Microendoscopic stereotactic-guided percutaneous radiofrequency trigeminal nucleotractotomy.

OBJECT: Over the past few decades, various authors have performed open or stereotactic trigeminal nucleotractotomy for the treatment of neuropathic facial pain resistant to medical treatment. Stereotactic procedures can be performed percutaneously under local anesthesia, allowing intraoperative neurological examination as a method for target refinement. However, blind percutaneous procedures in the region of the atlantooccipital transition carry a considerably high risk of vascular injuries that may bring prohibitive neurological deficit or even death. To avoid such complications, the authors present the first clinical use of microendoscopy to assist percutaneous radiofrequency trigeminal nucleotractotomy. The aim of this article is to demonstrate intradural microendoscopic visualization of the medulla oblongata through an atlantooccipital percutaneous approach. METHODS: The authors present a case of severe postherpetic facial neuralgia in a patient who underwent the procedure and had satisfactory results. Stereotactic computational image planning for targeting the spinal trigeminal tract and nucleus in the posterolateral medulla was performed, allowing for an accurate percutaneous approach. Immediately before radiofrequency electrode insertion, a fine endoscope was introduced to visualize the structures in the cisterna magna. RESULTS: Microendoscopic visualization offered clear identification of the pial surface of the medulla oblongata and its blood vessels, the arachnoid membrane, cranial nerve rootlets and their entry zone, and larger vessels such as the vertebral arteries and the branches of the posterior inferior cerebellar artery. CONCLUSIONS: The initial application of this technique suggests that percutaneous microendoscopy may be useful for particular manipulation of the medulla oblongata, increasing the safety of the procedure and likely improving its effectiveness.

Bulbar trigeminal stereotactic nucleotractotomy for treatment of facial pain.

Many pharmacological and surgical treatments are available for the treatment of chronic facial pain. However, many of them are expensive and often very ineffective. Past publications suggested that bulbar trigeminal stereotactic nucleotractotomy is a very useful procedure for the treatment of neuropathic or oncologic facial pain. The authors describe the results of treatment with stereotactic nucleotractotomy in 58 patients with chronic facial pain. The intensity of the pain was evaluated according to the visual analogue scale, and daily life activities were also evaluated. The conclusion was that this procedure is a safe and effective method for treatment of postherpetic neuralgia, Wallenberg's syndrome and oncologic facial pain but not of trigeminal neuralgia.

Computed tomography-guided trigeminal tractotomy-nucleotomy in the management of vagoglossopharyngeal and geniculate neuralgias.

OBJECTIVE: Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia. PATIENTS AND METHODS: Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients. RESULTS: Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC. CONCLUSION: The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.

The Duke experience with nucleus caudalis DREZ coagulation.

The results of 46 nucleus caudalis DREZ coagulations performed at Duke in the preceding 5 years are reviewed retrospectively, with a mean follow-up of 32 months. Fifteen (38%) of 39 patients with complete data indicated that they would undergo the procedure again. Fifteen (38%) described improved quality of life. Outcome was fair or better in 18 (46%). Complications in the form of ataxia were present in 21 (54%).

[Nucleotomy of the spinal trigeminal nucleus. Apropos of 2 post-traumatic neuralgia with surgical treatment]. / Nucléotomie du noyau spinal du trijumeau. A propos de deux névralgies trigéminales post-traumatiques opérées.

This report describes two patients with medically intractable post-traumatique trigeminal neuralgia, who underwent bipolar coagulation of the pars caudalis of the trigeminal spinal nucleus. Follow-up examination--36 months and 7 months, respectively, after the procedure-showed that the patients were free of pain.

[Ultrasonic destruction of the spinal trigeminal nucleus in the deafferentation orofacial pain syndrome]. / Ul'trazvukovovoe razrushenie trigeminal'nogo spinal'nogo iadra pri deafferentatsionnom orofatsial'nom bolevom sindrome.

Ultrasonic destruction of the trigeminal spinal nucleus was conducted in 12 patients with the deafferentation orofacial pain syndrome. The etiological factors and clinical manifestations of the deafferentation syndrome are analysed. The surgical techniques of destruction of the trigeminal spinal nucleus and the principles of intraoperative electrophysiological control are described. The length of the nucleus destruction and the clinical effect of the surgical intervention are compared. To relieve pain and dysesthesia in the peri- and intraoral areas the terminal nucleus must be destroyed at the level of the obex of the fourth ventricle.

Craniofacial postherpetic neuralgia managed by stereotactic spinal trigeminal nucleotomy.

Postherpetic craniofacial neuralgias are notoriously difficult to deal with. Nevertheless, stereotactic spinal trigeminal nucleotomy seems to be a rational approach, as both experimental and clinical data strongly suggest the relevance of nucleus caudalis for certain facial neurogenic pain phenomena. From a series of 136 consecutive nucleotomies, 80 were performed for deafferentation pain. The long-term results of 25 such cases, who underwent this procedure for postherpetic neuralgia, are reported. Their pain was referred to the Vth, to the VII, IX and Xth, and to the C2-3 dermatomes. Abolition of the allodynia, and disappearance of, or marked reduction in, the deep background pain was achieved in 76% of the cases overall. The follow-up period ranged from 1 to 13 years. There was no untoward side-effects. Technical and electrophysiological data germane to accurate target placement are discussed. Spinal trigeminal nucleotomy is then a specially suitable procedure for postherpetic craniofacial dysaesthesiae.

