintoma, melhor escala do Barrow Neurological Institute (BNI) depois do procedimento, tempo sem dor, tempo até recorrência e hipoestesia pós-procedimento. Resultados: Dezenove casos de neuralgia do trigêmeo clássica foram analisados e três casos de neuralgia do trigêmeo sintomática foram descritos. Tempo médio entre começo dos sintomas e GKRS foi de 99,6 meses e 78,9% dos pacientes já tinham sido submetidos a procedimento invasivo prévio. O tempo de acompanhamento médio foi de 21,7 meses. BNI I foi conseguido em 36,8%, IIIa em 21,1%, IIIb em 21,1%, IV em 5,3% e V em 15,7%. Nova hipoestesia apareceu em 12,1% dos casos, o que foi associado a conseguir BNI I pós-procedimento (p < 0,05). Tempo desde o diagnóstico até GKRS foi maior em pacientes que não conseguiram BNI I (143 vs. 76 meses). Distância da zona de entrada do nervo em pacientes que conseguiram BNI I foi maior (1,94 vs. 1,14mm). Distância do zona de entrada do nervo em pacientes com nova hipoestesia foi de 2,85mm vs. 1,06mm (p = 0,06) Conclusão: A resposta à GKRS está relacionada ao tempo entre diagnóstico e procedimento, pelo que a indicação de GKRS deve ser considerada cedo no tratamento desses pacientes.

Rizotomia dorsal seletiva na paralisia cerebral: critérios de indicação e protocolos de reabilitação fisioterapêutica pós-operatória / Selective dorsal rhizotomy in cerebral palsy: selection criteria and postoperative physical therapy protocols

RESUMO Objetivo: Identificar critérios de seleção para a rizotomia dorsal seletiva (RDS) na paralisia cerebral (PC), analisar os instrumentos de avaliação e descrever as características da fisioterapia nos protocolos pós-operatórios. Fontes de dados: Revisão do tipo integrativa nas bases de dados SciELO, PEDro, Cochrane Library e PubMed. Os termos em português e inglês "paralisia cerebral", "rizotomia dorsal seletiva" e "fisioterapia" foram utilizados na busca. Os critérios de inclusão foram: artigos que arrolaram indivíduos com PC, que realizaram fisioterapia nos protocolos de RDS e que descreviam características desses protocolos. Foram excluídos artigos de revisão da literatura e não houve restrição de período de publicação. Síntese dos dados: Incluíram-se 18 estudos, sendo a maioria coortes prospectivas, com acompanhamento dos pacientes de oito meses a dez anos. Os instrumentos das avaliações contemplam, na maior parte dos trabalhos, os domínios de funções e estruturas corporais e atividade. O percentual de secção das raízes posteriores foi próximo a 50%. A principal indicação para a RDS incluiu deambuladores com diplegia espástica, que preenchiam os seguintes critérios: espasticidade que interfere com a mobilidade, boa força muscular de membros inferiores e tronco, sem deformidades ortopédicas, distonia, ataxia ou atetose e boa função cognitiva. A fisioterapia é parte integrante dos protocolos de tratamento com RDS, devendo ser intensiva, específica e enfatizada principalmente no primeiro ano. Conclusões: Os estudos salientam a importância da seleção adequada dos pacientes para o sucesso dos resultados. A fisioterapia é intensiva e de longa duração, devendo necessariamente ter estratégias para modificar o antigo padrão motor.

ABSTRACT Objective: To identify selection criteria for selective dorsal rhizotomy (SDR) in cerebral palsy, to analyze the instruments used for evaluation, and to describe the characteristics of physical therapy in postoperative protocols. Data sources: Integrative review performed in the following databases: SciELO, PEDro, Cochrane Library, and PubMed. The terms in both Portuguese and English for "cerebral palsy", "selective dorsal rhizotomy", and "physical therapy" were used in the search. Studies whose samples enrolled individuals with cerebral palsy who had attended physical therapy sessions for selective dorsal rhizotomy according to protocols and describing such protocols' characteristics were included. Literature reviews were excluded and there was no restriction as to period of publication. Data synthesis: Eighteen papers were selected, most of them being prospective cohort studies with eight-month to ten-year follow-ups. In most studies, the instruments of assessment encompassed the domains of functions, body structure, and activity. The percentage of posterior root sections was close to 50%. Primary indications for SDR included ambulatory spastic diplegia, presence of spasticity that interfered with mobility, good strength of lower limbs and trunk muscles, no musculoskeletal deformities, dystonia, ataxia or athetosis, and good cognitive function. Postoperative physical therapy is part of SDR treatment protocols and should be intensive and specific, being given special emphasis in the first year. Conclusions: The studies underline the importance of appropriate patient selection to obatin success in the SDR. Postoperative physical therapy should be intensive and long-term, and must necessarily include strategies to modify the patient's former motor pattern.

