Electrical stimulation of the trigeminal tract in chronic, intractable facial neuralgia

In this paper the treatment of patients with chronic, intractable trigeminal neuralgia by invasive electrical stimulation of the Gasserion ganglion is reviewed. Two different surgical techniques are employed in this treatment. Most frequently, a method similar to the traditional technique for percutaneous glycerol and radiofrequency trigeminal rhizolysis is used: a small percutaneous stimulation electrode is advanced under fluoroscopic control through a thin needle via the foramen ovale to the Gasserian cistern. Some neurosurgeons use an open surgical technique by which the Gasserian ganglion is approached subtemporally and extradurally, and the bipolar pad electrode is sutured to the dura. When percutaneous test stimulation is successful (at least 50% pain relief) the electrode is internalized and connected to a subcutaneous pulse generator or RF-receiver. Data from 8 clinical studies, including 267 patients have been reviewed. Of all 233 patients with medication-resistant atypical trigeminal neuralgia 48% had at least 50% long term pain relief. The result of test stimulation is a good predictor of the long term effect, because 83% of all patients with successful test stimulation had at least 50% long term relief, and 70% had at least 75% long term relief. Patients generally preferred this invasive method over TENS. The success rate in patients with postherpetic trigeminal neuralgia was very low (less than 10%). It is suggested that the likelihood of pain relief by electrical stimulation is inversely related to the degree of sensory loss. It is concluded that invasive stimulation of the Gasserian ganglion is a promising treatment modality for patients with chronic, intractable, atypical trigeminal neuralgia.     

Five-and-a-half years' experience with percutaneous retrogasserian glycerol rhizotomy in treatment of trigeminal neuralgia

The results of treating trigeminal neuralgia with percutaneous retroganglionic glycerol rhizotomy in 319 patients from an overall series of 394 patients with 459 operations carried out over a period of 5 1/2 years are reported. Idiopathic trigeminal neuralgia was the diagnosis in 252 patients. 34 patients had trigeminal neuralgia associated with multiple sclerosis. The remaining 33 patients suffered from symptomatic trigeminal neuralgia or atypical facial pain. 230 patients (91.3%) with idiopathic trigeminal neuralgia and 30 patients (88.2%) with multiple sclerosis reported complete freedom from pain. In 12 patients (4.8%) of those with tic douloureux and in 1 patient (2.9%) with multiple sclerosis, pain was alleviated, and the patients required a reduced pharmacotherapy. 10 patients (3.9%) and 3 patients (8.8%) were considered to be treatment failures. The rate of recurrences within the first 2 years was 10.9 and 40.0%, respectively. In the long-term, the rate of recurrences in patients with tic douloureux was 36.9%. 144 patients (45.1%) noticed a hypesthesia. 132 patients (41.4%) had hypalgesia following the procedure, and there was a decrease of symptoms in the long-term observation in 20.0% of the patients. 59 patients (18.5%) developed dysesthesia postoperatively which regressed only to an inappreciable extent in the long-term course. In 16 patients (5.0%) exclusively with a preexisting organic lesion or who had received surgical pretreatment, there was a loss of corneal sensation. The investigation showed on the one hand the effectiveness of the method, but on the other hand also the possibility of marked sensory disorder in selected cases.     

Early trigeminal evoked potentials in tumours of the base of the skull and trigeminal neuralgia

Early scalp responses evoked by stimulation of the infraorbital nerve (W1, W2, W3) have been investigated in 23 patients affected by tumours of the base of the skull (parasellar area and cerebello-pontine angle) and in 38 patients suffering from ‘idiopathic’ trigeminal neuralgia. Differences in conduction times between healthy and affected side were evaluated and confronted with data obtained from 30 normal volunteers.Alterations of the response were found in all the patients with tumours of the base of the skull who had clinical signs in the trigeminal area and in 7 of the 12 cases without such signs. The usual pattern of alteration in cases with tumours of the parasellar area was a parallel involvement of W2 and W3 (both absent or delayed to the same extent), whereas in tumours of the cerebello-pontine angle W3 was more seriously affected than W2. Wave W1 was never altered. Pre- and post-operative recording sessions in 2 patients showed definite improvement of the responses after removal of the tumour.In 9 patients suffering from ‘idiopathic’ trigeminal neuralgia delays of conduction were found on the painful side, suggesting that damage to the trigeminal root, possibly at its entry zone into the pons, had taken place. Retrogasserian injection of glycerol was performed in 12 of the 38 patients with trigeminal neuralgia. Stimulation of the operated side showed disappearance of W2 and W3 in 9 cases, prolonged W1–W3 interval in 2 cases and no alterations in 1 case. The extent of response alteration usually paralleled the clinical results.     

