Percutaneous trigeminal tractotomy–nucleotomy with use of intraoperative computed tomography and general anesthesia: report of 2 cases

Thompson, Eric M.; Burchiel, Kim J.; Raslan, Ahmed M.

doi:10.3171/2013.6.focus13218

Cited by 15 publications

(10 citation statements)

References 6 publications

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“…89 Other similar image-guided procedures can be performed in the lower brainstem and upper cervical spinal cord to disrupt the trigeminal tract and nucleus in cases of intractable trigeminal neuropathic pain (TNP). 112 Midline myelotomy 77 may also fall into the category of destructive spinal cord procedures that may be selectively used in patients with intractable pelvic pain due to malignancy, although the data for this procedure is very limited.…”

Section: Cordotomy Tractotomy and Myelotomymentioning

confidence: 99%

“…It is estimated that 34,000 spinal cord stimulation (SCS) procedures are performed annually worldwide. 112 The current neuromodulatory approaches used for pain management are either pharmacological, utilizing intrathecal pumps to directly administer medications into the CSF space, or electrical, utilizing electrical stimulation to modulate various targets of the nervous system such as peripheral nerves, dorsal root ganglia, spinal cord, and brain. The main indication for neuromodulation is chronic pain not due to malignancy.…”

Section: Neuromodulationmentioning

confidence: 99%

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Contemporary concepts of pain surgery

Burchiel

Raslan

2019

Journal of Neurosurgery

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Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.

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Section: Cordotomy Tractotomy and Myelotomymentioning

confidence: 99%

Section: Neuromodulationmentioning

confidence: 99%

Contemporary concepts of pain surgery

Burchiel

Raslan

2019

Journal of Neurosurgery

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“…Although the CT-guided awake technique for TR-NC procedures is generally preferred when there is intractable craniofacial pain, successful intraoperative CT-guided trigeminal TR-NC while the patient is under general anesthesia has also been reported [8]. In their report, Thompson et al [8] presented two cases: one of a postherpetic neuralgia patient and another of a patient with postoperative hemi-cranial neuralgia in whom awake CT-guided trigeminal TR-NC failed because of intolerable pain when the patient was positioned in the prone position during the procedure. Nevertheless, those authors performed trigeminal TR-NC procedures using real-time intraoperative CT imaging to obtain radiologic confirmation of electrode position.…”

Section: Discussionmentioning

confidence: 99%

“…Although not commonly used, trigeminal TR-NC has been suggested as an effective procedure for the denervation of areas innervated by CNs V, VII, IX, and X to relieve pain. It is also considered a viable treatment option for patients with malignancy-related facial pain, anesthesia dolorosa, neuropathic facial pain, postherpetic neuralgia, glossopharyngeal neuralgia, geniculate neuralgia, refractory trigeminal neuralgia [8], and atypical facial pain [9]. Its success rate reportedly ranges from 84% to 94% in different series [1, 9].…”

Section: Introductionmentioning

confidence: 99%

CT-Guided Percutaneous Trigeminal Tractotomy-Nucleotomy for Intractable Craniofacial Pain

Bekâr

Ocak

Taşkapılıoğlu

et al. 2020

Stereotact Funct Neurosurg

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Object: In this report, we aimed to analyze the outcome results of our patients who underwent percutaneous trigeminal tractotomy (TR) and nucleotomy (NC) procedures, which are defined as destructive procedures targeting the descending trigeminal tractus and nucleus caudalis of the spinal trigeminal nucleus, respectively, for intractable craniofacial pain. Methods: The medical records of a total of 12 patients who underwent a total of 14 computed tomography (CT)-guided TR-NC procedures at our clinics between 2005 and 2017 were retrospectively reviewed. Results: A significant increase in patients' performance status (p = 0.015) as well as a significant decrease in the VAS score (p < 0.001) were achieved. Grade I pain relief (VAS = 0, no pain) was established in 66.7% of the patients, whereas grade II pain relief was observed in the remaining patients. Two of the patients suffered from recurrent pain after the initial procedure. Both patients underwent a second trigeminal TR-NC procedure, and grade I pain relief was re-established. The mean VAS score at 3-month follow-up was 1.4 ± 1.1, whereas this score at 6-month follow-up was 2 ± 1.3. The trigeminal TR-NC procedure resulted in a significant decrease in patients' VAS scores at 3-and 6-month follow-up visits compared with preoperative VAS scores (p < 0.001). Transient ataxia was noted in only one patient (8.3%) early after the procedure. Conclusions: The results presented in the current study support the efficacy of the percutaneous CT-guided trigeminal TR-NC procedure in the management of intractable facial pain in selected patients. The use of CT guidance allows direct visualization of the target area, thereby enhancing the safety and success of the procedure.

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“…This method requires partial sedation in order to perform intraoperative stimulation tests prior to nerve destruction [8] [9]. Managing patient sedation to an adequate level to achieve a reliable verbal response to nerve stimulation is notoriously problematic, especially in elderly patients whose hypersensitivity to sedatives results in a very narrow window in which light sedation can be adequately maintained [10].…”

Section: Discussionmentioning

confidence: 99%

Stereotactic Radiofrequency Ablation of Trigeminal Ganglion with Intraoperative CT Scans and under General Anesthesia

Patil¹,

Chamczuk²,

Nelson³

2016

OJMN

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Introduction: Traditionally radiofrequency ablation of the trigeminal ganglion is performed using fluoroscopy and under heavy sedation. Intra-operative stimulation studies are used in order to confirm the presence of the probe tip in the appropriate division. Unfortunately, in older patients it becomes challenging to transition between heavy sedation (for probe insertion and lesion generation) and light sedation (for stimulation studies). To solve this problem, the authors describe a method in which the procedure was performed under general anesthesia and appropriate needle position was confirmed by intraoperative CT scans. Furthermore, to make the procedure more accurate a stereotactic frame was used. Methods: Eleven procedures were performed on 10 patients from 2012-2015 with a median follow-up of 21 months. The age range of the patients was 33-90 years (median of 55), and with a male to female ratio of 6:4. Ablations were accomplished on the 3rd division in five patients, the 2nd division in three patients, and 2nd and 3rd divisions in two patients (one of them underwent bilateral procedures). The procedures were performed under general anesthesia, using a Patil stereotactic frame on the CT table. The center of the foramen ovale was chosen as the target. The probe insertion point was approximately 2.5 cm lateral to the angle of the mouth. To place the probe tip in the 3rd division it was advanced through the foramen ovale into the trigeminal ganglion until its tip was 5 mm anterior to the clival plane. To place it in the 2nd division, it was advanced until it was in the clival plane. The probe had an exposed tip of 8 mm and heating was done at 75˚C for 60 seconds. Results: Nine patients are pain-free; one patient, who had atypical facial pain did not benefit from the procedure; and one patient (with bilateral pain) has hyperesthesia on one side. Conclusion: Trigeminal ganglion ablation under general anesthesia is a good option for older patients and for those who cannot tolerate being awakened during the procedure. The stereotactic method enables easy placement of the probe and intraoperative CT scans affords confirmation of accurate probe placement.

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Percutaneous trigeminal tractotomy–nucleotomy with use of intraoperative computed tomography and general anesthesia: report of 2 cases

Cited by 15 publications

References 6 publications

Contemporary concepts of pain surgery

Contemporary concepts of pain surgery

CT-Guided Percutaneous Trigeminal Tractotomy-Nucleotomy for Intractable Craniofacial Pain

Stereotactic Radiofrequency Ablation of Trigeminal Ganglion with Intraoperative CT Scans and under General Anesthesia

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