Opioids for chronic pain treatment

Opioids for chronic pain treatment

Efficacy: Opioids can be highly effective for managing certain types of chronic pain, especially when other treatments have failed. They are typically reserved for severe pain, such as cancer-related pain or pain following major surgery.

Risks and Side Effects: Opioids come with significant risks and side effects. These can include physical dependence, tolerance (requiring higher doses for the same effect), withdrawal symptoms, constipation, drowsiness, and the potential for overdose, which can be fatal.

Alternative Treatments: Many alternative treatments are available for chronic pain, depending on the underlying cause. These may include physical therapy, non-opioid medications, lifestyle modifications, cognitive-behavioral therapy, and interventional procedures like nerve blocks.

Opioid Prescribing Guidelines: To address the opioid epidemic, many countries, including the United States, have established stricter guidelines for opioid prescribing. These guidelines aim to limit the use of opioids for chronic pain and promote safer prescribing practices.

Patient Education: Patients and healthcare providers should engage in open and honest discussions about the benefits and risks of using opioids for chronic pain management. It’s essential for patients to be informed about the potential side effects and risks, as well as to have a clear understanding of the treatment plan and goals.

Monitoring and Follow-Up: Opioid therapy for chronic pain should be closely monitored by a healthcare provider. Regular check-ups are important to assess the effectiveness of the treatment, monitor for any signs of misuse or dependence, and adjust the treatment plan as necessary.

Risk Assessment: Healthcare providers should conduct a thorough assessment of each patient’s risk factors for opioid misuse, addiction, and overdose before prescribing opioids for chronic pain. This may involve screening tools and discussions about the patient’s medical history and substance use history.

Multi-Disciplinary Approach: Chronic pain management often benefits from a multidisciplinary approach, which can include a combination of therapies, treatments, and support from different healthcare professionals, such as pain specialists, physical therapists, and mental health professionals.

It’s important to note that the use of opioids for chronic pain is a complex issue that should be approached with caution and care. In recent years, there has been a growing emphasis on reducing opioid prescriptions and promoting alternative treatments due to the opioid epidemic and the associated risks. Patients with chronic pain should work closely with their healthcare providers to develop a personalized pain management plan that considers their specific needs, circumstances, and the potential benefits and risks of opioid therapy.

The risk of addiction associated with the use of opioids for chronic pain treatment is a significant concern and a topic of extensive research and clinical consideration. It’s crucial to understand that while opioids can be effective at managing pain, they also carry a substantial risk of addiction, especially when used for an extended period. Here are some key points to consider regarding the risk of addiction associated with opioids for chronic pain treatment:

Dependence vs. Addiction: It’s important to differentiate between physical dependence and addiction. Physical dependence occurs when the body becomes accustomed to the presence of the opioid, leading to withdrawal symptoms when the medication is discontinued. Addiction, on the other hand, involves compulsive drug use, cravings, and a loss of control over drug-seeking behavior.

Risk Factors: Several risk factors can increase the likelihood of developing an opioid addiction, including a personal or family history of substance use disorders, a history of mental health issues, and a history of previous substance misuse.

Duration of Use: The longer opioids are used, the greater the risk of developing addiction. While they may be appropriate for short-term pain management, using them for an extended period increases the likelihood of dependence and addiction.

Dosing and Tolerance: Opioid tolerance can develop over time, leading individuals to require higher doses to achieve the same level of pain relief. This can contribute to the risk of addiction, as increasing doses can heighten the potential for dependence.

Prescribing Practices: Prescribing practices play a crucial role in the risk of opioid addiction. Healthcare providers should carefully assess patients for their suitability for opioid therapy, prescribe the lowest effective dose, and monitor patients for signs of misuse or addiction.

Alternative Treatments: For chronic pain management, there are often alternative treatments available that carry a lower risk of addiction, such as non-opioid medications, physical therapy, acupuncture, and behavioral interventions. These options should be considered before resorting to opioids.

Opioid Epidemic: The opioid epidemic in many countries, including the United States, has raised awareness of the risks associated with opioid use. Stricter guidelines and regulations have been put in place to reduce opioid prescribing, especially for chronic pain.

Education and Monitoring: Patients and healthcare providers should engage in open and honest communication about the risks associated with opioids. Regular monitoring and evaluation of the patient’s condition and pain management plan are essential to identify any early signs of misuse or addiction.

Treatment for Addiction: If addiction does develop, it’s crucial to provide access to appropriate treatment and support. Medications like buprenorphine and methadone, along with counseling and behavioral therapies, can be effective in managing opioid addiction.

In summary, while opioids can be effective in managing chronic pain, their potential for addiction is a substantial concern. The risk of addiction is influenced by various factors, including the duration of use, dosing, personal history, and prescribing practices. It’s essential for both patients and healthcare providers to be informed about these risks and to carefully weigh the benefits and potential harms of using opioids for chronic pain treatment. In many cases, alternative, less addictive treatments may be more suitable for managing chronic pain.


A qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed.

Setting: West Virginia.

Participants: Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists.

Intervention: Semistructured interviews.

Main outcome measure: To better understand the impact of restrictive prescribing measures on people who used opioids for CP.

Results: Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a “life saver.”

Conclusions: Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to “get high” but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management.

Key message: Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence 1).


In conclusion, the study offers valuable insights into the challenges faced by individuals using opioids for chronic pain and the unintended consequences of restrictive prescribing measures. It emphasizes the importance of tailored, comprehensive care and access to appropriate treatments, taking into account the complex interplay of chronic pain, opioid use, and opioid use disorder. The findings have relevance not only in West Virginia but also in regions grappling with similar issues related to opioids and chronic pain management.


There is no evidence to support the use of epidural injections of steroids, local anesthetics and/or opioids for low back pain without radiculopathy

Opioid may be required for severe pain, usually severe radicular pain. For non-specific back pain, there was no earlier return to full activity than with Nonsteroidal anti-inflammatory drug or APAP 2) Opioids should not be used > 2–3 weeks, at which time NSAIDs should be instituted unless contraindicated

see Opioid for low back pain.


Opioids remain a mainstay in the treatment of acute and chronic pain, despite numerous and potentially dangerous side effects. There is a great unmet medical need for alternative treatments for patients suffering from pain that do not result in addiction or adverse side effects.

Since 2016, 35 of 50 USA states have passed opioid-limiting laws.

Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain 3).


Intrathecal (IT) opioid pumps are one therapeutic cornerstone of refractory non-malignant pain syndromes. The aim of this study was to evaluate efficacy, surgical and pharmacological complications of IT pumps beyond a time span of 10 years.

In this retrospective single-center cohort study, 27 patients (14 female, 13 male, age 64.0 ± 8.9 (median, 1 SD) yrs) were identified. Pain intensity using the numerical rating scale (NRS), pain and IT pump characteristics, and complications were analyzed. The German Pain Questionaire was used to investigate the physical and mental health status.

Overall time of IT therapy from first implantation to last follow-up was 20.4 ± 6.0 yrs. Time to implantation of the second pump (n=18) was 10.0 ± 5.3 yrs, between the second and third pump (n=6) 6.5 ± 2.7 yrs, and two patients received their 4th pump six years later. Before implantation, NRS was 9.0 ± 0.9, one year after implantation 7.0 ± 1.8 and 4.0 ± 2.3 at the last follow-up. IT drug dose remained stable after 3 years. Opioid intoxications occurred in three patients (10%). One patient (3%) underwent revision surgery due to a catheter infection. Drug side effects occurred in 4 patients (14%). Our patient group has pain-related restrictions in physical activities with menial impact regarding mental and emotional stress.

Even after a time span of over 15 years and several exchanges of pump systems, pain intensity is still reduced. After 3 years, IT drug dose remained unchanged with low side-effects and complication rates 4).


1)

Sedney CL, Dekeseredy P, Davis M, Haggerty T. A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing. J Opioid Manag. 2023 Special-Issue;19(7):95-102. doi: 10.5055/jom.2023.0803. PMID: 37879664.
2)

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994
3)

Reid DBC, Patel SA, Shah KN, Shapiro BH, Ruddell JH, Akelman E, Palumbo MA, Daniels AH. Opioid-Limiting Legislation Associated with Decreased 30-Day Opioid Utilization Following Anterior Cervical Decompression and Fusion. Spine J. 2019 Sep 2. pii: S1529-9430(19)30960-X. doi: 10.1016/j.spinee.2019.08.014. [Epub ahead of print] PubMed PMID: 31487559.
4)

Sommer B, Karageorgos N, AlSharif M, Stubbe H, Hans FJ. Long-term outcome and adverse events of intrathecal opiod therapy for non-malignant pain syndrome. Pain Pract. 2019 Jul 10. doi: 10.1111/papr.12818. [Epub ahead of print] PubMed PMID: 31291509.

Pneumocephalus clinical features

Pneumocephalus clinical features

Pneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries 1).


Clinical presentation includes headaches in 38 %, nausea and vomitingseizures, hemiparesisdizzinessobtundation and depressed neurological status 2).


An intracranial succussion splash is a rare (occurring in ≈ 7%) but pathognomonic finding. Tension pneumocephalus may additionally cause signs and symptoms just as any mass (may cause focal deficit or increased ICP).

A minority of patients describe ‘bruit hydro-aerique’ (a splashing noise on head movement, equivalent to the succussion splash of pyloric stenosis) 3).

This noise may also be audible to the examiner with the aid of a stethoscope.


Patients often report sounds in the head after craniotomy.

In a prospective observational study of patients undergoing craniotomy with dural opening. Eligible patients completed a questionnaire preoperatively and daily after surgery until discharge. Subjects were followed up at 14 days with a telephone consultation.