家族性三叉神经痛

三叉神经痛是一种临床常见疾病,典型的三叉神经痛主要表现为阵发性、闪电样的疼痛发作,疼痛剧烈,常无法忍受,呈电灼、针刺、撕裂样,每次发作持续时间数秒至数分钟不等。疼痛多发生于单侧,常有扳机点表现,其多表现为散发,而家族性三叉神经痛报道罕见,至今世界范围内报道仅50余个家系,其临床表现及发病特点与散发性三叉神经痛存在明显差别,尽管散发三叉神经痛患者的病因为责任血管压迫三叉神经REZ区已被普遍接受,但关于家族性三叉神经痛的病因是否为血管压迫存在争议,其遗传模式也没有达成一致的意见,文章复习了相关文献,并通过对这些文献进行分析综合,结合我们治疗三叉神经痛的经验,对其病因、发病机制、诊断和治疗原则、遗传模式等作了系统综述。     

Radiofrequency thermocoagulation of Gasserian ganglion and its rootlets for trigeminal neuralgia.

Thirty-nine patients with trigeminal neuralgia, not controlled by medical treatment, were treated by radio-frequency thermocoagulation of the Gasserian ganglion and its posterior rootlets. Thirty-six received satisfactory pain relief. In 30 patients touch sensation in the treated territory was preserved. The corneal reflex was affected in only six patients, two of whom subsequently developed keratitis. There were no other complications apart from a minor unpleasant sensation in eight patients. By selectively destroying pain fibres this technique offers the scope of preserving touch sensation in the treated area. Moreover, the zone of analgesia can be restricted to the affected region by sensory mapping through electrode stimulation before thermocoagulation. Its simplicity, low morbidity, associated short hospital stay, and the increased ability to preserve touch sensation, especially of the cornea, seem to make it preferable to other forms of surgical management for trigeminal neuralgia.     

Microsurgical Vascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm

Vascular cross-compression of cranial nerves has been proposed as the cause of cranial neuropathies, including trigeminal neuralgia and hemifacial spasm. Over the last decade we have used microsurgical vascular decompression to treat these two disorders. Results in 50 patients treated for trigeminal neuralgia have been excellent in 42, good in 5 and poor in 2; and 1 patient was cured after a second operation. Results in 22 patients treated for hemifacial spasm have been excellent in 18, good in 2 and fair in 1. One patient died. There were no late recurrences of symptoms.The pathophysiological mechanisms of trigeminal neuralgia and hemifacial spasm remain unknown.     

Trigeminal neuralgia in a patient with multiple sclerosis treated with high cervical spinal cord stimulation. Case report

A 42-year-old male with advanced multiple sclerosis had severe left-sided trigeminal neuralgia in the maxillary and mandibular divisions that was extremely difficult to control with medications. Glycerol injection in the gasserian cystern provided only temporary results. Two electrodes were implanted epidurally at the C1-2 level, one in the midline and the other to the left of midline. Electrical stimulation produced complete relief from the painful paroxysms.     