Resultados funcionales de corto plazo en rizotomía dorsal selectiva para el tratamiento de espasticidad en niños con parálisis cerebral / Short-term functional outcomes of selective dorsal rhizotomy for the treatment of spasticity in children with cerebral palsy

Introduction: selective dorsal rhizotomy (SDR) is a neurosurgical, non-reversible intervention to treat disabling spasticity in children with cerebral palsy (CP), improving their motor function and general performance. Objective: to assess functional outcomes of SDR in CP patients at Institutos teletón Chile, 6 and 12 months post-surgery. Patients and Method: Clinical records of all patients that underwent a SDR procedure between November 2010 and November 2013 were reviewed. Eighteen cases (spastic diplegia; age 7.5 +/- 2.9 years) were found, and their relevant pre-, peri- and post operative data after 6 and 12 months, were analyzed, as: clinical history, physical examination, evidence of preventricular leukomalacia (PVL), aspects related to surgery, and functional outcomes, including Gross Motor Function Measurement (GMFM)-66 and -88, Pediatric Evaluation Disability Inventory (PEDI) and gait lab (GL) using Gait Deviation Index (GDI). Results: Fifty percent of the subjects were classified as GMFCS II-III and the other 50 percent as GMFCS IV. A clinical important reduction in lower limb spasticity, particularly in triceps surae and hip flexors was observed in all patients, as well as improved muscular strength in many of them. GMFM-66 and GMFM-88 scores improved (p < 0.01). A trend towards improvement, without significant differences was observed in PEDI scores (GMFCS IV patients), and a significant improvement in GDI in ambulant patients (p < 0.015). Conclusions: SDR is a valid option to achieve long-lasting control of spasticity, 12 months after surgery, in children with spastic cerebral palsy, improving also functional capacity.

Introducción: la rizotomía dorsal selectiva (RDS) es una intervención neuro-quirúrgica irreversible para tratarla espasticidad discapacitante en niños con parálisis cerebral (PC). Su finalidad es mejorar la función motora y funcionalidad global de los pacientes. Objetivo: Evaluar los resultados funcionales de la RDS en los pacientes de Institutos teletón Chile con PC a los 6 y 12 meses postoperatorio. Pacientes y Método: Se revisan las fichas clínicas de los pacientes operados de RDS entre noviembre de 2010 y noviembre de 2013. Se encuentran 18 casos (diplejia espástica; edad 7,5 +/- 2,9 años), cuyos datos clínicos relevantes pre, peri y postoperatorios a 6 y 12 meses, fueron analizados: historia y examen físico; presencia de leucomalacia periventricular (LMPV); aspectos quirúrgicos y resultados funcionales de: Gross Motor Function Measurement (GMFM)-66 y 88, Pediatric Evaluation Disability Inventory (PEDI) y en laboratorio de marcha (LM), el Gait Deviation Index (GDI). Resultados: 50 por ciento correspondieron a pacientes GMFCS II-III y 50 por ciento a GMFCS IV. Se obtuvo importante reducción clínica de espasticidad de extremidades inferiores, especialmente plantiflexores de tobillo y flexores de cadera en todos los pacientes y en muchos un aumento de la fuerza muscular. Hubo mejoría en función motora gruesa evaluado con GMFM-66 (p < 0,001) y GMFM-88 (p < 0,001). tendencia a mejoría, sin diferencias significativas en PEDI (pacientes GMFCS IV) y mejoría significativa de GDI en pacientes ambulantes (p < 0,015). Conclusiones: La RDS es una opción válida para el control duradero de la espasticidad, a 12 meses, en niños con parálisis cerebral espástica, proporcionando además mejorías funcionales.