One hundred fifty-one patients with various pathologies were included. Of these, 47 (31 %) reported hearing sounds in their head, lasting an average 4-6 days (median, 4 days, mean, 6 days, range, 1-14 days). The peak onset was the first postoperative day and the most commonly used descriptors were ‘clicking’ [20/47 (43 %)] and ‘fluid moving’ in the head [9/47 (19 %)]. A significant proportion (42 %, 32/77) without a wound drainage experienced intracranial sounds compared to those with a drain (20 %, 15/74, p < 0.01); there was no difference between suction and gravity drains. Approximately a third of the patients in both groups (post-craniotomy sounds group: 36 %, 17/47; group not reporting sounds: 31 %, 32/104), had postoperative CT scans for unrelated reasons: 73 % (8/11) of those with pneumocephalus experienced intracranial sounds, compared to 24 % (9/38) of those without pneumocephalus (p < 0.01). There was no significant association with craniotomy site or size, temporal bone drilling, bone flap replacement, or filling of the surgical cavity with fluid.

Sounds in the head after cranial surgery are common, affecting 31 % of patients. This is the first study into this subject, and provides valuable information useful for consenting patients. The data suggest pneumocephalus as a plausible explanation with which to reassure patients, rather than relying on anecdotal evidence, as has been the case to date 4).


Rapid neurologic deterioration following craniofacial resection may be caused by the development of tension pneumocephalus 5).


1)

Kim TK, Yoon JR, Kim YS, Choi Y, Han S, Jung J, Park IS. Pneumocephalus and headache following craniotomy during the immediate postoperative period. BMC Surg. 2022 Jun 29;22(1):252. doi: 10.1186/s12893-022-01701-0. PMID: 35768812.
2)

Markham JW. The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien). 1967;16(1):1-78. PubMed PMID: 6032371.
3)

Zasler ND, Katz DI, Zafonte RD. Brain Injury Medicine, Principles And Practice. Demos Medical Publishing. (2007) ISBN:1888799935.
4)

Sivasubramaniam V, Alg VS, Frantzias J, Acharya SY, Papadopoulos MC, Martin AJ. ‘Noises in the head’: a prospective study to characterize intracranial sounds after cranial surgery. Acta Neurochir (Wien). 2016 Aug;158(8):1429-35. doi: 10.1007/s00701-016-2872-7. Epub 2016 Jun 21. PubMed PMID: 27328839.
5)

Yates H, Hamill M, Borel CO, Toung TJ. Incidence and perioperative management of tension pneumocephalus following craniofacial resection. J Neurosurg Anesthesiol. 1994 Jan;6(1):15-20. PubMed PMID: 8298259.

Aggressive vertebral hemangioma

Aggressive vertebral hemangioma

Accurate preoperative diagnosis is essential because they are highly vascular with a high tendency for intraoperative bleeding.

Management of aggressive VHs involves pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery 1).

Surgery is required in cases of rapid or progressive neurological symptoms like compressive myelopathy or radiculopathy.

Vertebral hemangioma resection can be a real challenge for spine surgeons, given the high potential of massive intraoperative bleeding. For this reason, preoperative transarterial embolization of this tumor is supported by the available literature 2).


A navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor, especially in the anterior cortical surface of the vertebral body, and easily resections even hard tumors. This method results in reducing residual tumors and maintaining safe resection 3).

Radiotherapy can be used in patients with slowly progressive neurological deficits.

While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure 4).

Other emerging options in cases of aggressive hemangiomas include radiofrequency ablation with a hemostatic agent (e.g. FLOSEAL, Baxter, USA), and bone autograft placement 5).


Minimally invasive procedures may be successful in smaller lesions 6).

The case of a pregnancy who was diagnosed with an aggressive vertebral hemangioma that further led to progressive paraparesis. We had to take the fact that she was pregnant into account in the diagnostic procedure, the choice of examination method, and also the method of therapy. The goal of this case report is threefold: (1) provide an overview of the possible methods of management, specifically imaging, which will aid in diagnosis and based on that, (2) determine the appropriate therapy, and (3) review the risks and benefits of each will be presented when choosing individual approaches 7).


1)

Goraya GS, Singhal S, Paul BS, Paul G. Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder. Cureus. 2022 Jan 24;14(1):e21568. doi: 10.7759/cureus.21568. PMID: 35228927; PMCID: PMC8873442.
2)

Fiore G, Bertani GA, Tariciotti L, Borsa S, Paolucci A, Taramasso L, Locatelli M, Pluderi M. Vertebral Body Infarction after Transarterial Preoperative Embolization of a Vertebral Hemangioma. J Neurol Surg A Cent Eur Neurosurg. 2021 Dec 12. doi: 10.1055/s-0041-1739215. Epub ahead of print. PMID: 34897610.
3)

Nagashima Y, Nishimura Y, Haimoto S, Eguchi K, Awaya T, Ando R, Akahori S, Hara M, Natsume A. Piecemeal resection of aggressive vertebral hemangioma using real-time navigation-guided drilling technique. Nagoya J Med Sci. 2021 Nov;83(4):861-868. doi: 10.18999/nagjms.83.4.861. PMID: 34916728; PMCID: PMC8648519.
4)