原发性三叉神经痛和疱疹后三叉神经痛临床特征及射频热凝术后效果分析

摘要 目的：探讨原发性三叉神经痛（PTN）和疱疹后三叉神经痛（PHN）的临床特征,并比较经卵圆孔射频热凝术（RF-TC）治疗PTN和PHN的临床疗效。方法：随机选取2019年1月至2020年8月在我院治疗的三叉神经痛患者123例,其中原发性三叉神经痛90例,带状疱疹后神经痛33例。所有患者均通过RF-TC进行治疗,治疗后通过视觉模拟量表（VAS）、巴罗神经研究所疼痛强度量表对面部疼痛评分进行疼痛评估,通过巴罗神经研究所麻木评分进行麻木评定,通过健康问卷-9对患者抑郁情况进行评估,通过匹斯堡睡眠质量指数测量患者心理状态。结果：PTN患者发病年龄显著低于PHN患者（P<0.05）,而病程显著高于PHN患者（P<0.05）;PHN患者的眼支发生率高于PTN患者（39.39% vs 8.89%, P<0.05）。两组患者经RF-TC治疗前后VAS评分无显著差异（P>0.05）。PHN组从轻度到重度影响睡眠质量的比例显著高于PTN组（30.30% vs 10.00%, P<0.05）。PTN组患者治疗后中重度抑郁患者比例显著高于PHN组患者（21.11% vs 9.09%, P<0.05）。两组患者经RF-TC治疗后,临床治疗有效率、面麻木程度以及巴罗神经研究所疼痛强度量表评定的面部疼痛无显著差异（P>0.05）。结论：经卵圆孔射频热凝术治疗原发性三叉神经痛和带状疱疹后三叉神经痛是安全有效的,但治疗后疱疹后三叉神经痛失眠的发生率较高,而原发性三叉神经痛的抑郁发生率较高。     

Results of treatment of trigeminal neuralgia by microvascular decompression of the Vth nerve at its root entry zone.

Eighty five patients suffering from trigeminal neuralgia resistant to medical therapy underwent surgical treatment for relief of pain at the Department of Neurosurgery University Alexander Hospital Sofia from 1981 until 1997. Microvascular decompression at the root entry zone of the V(th) nerve has been performed using the technique of Jannetta. The operative exploration of the parapontine root entry zone disclosed neurovascular conflicts in 87.1% of the cases. They represented displacement and/or distortion, sometimes pressure grooves, discoloration, altered vascularity of the V(th) nerve. The analysis of early postoperative results have shown an excellent outcome in 90.6% of the cases, good in 3.5% and poor in 2.4% with mortality of 3.5% early in these series when no postoperative monitoring was available. The follow up study one year after surgery revealed 90.2% excellent and 3.7% good results and poor outcome and recurrences in 6.1% of the cases. Patients with long lasting trigeminal neuralgia, previous destructive procedures, venous compression, lack of convincible evidences for neurovascular conflicts had less favorable outcome or recurrences. In the last years partial sensory rhizotomy was performed in cases when no neurovascular conflicts were found out. Patients with unquestionable arterial compression leading to displacement associated with distortion and pressure grooves had excellent outcomes. Early recurrences were associated with missed pathology at the entry zones. During reexplorations for late recurrences new arterial compression was found in less than half of the cases.     

Triamcinolone-Procaine in the Treatment of Zoster and Postzoster Neuralgia

Twenty-four patients with herpes zoster were treated with injections of 2 percent procaine hydrochloride containing 2 mg of triamcinolone per ml. The treatments were given subcutaneously under the cutaneous lesions and in areas of pain. The results were excellent in 22 patients. There was one failure—postzoster neuralgia in an 82-year-old woman.Of 12 patients with postherpetic neuralgia, eight had improvement of 70 to 90 percent and three had complete relief.There were no significant complications in either group.     

Treatment of spasmodic torticollis by dorsal column stimulation.

A new method is described to treat spasmodic torticollis with the implantation of a dorsal column stimulator at the C1--2 level or with transcutaneous stimulation. 22 patients were evaluated. 3 had sufficient relief to be treated with transcutaneous stimulation only. An additional 6 patients had surgically implanted dorsal column stimulators. It was empirically determined that a frequency of 800--1,100 Hz gave the best relief from torticollis. 1 patient had an excellent result; 3 have had good results; 1 had a fair result, and 1 had a poor result. An additional patient with dystonia musculorum deformans was considerably improved by the use of dorsal column stimulation.     

Electrical stimulation of the posterior limb of the internal capsule for treatment of thalamic pain

Electrical stimulation of the posterior limb of the internal capsule was performed in 7 patients with thalamic pain who had developed dysesthesia, hyperpathia and/or spontaneous burning pain. Ramped bipolar stimulation elicited sensory responses, such as warm or comfortable sensation. Follow-up from 9 months to 2 years and 7 months showed that 3 patients had a good result, two had fair and the remaining two had poor results. No serious side effects were seen. The mechanism of pain relief by the internal capsule stimulation is discussed.     