Rizotomia dorsal seletiva (RDS) para espasticidade: técnica minimamente invasiva no cone medular / Selective dorsal rhizotomy (SDR) for spasticity: minimally invasive technique at conus medullaris

A rizotomia dorsal seletiva é um procedimento cirúrgico bem aceito no manejo da espasticidade e tem como objetivo o alívio desse sintoma em pacientes cuidadosamente selecionados. Neste estudo, apresentamos o método que utilizamos em nosso serviço para indicação de pacientes, bem como a técnica cirúrgica e o método de monitorização neurofisiológica intraoperatória utilizado para otimizar os resultados. Realizamos também uma revisão bibliográfica utilizando os sites de busca da PubMed/MedLine e Lilacs, com artigos publicados entre os anos de 1965 e 2013. Os descritores utilizados foram: "rizotomia", "espasticidade", "paralisia cerebral" e "monitorização intraoperatória". Foram selecionados 17 artigos para este estudo.

Selective dorsal rhizotomy is a well-accepted cirurgic procedure utilized for relieving spasticity in carefully selected patients. In this work, we present the method we use to indicate the patients, the operative technique, and the intraoperative monitoring technique used in order to obtain the best results. We also reviewed the literature through the online databases PubMed/MedLine and Lilacs, with published papers from 1965 to 2013, descriptors included "rhizotomy", "spasticity", "cerebral palsy" and "intraoperative monitoring". We selected 17 articles for this study.

Trigeminal neuralgia: microvascular decompression with partial posterior root rihzotomy: Assiut university experience

Microvasclar decompression [MVD] for treatment of trigeminal neuralgia [TN] is a well accepted method of treatment for confirmed cases with vascular compression of trigeminal root, adding partial posterior root rhizotomy to microvascular decompression or doing it alone in cases with negative exploration for vascular compression is a successful mean of treatment, with satisfactory long term outcome. 20 cases of trigeminal neuralgia were treated by retrosigmoid approach and exploration of the posterior root of the trigeminal nerve between March 2008 to December 2012 in the department of neurosurgery, Assiut university hospital Egypt. Patients were studied retrospectively, 17 patients found to have definite vascular compression over the posterior root and underwent microvascular decompression with adding posterior root rhizotomy 3 patients had negative exploration for vascular compression and had only partial rhizotomy of the posterior root of trigeminal nerve. All patients had definitive improvement after surgery, 18 cases stopped their usual medications and became pain free without need of medications, 2 cases had improvement of pain after surgery with the aid of medications. One patient had partial hearing loss with partial facial palsy after surgery which improved with physiotherapy after 3 months, the same patient had corneal ulcer and developed corneal opacity in one eye, 12 patients [60%] developed parasthia and numbness in the distribution of the trigeminal nerve, one patient had just wound infection. Adding rhizotomy to posterior root of trigemninal nerve could he a way, to improve the result of microvascular decompression and to treat cases without vascular compression

Tratamiento neuroquirúrgico mínimamente invasivo de la neuralgia del trigémino: rizotomia percutánea con balón / Minimally invasive neurosurgical treatment of trigeminal neuralgia: percutaneous balloon Rhizotomy