Srinivasan G, Moses V, Padmanabhan A, Ahmed M, Keshava SN, Krishnan V, Joseph BV, Raju KP, Rajshekhar V. Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas. Neuroradiology. 2021 Nov;63(11):1935-1945. doi: 10.1007/s00234-021-02788-7. Epub 2021 Aug 24. PMID: 34427707.
5)

Canbay S, Kayalar AE, Gel G, Sabuncuoğlu H. A novel surgical technique for aggressive vertebral hemangiomas. (2019) Neurocirugia (Asturias, Spain). 30 (5): 233-237. doi:10.1016/j.neucir.2018.08.003
6)

Vasudeva VS, Chi JH, Groff MW. Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus. 2016 Aug;41(2):E7. doi: 10.3171/2016.5.FOCUS16169. PMID: 27476849.
7)

Ridzoňová L, Fedičová M, Andráš T, Urdzík P, Gdovinová Z. Lower-limb progressive paraparesis management and diagnosis overview in a pregnant woman with vertebral haemangioma. Womens Health (Lond). 2022 Jan-Dec;18:17455057221099018. doi: 10.1177/17455057221099018. PMID: 35574823.

Microvascular decompression for trigeminal neuralgia outcome

Microvascular decompression for trigeminal neuralgia outcome

Microvascular decompression (MVD) is the most effective long-term surgical treatment for trigeminal neuralgia (TN) patients. The risk factors for poor pain control following MVD surgery are not fully understood.


A significant proportion of patients with significant neurovascular compression fail to achieve long-term pain relief after technically successful surgery. Neuroimaging using magnetic resonance imaging (MRI) provides a non-invasive method to generate objective biomarkers of eventual response to TN surgery 1).


Younger patients with TN had worse long-term pain outcomes following MVD. Additional factors associated with postoperative recurrence included poor preoperative pain control (BNI score > IV) and multivessel compression. Furthermore, SCA combined with PV was confirmed to be associated with a worse outcome 2).


Not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

It does not achieve 100 % cure rate. Re-exploration of the posterior fossa may carry increased risk over first-time MVD and is not always successful, so other treatments are needed.


Age itself does not seem to represent a major contraindication of microvascular decompression for typical trigeminal neuralgia 3).

Patients 60 yr of age and older have significantly better long-term pain outcomes following MVD than younger patients 4).


1)

Wang Z, Zhao Z, Song Z, Wang Y, Zhao Z. The application of magnetic resonance imaging (MRI) for the prediction of surgical outcomes in trigeminal neuralgia. Postgrad Med. 2022 May 3:1-7. doi: 10.1080/00325481.2022.2067612. Epub ahead of print. PMID: 35503235.
2)

Shi J, Qian Y, Han W, Dong B, Mao Y, Cao J, Guan W, Zhou Q. Risk factors for outcomes following microvascular decompression for trigeminal neuralgia. World Neurosurg. 2020 Jan 17. pii: S1878-8750(20)30100-5. doi: 10.1016/j.wneu.2020.01.082. [Epub ahead of print] PubMed PMID: 31958591.
3)

Mastronardi L, Caputi F, Rinaldi A, Cacciotti G, Roperto R, Scavo CG, Stati G, Sufianov A. Typical Trigeminal Neuralgia: Comparison of Results between Patients Older and Younger than 65 Operated on with Microvascular Decompression by Retrosigmoid Approach. J Neurol Surg A Cent Eur Neurosurg. 2019 Aug 29. doi: 10.1055/s-0039-1693126. [Epub ahead of print] PubMed PMID: 31466107.
4)

Bick SK, Huie D, Sneh G, Eskandar EN. Older Patients Have Better Pain Outcomes Following Microvascular Decompression for Trigeminal Neuralgia. Neurosurgery. 2019 Jan 1;84(1):116-122. doi: 10.1093/neuros/nyy011. PubMed PMID: 29562363.

Percutaneous balloon compression trigeminal rhizotomy complications

Percutaneous balloon compression trigeminal rhizotomy complications

Percutaneous balloon compression trigeminal rhizotomy-related trigemino-cardiac reflex (TCR) can induce dramatic hemodynamic disturbances 1).


Postoperative morbidity included common side effects such as facial numbness in 66 (97.1 %) patients, masseter muscle weakness in 19 (27.9 %) patients, paresthesia in 7 (10.3 %) patients, and diplopia secondary to abducens nerve weakness in 1 (1.5 %) patient 2)


The main reason for ineffective or short-term recurrence of PBC in trigeminal neuralgia patients is the ineffectively compressed of trigeminal ganglion.According to the different types of patients,the use of individualized modified surgical scheme can improve the efficacy of PBC surgery 3).