Effectiveness of radiofrequency thermocoagulation in recurrent trigeminal neuralgia after previous retrogasserian rhizotomy

Between 1974 and 1984, 428 trigeminal neuralgia cases were treated by controlled radiofrequency thermocoagulation (RFTC). 29 had recurrent trigeminal neuralgia after intracranial surgery. 26 of the 29 patients were treated by retrogasserian rhizotomy and 3 by posterior fossa exploration. Among the 26 recurrent trigeminal neuralgia following retrogasserian rhizotomy, RFTC was effective in 23 cases (88.5%), and in 3 cases (11.5%) RFTC was effective for a short period. Repeated RFTC was unable to control the pain attacks which were later relieved by posterior fossa exploration and root section. Of the 3 recurrent trigeminal neuralgia following posterior fossa exploration, RFTC was effective in 2 cases (66.6%).     

Treatment of Trigeminal Neuralgia with Percutaneous Glycerol Injection into Meckel’s Cavity: Experience in 4012 Patients

Percutaneous glycerol injection into Meckel’s cavity is widely used to treat trigeminal neuralgia. Reports published to date summarized clinical experiences in small or intermediately sized groups of patients. The efficacy of this procedure in a large group of patients has not been evaluated so far. From December 1983 to November 2008, patients with primary trigeminal neuralgia were treated in our clinic using percutaneous glycerol injection into Meckel’s cavity which was conducted according to the Hakanson’s anterior puncture method with some modifications. In total, 4012 patients (2205 female) with a mean age of 56.5 (23–87) years were treated. The majority of patients (99.23%) experienced unilateral pain, while a small cohort of patients (31; 0.77%) had bilateral pain. The immediate success rate of the procedure was 97.1%. There was a significant (P < 0.01) positive correlation between the presence of cerebrospinal fluid (CSF) outflow and the curative effect. Follow-up was done in 3157 patients for the period of 1–25 years. The long-term success rate was 81.18%. No serious adverse effects were observed. The procedure is very effective and applicable to a wide variety of patients with trigeminal neuralgia. The presence of CSF outflow during puncture predicts better immediate and long-term outcomes.     

Epileptiform activity in the somatosensory cortex of rats with trigeminal neuralgia]

It was shown in experiments on rats that penicillin 1 microliter microinjection (100 U) into the caudal nucleus of the spinal tract of the trigeminal nerve, accounting for formation of a generator of pathologically enhanced excitation (GREE), brings about in rats the pain syndrome with characteristic for trigeminal neuralgia behavioural manifestations and the emergence of epileptiform activity in the somatosensory cortex, especially pronounced in the contralateral hemisphere. The emergence of this activity reflects, on the one hand, the action of the GREE in the caudal nucleus of the trigeminal nerve and, on the other hand, the involvement of the somatosensory cortex taking over stimulation from the hyperactive caudal nucleus, into formation of a pathological algic system of this form of trigeminal neuralgia.     

带状疱疹后神经痛的射频治疗

带状疱疹后神经痛(postherpetic neuralgia,PHN)是带状疱疹的严重并发症,发病机制复杂,是一种难治性、顽固性的神经病理性疼痛,常见于老年患者或免疫功能低下的患者,严重影响日常生活。带状疱疹后神经痛的治疗方法包括药物治疗、神经刺激法、射频疗法以及神经阻滞法等。其中,射频疗法作为一项临床较为常用的治疗手段,已在各种慢性疼痛的治疗上取得了有效应用。本文将综合国内外近期的相关研究,对射频的机制、射频的分类、射频治疗PHN的疗效和治疗靶点的选择进行总结。     

Percutaneous Radio-Frequency Rhizotomy in the Treatment of Trigeminal Neuralgia

A percutaneous technique of selective partial trigeminal root coagulation was evaluated in the treatment of 38 patients suffering from trigeminal neuralgia, 1 patient with pain secondary to oral carcinoma and 1 patient with atypical facial pain. The pain of trigeminal neuralgia was relieved in 94.7 percent of patients. Pain was relieved in the patient with oral carcinoma, but not in the patient with atypical facial pain. There was no mortality and no permanent morbidity outside of the trigeminal nerve lesion. The procedure requires only a brief hospital stay without the time, expense and hazards of open cranial surgical procedures.     