Introducción: la neuralgia del trigémino esencial es una enfermedad en extremo invalidante, y si bien en sus primeras etapas el tratamiento farmacológico es eficaz, un porcentaje de pacientes se hacen refractarios. Es en estos casos en los que se plantea la opción de un tratamiento neuroquirúrgico. Material y método: se realiza un análisis retrospectivo de la casuística de pacientes a los cuales se les ha realizado una rizotomía trigeminal percutánea con balón en el Hospital Regional de Tacuarembó, en el Hospital Maciel, en el Hospital de Clínicas y en varios centros mutuales de Montevideo y del interior del país. En total se operaron 95 pacientes entre diciembre de 2004 y setiembre de 2010; 29 pacientes se operaron bajo neurolepto analgesia y 66 bajo anestesia general. Se utilizaron trócares específicos para la técnica y catéteres Fogarty® N° 4. En todos los casos se utilizó intensificador de imágenes para localizar el agujero oval. El promedio de internación en los casos no complicados fue de 48 horas. Resultados: 100 por ciento de los pacientes experimentaron un alivio completo del dolor en el período posoperatorio inmediato. El seguimiento ha sido entre dos meses y cinco años. En todos loscasos se suspendió la medicación en un plazo de tres a cuatro meses luego de la cirugía. De los pacientes operados entre 2004 y 2008, que constituye el subgrupo de enfermos con un seguimiento mínimo de dos años, el dolor recidivó en 16 por ciento de los casos. En un paciente (1 por ciento) se observaron complicaciones. No hubo mortalidad en esta serie. Conclusiones: la rizotomía percutánea con balón es una técnica muy segura, con excelente resultado en el alivio del dolor, permitiendo la suspensión del tratamiento farmacológico, que en muchos casos genera severos efectos colaterales, y que ofrece la posibilidad de ser repetidaen caso de recidiva con muy buena respuesta.

Introduction: essential trigeminal neuralgia is an extremely incapacitating disease, and, in spite of pharmacological treatment being effective in the first stages, a certain percentage of patients become refractory. In these cases, neurosurgical treatment is considered as a valid option. Method: a restrospective analysis of the casuistics was conducted for patients who were treated with percutaneous trigeminal rhizotomy in TacuarembóÆs Regional Hospital, in Hospital Maciel, in the University Hospital and in several private healthcare institutions in Montevideo, the capital city, and in the rest of the country. A total of 95 patients were operated from December 2004 through September 2010; 29 patients were operated under neuroleptic analgesia and 66 under general anesthesia. Technique-specific trocar needles and Fogarty® N° 4 catheters were used. In all cases, image intensifiers were used for the localization of the oval whole. Average hospital stay was 48 hours for non-complicated cases. Results: 100 percent of patients were completely relieved frompain in the immediate post-operative period. Follow-up ranged from two months to five years. In all cases, medication was suspended within three to four months after surgery. Out of the patients operated between 2004 and 2008, which correspond to the sub-group of patients whose follow-up lasted at least two years, pain recidivated in 16 percent of cases. One patient (1 percent) evidenced complications.There was no mortality in this group.Conclusions: percutaneous baloon rhizotomy is a very safe technique, and it is very effective to relieve pain, enabling the suspension of harmacological treatment, which in many cases results in severe side effects, and it is also possible to be repeated in the event of recidivism, achieving very good results.

Introdução: a nevralgia de trigêmeo essencial é uma doença invalidante, e embora o tratamento farmacológico seja eficaz em suas primeiras etapas, uma porcentagem de pacientes se tornam refratários. Nestes casos se sugere o tratamento neurocirúrgico como opção terapêutica. Material e método: realizou-se una análise retrospectiva da casuística de pacientes submetidos à rizotomia trigeminal percutânea com balão nos hospitais Regional de Tacuarembó, Maciel, Clínicas e em vários centros de atenção médica de Montevidéu e do interior do país. Foram operados 95 pacientes entre dezembro de 2004 e setembro de 2010; 29 pacientes foram operados com neuroleptoanalgesia e 66 com anestesia general. Foram utilizados trocartes específicos para a técnica e cateteres Fogarty® N° 4. Em todos os casos um intensificador de imagens para localizar o forâmen oval foi utilizado. O tempo médio de internação nos casos não complicados foi de 48 horas. Resultados: 100 por cento dos pacientes relataram alivio completo da dor no período pós-operatório imediato. O seguimento foi de dois meses a cinco anos. Em todos os casos se suspendeu a medicação depois de três a quatro meses da cirurgia. Considerando os pacientes operados entre 2004 e 2008, que constituem o subgrupo comseguimento mínimo de dois anos, a dor recidivou em 16 por cento dos casos. Um paciente (1 por cento) apresentou complicações.Não foram registrados óbitos nesta série. Conclusões: a rizotomia percutânea com balão é uma técnica segura, com excelente resultado para aliviar a dor, permitindo a suspensão do tratamento farmacológico, que em muitos casos gera efeitos colaterais graves, e oferece a possibilidade de ser repetida caso haja recidiva, com resposta muito boa.