Bloody saliva Stensen duct puncture

Facial hematoma/A-V fistula Puncture of internal MA and pterygoid plexus

Injury to ICA, jugular vein Excessively medial displacement of the needle causing injury to the ICA in the FL,

posterolateral displacement causing injury to the jugular vein

Injury to Eustachian tube Posterior displacement of the needle

Blindness Needle inserted anteriorly and medially passing through inferior orbital fissure to the orbital apex


Carotid-cavernous fistula ICA injury in the CS

Temporal lobe hematoma Dura mater penetration and intradural balloon inflation

Brainstem lesion Guiding stylet/balloon catheter far from the petrous ridge

Diplopia Compression of CN VI (most common) or CN IV

Meningitis Oral mucosa puncture, contamination or improper sterility 4).


Lichtor and Mullan from one hundred patients treated by this method that have been followed for 1 to 10 years; treatment has been technically successful in 97% of cases. Relief persisted at five years in 80%, and it is estimated that at 10 years the figure will be 70%. There were no deaths, no cerebral damage, no keratitis, and no analgesia dolorosa; 4% of the patients reported dysesthesia 5).

Most of the minor surgical complications observed were also related to avoidable technical errors 6)


1)

Wang CM, Guan ZY, Wang QC, Zhang J, Ma Y, Zhao P. The Effect of Depth of Anesthesia on Hemodynamic Changes Induced by Therapeutic Compression of the Trigeminal Ganglion. J Neurosurg Anesthesiol. 2019 May 27. doi: 10.1097/ANA.0000000000000612. [Epub ahead of print] PubMed PMID: 31145173.
2)

Du, YF., Gu, Q., Yang, DB. et al. Percutaneous balloon compression for primary trigeminal neuralgia in patients older than 80 years. Chin Neurosurg Jl 1, 8 (2015). https://doi.org/10.1186/s41016-015-0007-2
3)

Chong YL, Xu W, Wang J, Jiang CR, Liang WB. [The ineffective or short-term recurrence of trigeminal neuralgia after microballoon compression:different causes and management strategies]. Zhonghua Wai Ke Za Zhi. 2022 May 1;60(5):473-478. Chinese. doi: 10.3760/cma.j.cn112139-20210825-00391. Epub ahead of print. PMID: 35359090.
5)

Lichtor T, Mullan JF. A 10-year follow-up review of percutaneous microcompression of the trigeminal ganglion. J Neurosurg. 1990 Jan;72(1):49-54. doi: 10.3171/jns.1990.72.1.0049. PMID: 2294184.
6)

Lobato RD, Rivas JJ, Sarabia R, Lamas E. Percutaneous microcompression of the gasserian ganglion for trigeminal neuralgia. J Neurosurg. 1990 Apr;72(4):546-53. doi: 10.3171/jns.1990.72.4.0546. PMID: 2319312.

Radiofrequency ablation for Spinal osteoid osteoma

Radiofrequency ablation for Spinal osteoid osteoma

Complete excision With osteoid osteomas, only complete surgical excision ensures the least risk of local recurrence, and effectively provides immediate pain relief and early mobilization. Newer, minimally invasive methods, including. percutaneous CT-guided radiofrequency ablation (RFA), are gaining popularity internationally for the treatment of extra spinal tumors 1).


Complete surgical excision of the nidus is curative, providing symptomatic relief, and is the traditionally preferred treatment. However, surgery has disadvantages, including the difficulty of locating the lesion intraoperatively, the need for prolonged hospitalization, and the possibility of postoperative complications ranging from an unsatisfactory cosmetic result to a fracture. Percutaneous radiofrequency (RF) ablation, which involves the use of thermal coagulation to induce necrosis in the lesion, is a minimally invasive alternative to surgical treatment of osteoid osteoma. With reported success rates approaching 90%, RF ablation should be considered among the primary options available for treating this condition 2).

Sagoo et al. sought to systematically assess and summarize the available literature on the clinical outcomes and complications following radiofrequency ablation (RFA) for painful spinal osteoid osteoma (OO).

PubMedScopus, and CENTRAL databases were searched in accordance with PRISMA guidelines. Studies with available data on safety and clinical outcomes following RFA for spinal OO were included.

In the 14 included studies (11 retrospective; 3 prospective), 354 patients underwent RFA for spinal OO. The mean ages ranged from 16.4 to 28 years (Females = 31.3%). Lesion diameters ranged between 3 and 20 mm and were frequently seen in the posterior elements in 211/331 (64%) patients. The mean distance between OO lesions and neural elements ranged between 1.7 and 7.4 mm. The estimated pain reduction on the numerical rating scale was 6.85/10 (95% confidence intervals [95%CI] 4.67-9.04) at a 12-24-month follow-up; and 7.29/10 (95% CI 6.67-7.91) at a >24-month follow-up (range 24-55 months). Protective measures (e.g., epidural air insufflation or neuroprotective sterile water infusion) were used in 43/354 (12.1%) patients. Local tumor progression was seen in 23/354 (6.5%) patients who were then successfully re-treated with RFA or open surgical resection. Grade I-II complications such as temporary limb paresthesia and wound dehiscence were reported in 4/354 (1.1%) patients. No Grade III-V complications were reported.