Lesions of spinal and trigeminal dorsal root entry zone for deafferentation pain. Experience of 35 cases.

Spinal and trigeminal dorsal root entry zone destruction (DREZ-tomy) was performed on 35 patients with deafferentation pain of various types. Overall, satisfactory pain relief was obtained in 65.5% of spinal DREZ-tomy cases in the follow-up observation. The result in the brachial plexus avulsion group was the best (82.4% improved), followed by the limb pain group without root avulsion (50.0%), but the truncal or visceral pain group showed the worst result (33.3%). Two patients with postherpetic trigeminal neuralgia were completely relieved of pain in the average follow-up period of 32 months, while in 2 patients with postrhizotomy facial pain, pain recurred 4 months after the operation in 1, and, in the other, pain in the medial part of the face remained unchanged. Complications were seen in about 60% of the patients, which were, however, all mild, except for 2 cases of death due to gastrointestinal disease.

Clinical review of nucleus caudalis dorsal root entry zone lesions for facial pain.

Twenty-seven patients with intractable facial pain underwent dorsal root entry zone thermocoagulation lesion of the nucleus caudalis of the spinal trigeminal nucleus. Retrospective review revealed a success rate of 85% in the immediate postoperative period declining to 52% on subsequent follow-up. The best results were in the subgroup of patients with postherpetic neuralgia, of which 67% achieved definite relief. There tended to be some correlation of satisfactory results and pain quality as well as extent of pain along trigeminal territory. The operative morbidity was low although most patients were observed to have a mild transient ipsilateral dysmetria.

Benzodiazepine binding increases in the superficial laminae of the trigeminal subnucleus caudalis following central rhizotomy.

Benzodiazepine (BZ) binding is being studied in the spinal trigeminal nucleus of the cat 3 and 11 days following unilateral retrogasserian rhizotomy using in vitro autoradiography and computer-assisted densitometry. At 3 days following rhizotomy there is an increase in number and decrease in affinity of flunitrazepam binding sites in the superficial laminae of subnucleus caudalis of the spinal trigeminal complex. By 11 days, affinity remains below control values and binding site number shows an insignificant but detectable increase. There is no change in binding site characteristics in deeper laminae at either survival time. The results are discussed in relation to the physiological hyperactivity and synaptic changes which occur following such lesions and to other conditions of deafferentation.

[Partial vertical nucleotomy as a modification of tractotomy of the trigeminal nerve]. / Partielle vertikale Nukleotomie als Modifikation der Traktotomie des Nervus trigeminus.

The authors report on partial vertical nucleotomy, a modification of tractotomy of the quintothalamic tract. In 1979 eight patients underwent this procedure. Three of them showed a recurrence of pain from genuine trigeminal neuralgia. Three patients had symptomatic trigeminal neuralgia, one patient atypical neuralgia of the face without organic cause, whereas in one case the neuralgia occurred subsequent to a herpes zoster. At the time of examination all patients were free from pain.

[Partial vertical nucleotomy. A neurosurgical intervention in some forms of therapy-resistant facial neuralgia]. / Partielle vertikale Nukleotomie. Ein neurochirurgischer Eingriff bei einigen Formen des therapieresistenten Gesichsschmerzes.

The partial vertical nucleotomy is presented as a new neurosurgical method for the treatment of therapy-resistant pain in the spreading area of the N. trigeminus. Strict indications are laid down which are mainly restricted to therapy-resistant pain in the above mentioned spreading area in the presence of diffusely growing malignant tumours, after traumas and infections and predominantly in forms of idiopathic trigeminal neuralgia that has been treated without any results over a period of many years. In the experimental part of the article; material and method as well as results of anterograde transport on the efferent trigeminal pathways in rabbits by means of horseradish peroxi- dase (HRP) and its representation by means of tratramethylbenzidine (TMB) are discussed. Furthermore fibre preparations of the tractus and nucles spinalis nervi trigemini and the radiating fibres of the Nervus vagus are shown.

A method for bulbospinal trigeminal nucleotomy in the treatment of facial deafferentation pain.

Many types of facial pain are difficult to treat, such as postherpetic, posttraumatic, or pain following denervation procedures used in the treatment of trigeminal neuralgia (anesthesia dolorosa), all of which involve deafferentation of the spinal trigeminal nucleus.

[The role of open neurosurgery in the treatment of cancer pain]. / Il ruolo della neurochirurgia a cielo aperto nel trattamento del dolore neoplastico.

After a brief foreword on the indication of open surgery in the treatment of neoplastic pain those procedures are detailed which are more effective and widely used: Posterior Rhizotomy, Cordotomy, Mediolongitudinal Mielotomy and Bulbar trigeminal tractotomy. Of each procedure main technical features, indications and complications are detailed. It is concluded that these techniques are still very useful in management of severe cancer pain.