Percutaneous radiofrequency rhizotomy and neurovascular decompression of the trigeminal nerve for the treatment of facial pain / Rizotomia percutânea por radiofreqüência e a descompressão neurovascular do nervo trigêmeo no tratamento das algias faciais

OBJECTIVE: To determine the outcomes of 354 radiofrequency rhizotomies and 21 neurovascular decompressions performed as treatment for 367 facial pain patients (290 idiopathic trigeminal neuralgia, 52 symptomatic trigeminal neuralgia, 16 atypical facial pain, 9 post-herpetic neuralgia). METHOD: Clinical findings and surgery success rate were considered for evaluation. A scale of success rate was determined to classify patients, which considered pain relief and functional/sensorial deficits. RESULTS: Radiofrequency rhizotomy was performed in 273 patients with idiopathic trigeminal neuralgia and in all other patients, except for trigeminal neuropathy; neurovascular decompression was performed in 18 idiopathic trigeminal neuralgia patients; 100 percent idiopathic trigeminal neuralgia, 96.2 percent symptomatic trigeminal neuralgia, 37.5 percent atypical facial pain and 88.9 percent post-herpetic neuralgia had pain relief. CONCLUSION: Both techniques for idiopathic trigeminal neuralgia are usefull. Radiofrequency rhizotomy was also efficient to treat symptomatic facial pain, and post-herpetic facial pain, but is not a good technique for atypical facial pain.

OBJETIVO: Determinar eficácia e achados pós-operatórios após 354 rizotomias por radiofreqüência e 21 descompressões neurovasculares como tratamento de 367 pacientes com dor facial (290 neuralgia idiopática do trigêmeo, 52 neuralgia sintomática do trigêmeo, 16 dor facial atípica, 9 neuralgia pós-herpética). MÉTODO: Achados clínicos e taxa de sucesso das cirurgias foram considerados para a avaliação. Uma escala avaliando alívio da dor e complicações sensoriais e funcionais foi utilizada para classificar os pacientes. RESULTADOS: A rizotomia por radiofreqüência foi realizada em 273 pacientes com neuralgia idiopática do trigêmeo e em todos os outros pacientes, exceto neuropatia trigeminal; descompressão neurovascular foi realizada em 18 pacientes com neuralgia idiopática do trigêmeo; 100 por cento dos pacientes com neuralgia idiopática do trigêmeo, 96.2 por cento dos pacientes com neuralgia sintomática, 37.5 por cento dos pacientes com dor facial atípica e 88.9 por cento dos doentes com neuralgia pós-herpética tiveram alívio da dor. CONCLUSÃO: Ambas as técnicas são úteis para a neuralgia idiopática do trigêmeo. A rizotomia por radiofreqüência foi também eficiente para tratar neuralgia sintomática do trigêmeo e pós-herpética, mas não foi uma boa técnica como tratamento da dor facial atípica.

Percutaneous trigeminal glycerol rhizotomy as a treatment for trigeminal neuralgia

To evaluate the efficacy of percutaneous trigeminal glycerol rhizotomy in 15 patients with trigeminal neuralgia, who were either not responding or only partially responding to medical therapy. Design: Case - series study. Setting: Neurosurgical Unit, Mosul Teaching Hospital, during the period from May 1992 to July 1994. Patients and All patients were investigated by plain skull radiographs and CT examinations to rule out the possibility of tumour or any other pathology. The injection was done in the operating theater aided by TV screen using sterile undiluted glycerol. The foramen ovale was approached percutaneously 2.5-3 cm. lateral to the angle of the mouth. The injection was given into the retrogasserian rootlets while the patient was in a semisitting position with the neck being slightly flexed. Trigeminal sensations were tested 2 hours post-injection. The final results after 9-36 months follow-up period indicated that 8 patients had complete pain relief and 3 patients had mild residual pain controlled adequately by medications making a total of 11 patients [73%] who had good pain control. No serious or long lasting complications were encountered. This method of treatment appeared to be useful in old frail patients especially after failure of medical therapy. It is also of value in managing patients with bilateral trigeminal neuralgia