RFA demonstrated safety and clinical efficacy in most patients harboring painful spinal OO lesions. However, further prospective studies evaluating these outcomes are warranted 3).

Percutaneous Radiofrequency Ablation Using a Navigational Bipolar Electrode System 4).


Between 2002 and 2012, a total of 61 patients (46 male and 15 female, mean age 26.4 ± 12.7 years) were subjected to RFA for spinal OO. The diagnosis of OO was made after a period of pain and symptoms of 20.6 ± 14.4 months. RFA was performed under conscious sedation and local analgesia. Clinical symptoms were evaluated at 3, 6, and12 months, and at the end of the time of the present investigation. Mean follow-up was 41.5 ± 7.1 months.

Results: The primary efficacy of RFA, complete regression of symptoms, was obtained in 57 out of 61 patients (93.4%). Four out of 61 (6.5%) patients showed a relapse of OO (after 3 months); 2 out of 4 were subjected to a second RFA, the remaining ones were subjected to surgery. There was one complication (case of lower limb paresthesia for 30 days after the ablation) and one possible complication (a disc herniation).

Conclusion: CT-guided RFA is an excellent treatment for spinal OO. Our data suggest that this procedure should be considered for the first stage of therapy for this disease 5)


Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity 6).


The records of all patients with osteoid osteomas of the spine managed with thermal ablation at two academic centers from 1993 to 2008 were reviewed.

Results: Seventeen patients (13 male patients, four female patients; mean age, 25.9 years) had lesions in the lumbar (seven patients), thoracic (six patients), cervical (three patients), and sacral (one patient) regions of the spine. Two lesions were in the vertebral body, one was within the dens, and the others were in the posterior elements. The mean lesion diameter was 8.8 mm, and the mean distance between the lesion and the closest neural element was 4.3 mm. The lesions were managed with laser (13 lesions) or radiofrequency (four lesions) ablation. Special thermal protection techniques involving the epidural injection of gas or cooled fluid were used. Pain levels were assessed immediately before the procedure and on the day after the procedure. Long-term follow-up findings were available for 11 patients. No complications were encountered, and all patients reported relief of pain. The 11 patients who participated in long-term follow-up reported continued relief of pain.

Conclusion: Percutaneous thermal ablation can be used to manage spinal osteoid osteomas close to the neural elements. Special thermal protection techniques may add a margin of safety 7).


A prospective study on 24 patients with spinal osteoid osteoma treated with radiofrequency ablation (RFA).

Objective: To determine if and when computed tomography (CT)-guided RFA is a safe and effective treatment for spinal osteoid osteomas.

Summary of background data: Surgery has been considered the standard treatment for spinal osteoid osteomas. Surgery may cause spinal instability, infection, and nervous injury. We evaluated CT-guided RFA as an alternative treatment.

Methods: A total of 28 RFA procedures in 24 patients with spinal osteoid osteoma were performed, using a 5-mm noncooled electrode. Clinical symptoms and spinal deformity were evaluated before and after the procedure. Unsuccessful treatment was defined as the presence of residual or recurrent symptoms. The mean follow-up was 72 months (range: 9-142 months).

Results: Nineteen (79%) patients were successfully treated after 1 RFA, and all except one after repeat RFA. One patient with nerve root compression needed further surgery. No complications were observed. Spinal deformity persisted in 3 of 7 patients after successful RFA.

Conclusion: CT-guided RFA is a safe and effective treatment for spinal osteoid osteoma. Surgery should be reserved for lesions causing nerve root compression 8).


1)

Gasbarrini A, Cappuccio M, Bandiera S, Amendola L, van Urk P, Boriani S. Osteoid osteoma of the mobile spine: surgical outcomes in 81 patients. Spine (Phila Pa 1976). 2011 Nov 15;36(24):2089-93. doi: 10.1097/BRS.0b013e3181ffeb5e. PMID: 21304430.
2)

Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW, Menendez L. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics. 2009 Nov;29(7):2127-41. doi: 10.1148/rg.297095081. PMID: 19926767.
3)

Sagoo NS, Haider AS, Chen AL, Vannabouathong C, Larsen K, Sharma R, Palmisciano P, Alamer OB, Igbinigie M, Wells DB, Aoun SG, Passias PG, Vira S. Radiofrequency ablation for spinal osteoid osteoma: A systematic review of safety and treatment outcomes. Surg Oncol. 2022 Mar 25;41:101747. doi: 10.1016/j.suronc.2022.101747. Epub ahead of print. PMID: 35358911.
4)

Tomasian A, Jennings JW. Spinal Osteoid Osteoma: Percutaneous Radiofrequency Ablation Using a Navigational Bipolar Electrode System. AJR Am J Roentgenol. 2018 Oct;211(4):856-860. doi: 10.2214/AJR.17.19361. Epub 2018 Aug 7. PMID: 30085840.
5)