微球囊压迫介入治疗三叉神经痛

目的：三叉神经痛是口腔科常见疾病之一,病因不清。令患者难于忍受。多年来人们探索出很多的治疗手段,这些方法均不同程度伴有疗效、副损伤及并发症上的各种缺点。经研究经介入方法利用微球囊能改变了三叉神经半月节的解剖位置从而缓解其周围压力,进而治疗了三叉神经痛且疗效很好。结论：微球囊加压介入治疗三叉神经痛是目前有效治疗三叉神经痛的方法。     

Distribution of lumbar spinal evoked potentials and their correlation with stimulation-induced paresthesiae

In 7 awake patients with neuropathic lower extremity pain, spinal somatosensory evoked potentials (SEP) were elicited from the non-painful leg by electrical stimulation of the peroneal nerve and mechanical stimulation of the hallux ball. Recording was made epidurally in the thoraco-lumbar region by means of an electrode temporarily inserted for trial of pain-suppressing stimulation.In response to peroneal nerve stimulation, two major SEP complexes were found. The first complex consisted, as has been described earlier, of an initial positivity (P12), a spike-like negativity (N14), a slow negativity (N16) and a slow positivity (P23). The second complex consisted of a slow biphasic wave, conceivably mediated by a supraspinal loop. Both complexes had a similar longitudinal distribution with amplitude maxima at the T12 vertebral body.The SEP evoked by mechanical hallux ball stimulation had a relatively small amplitude, and there was no significant second complex. The relationship between stimulus intensity and SEP amplitude was negatively accelerating.The longitudinal distribution of spinal SEP was compated with the somatotopic distribution of paresthesiae induced by stimulation through the epidural electrode. It was found that stimulation applied at the level of maximal SEP generally induced paresthesiae in the corresponding peripheral region. Therefore, spinal SEP may be used as a guide for optimal positioning of a spinal electrode for therapeutic stimulation when implanted under general anesthesia.An attempt was made to record the antidromic potential in the peroneal nerve elicited from the dorsal columns by epidural stimulation. The antidromic response was, however, very sensitive to minimal changes of stimulus strength and body position of the patient, and was also contaminated by simultaneously evoked muscular reflex potentials.Thus, peripheral responses evoked by epidural stimulation appeared too unreliable to be useful for the permanent implantation of a spinal electrode for therapeutic stimulation.     

Glossopharyngeal neuralgia secondary to vascular compression in a patient with multiple sclerosis: a case report

ABSTRACT: Glossopharyngeal neuralgia is an uncommon, painful syndrome, characterized by paroxysmsof pain in the sensory distribution of the 9th cranial nerve. Idiopathic glossopharyngealneuralgia may be due to compression of the glossopharyngeal nerve by adjacent vessels,while secondary glossopharyngeal neuralgia is associated with identifiable lesions affectingthe glossopharyngeal nerve at different levels of its neuroanatomic pathway.Glossopharyngeal neuralgia is rare in the general population, but is more common in patientswith multiple sclerosis. CASE PRESENTATION: A 56-year-old Caucasian woman with multiple sclerosis and migraine presented to ourfacility with intermittent lancinating pain to the right of her throat, tongue, and the floor ofher mouth that had been occurring for the past year. The pain was intense, sharp, andstabbing, which lasted two to six seconds with radiation to the right ear. Initially, the attackswere infrequent, however, they had become more intense and frequent over time. Our patientreported weight loss, headache, painful swallowing, and the inability to maintain sleep due topainful attacks. A neurological examination revealed a right-handed woman with triggerpoints in the back of the tongue and throat on the right side. She also had dysphagia,hoarseness, and pain in the distribution of the right glossopharyngeal nerve. Mild righthemiparesis, hyperreflexia, dysmetria, and an ataxic gait were present. A magnetic resonanceimaging scan of the brain was consistent with multiple sclerosis and magnetic resonanceangiography demonstrated a loop of the posterior inferior cerebellar artery compressing theright glossopharyngeal nerve. She responded satisfactorily to carbamazepine. Microvasculardecompression and Gamma Knife? radiosurgery were discussed in case of failure of themedical treatment; however, she declined these options. CONCLUSIONS: Glossopharyngeal neuralgia in multiple sclerosis may occur due to vascular compressivelesions and it should not be solely attributed to the underlying demyelinating process.Vascular compression of the glossopharyngeal nerve could independently causeglossopharyngeal neuralgia in patients with multiple sclerosis, and vascular imaging toexclude such a diagnosis is recommended.