Albisinni U, Facchini G, Spinnato P, Gasbarrini A, Bazzocchi A. Spinal osteoid osteoma: efficacy and safety of radiofrequency ablation. Skeletal Radiol. 2017 Aug;46(8):1087-1094. doi: 10.1007/s00256-017-2662-1. Epub 2017 May 11. PMID: 28497160.
6)

Faddoul J, Faddoul Y, Kobaiter-Maarrawi S, Moussa R, Rizk T, Nohra G, Okais N, Samaha E, Maarrawi J. Radiofrequency ablation of spinal osteoid osteoma: a prospective study. J Neurosurg Spine. 2017 Mar;26(3):313-318. doi: 10.3171/2016.8.SPINE16462. Epub 2016 Dec 2. PMID: 27911227.
7)

Rybak LD, Gangi A, Buy X, La Rocca Vieira R, Wittig J. Thermal ablation of spinal osteoid osteomas close to neural elements: technical considerations. AJR Am J Roentgenol. 2010 Oct;195(4):W293-8. doi: 10.2214/AJR.10.4192. PMID: 20858792.
8)

Vanderschueren GM, Obermann WR, Dijkstra SP, Taminiau AH, Bloem JL, van Erkel AR. Radiofrequency ablation of spinal osteoid osteoma: clinical outcome. Spine (Phila Pa 1976). 2009 Apr 20;34(9):901-4. doi: 10.1097/BRS.0b013e3181995d39. PMID: 19360000.

Percutaneous foramen ovale puncture

Percutaneous Foramen Ovale Puncture

Foramen ovale (FO) puncture allows percutaneous trigeminal rhizotomyForamen ovale electrode placement, and selected biopsy studies.

Balloon compression of the gasserian ganglion has been a well-established percutaneous treatment of trigeminal neuralgia since the 1980s.

For this procedure, different potential operative and technical nuances exist.

Puncture of the foramen ovale by conventional single-plane fluoroscopy can be difficult in cases of local anatomic abnormalities.

Mendes et al. presented the case of a 49-year-old woman diagnosed with idiopathic trigeminal neuralgia refractory to pharmacological treatment. After failure of puncture by conventional fluoroscopy for percutaneous gasserian ganglion balloon compression due to a narrow foramen ovale, the patient was submitted to puncture guided by computed tomography.

Alternative imaging methods, such as computed tomography, should be considered when Percutaneous Foramen Ovale Puncture by conventional single-plane fluoroscopy fails, to minimize the risk of potential complications triggered by frustrated puncture attempts 1).


Between March 2018 and February 2021, 20 peroral balloon compression rhizotomy procedures with a 3D-PSGT were performed in 18 consecutive trigeminal pain patients (13 female, mean age 58 yr). We registered the procedure duration, side effects, complications, and trigeminal function. The therapeutic effect was gauged from reduction of TP and use of analgesics.

Results: All catheter insertions and rhizotomy procedures were successful at the first attempt. Apart from fluoroscopy, no auxiliary material was necessary. The average length of surgery was 19 min (range, 11-27 min). In total, 8 patients indicated complete analgesia and 6 patients pain relief; in 4 patients, persistence of TP was observed during follow-up examinations of up to 20 mo. In total, 6 patients reported of new mild to moderate facial hypesthesia affecting the trigeminal branches V2, V3, or V1-3. No masticatory musculature or corneal affections and device-related complications occurred.

The peroral 3D-PSGT trigeminal rhizotomy is straightforward for the neurosurgeon. This operative approach allows for rapid, safe, and simple foramen ovale puncture cannulation in TP patients and reduces the use of additional equipment, radiation exposure, and procedure time 2).

Although Gasserian ganglion block is an established treatment for trigeminal neuralgia, the foramen ovale cannot always be clearly visualized by classical X-ray radiography.

Cannulation procedures, including those utilizing neuronavigational technology, are occasionally complicated by anatomical variation of the FO, sometimes resulting in miscannulation and subsequent adverse events. The FO, while commonly thought of as oval-shaped, has also been described as “almond,” “banana,” “D shape,” “pear,” and “triangular.” 3).

Advancement of the catheter more than 10 mm from the foramen ovale is likely to damage the internal carotid artery and the abducens nerve at the medial side of the petrolingual ligament. Thermocoagulation of the lateral wall of the cavernous sinus may damage the cranial nerves by heat, giving rise to pareses 4).

Forty-five patients were included in the study. All patients underwent a computed tomography examination. Among them, the simulated preoperative puncture pathway was reconstructed on the basis of computed tomography scan examination for 22 patients. Procedures were performed by 2 surgeons: one experienced surgeon and another young surgeon with surgical qualification. The puncturing time and cumulative radiation exposure dose, from start of the puncturing until reaching the foramen ovale, were recorded. Postoperative pain relief, facial hypoesthesia, masticatory muscle weakness, and other complications were recorded.

Results: In all cases, the procedure of cannulation was completed successfully. The puncturing time for both the experienced and young surgeon with the use of preoperative image simulation seemed to be time-saving. The young surgeon had less cumulative radiation exposure with the use of preoperative image simulation. Moreover, the intraoperative puncture pathways were almost consistent with the preoperative simulated images. The rest of the process went smoothly. Short-term outcomes of all the 45 patients were satisfactory.

Based on our preliminary experience, the preoperative image simulation-guided technique is useful during these cases 5).


Guo et al., described a technique that includes a stereotactic approach in the preoperative plan in cases where the foramen ovale is difficult to access for radiofrequency thermocoagulation of the Gasserian ganglion.

The study included 395 patients for whom three-dimensional computed tomographic reconstruction of the skull base, maxilla, and mandible was conducted before surgery. Accessibility of the foramen ovale was defined using numerical data from the three-dimensional computed tomographic reconstruction images. In those patients for whom accessibility of the foramen ovale was considered difficult, the authors used a stereotactic frame to design an individual operative plan. Adjustments of a single point of data,-that is, a change in X axis, Y axis, or an arc angle-were guided by radiographic fluoroscopy images. After verifying successful cannulation and electroneurophysiology, thermocoagulation targets-especially multiple targets recorded as data on the Z axis of the stereotactic approach-were identified and treated.

There were 24 patients who met the predetermined criteria for having a difficult-to-access foramen ovales-that is, they had at least two contributing factors and/or involvement of division V1 . Twenty-one of the 24 patients required a single satisfactory puncture; three patients required two to three punctures to successfully access the foramen ovale. There were no permanent complications from the procedure.

The authors conclude that this stereotactic approach combined with three-dimensional computed tomographic reconstruction model can improve the accuracy, safety, and efficiency of percutaneous radiofrequency thermocoagulation in patients with trigeminal neuralgia for whom the foramen ovale is difficult to access 6).


Ding et al., assessed the feasibility of accessing the Gasserian ganglion through the FO from a mandibular angle under computed tomography (CT) and neuronavigation guidance.A total of 108 patients with TN were randomly divided into 2 groups (Group G and Group H) using a random number table. In Group H, anterior Hartel approach was used to puncture the FO; whereas in Group G, a percutaneous puncture through a mandibular angle was used to reach the FO. In both groups, procedures were guided by CT imaging and neuronavigation. The success rates, therapeutic effects, complications, and recurrence rates of the 2 groups were compared.The puncture success rates in Group H and Group G were 52/54 (96.30%) and 49/54 (90.74%), respectively (P = 0.24). The 2 procedural failures in Group H were rescued by using submandibular trajectory, and the 5 failures in Group G were successfully reapproached by Hartel method. Therapeutic effects as measured by Barrow Neurological Institute Pain Scale (P = 0.03) and quality of life (QOL) scores (P = 0.04) were significantly better in Group G than those in Group H at 36 months posttreatment. Hematoma developed in 1/54 (1.85%) cases in Group H, and no cases of hematoma were observed in Group G (P = 0.33). In Group H, RFT resulted in injury to the unintended trigeminal nerve branches and motor fibers in 27/52 (51.92%) cases; in Group G, it resulted in the same type of injury in 7/49 cases (14.29%) (P < 0.01). In Group H, the 24- and 36-month recurrence rates were 12/51 (23.53%) and 20/51 (39.22%), respectively; in Group G, these recurrence rates were 7/49 (12.24%) and 9/49 (16.33%, P = 0.03), respectively.CT- and neuronavigation-guided puncture from a mandibular angle through the FO into the Gasserian ganglion can be safely and effectively used to deliver RFT for the treatment of pTN. This method may represent a viable option to treat TN in addition to Hartel approach 7).


The goals of a study of Peris-Celda et al., were to demonstrate the anatomical basis of complications related to FO puncture, and provide anatomical landmarks for improvement of safety, selective lesioning of the trigeminal nerve (TN), and optimal placement of electrodes.

Both sides of 50 dry skulls were studied to obtain the distances from the FO to relevant cranial base references. A total of 36 sides from 18 formalin-fixed specimens were dissected for Meckel cave and TN measurements. The best radiographic projection for FO visualization was assessed in 40 skulls, and the optimal trajectory angles, insertion depths, and topographies of the lesions were evaluated in 17 specimens. In addition, the differences in postoperative pain relief after the radiofrequency procedure among different branches of the TN were statistically assessed in 49 patients to determine if there was any TN branch less efficiently targeted.

Most severe complications during FO puncture are related to incorrect needle placement intracranially or extracranially. The needle should be inserted 25 mm lateral to the oral commissure, forming an approximately 45° angle with the hard palate in the lateral radiographic view, directed 20° medially in the anteroposterior view. Once the needle reaches the FO, it can be advanced by 20 mm, on average, up to the petrous ridge. If the needle/radiofrequency electrode tip remains more than 18 mm away from the midline, injury to the cavernous carotid artery is minimized. Anatomically there is less potential for complications when the needle/radiofrequency electrode is advanced no more than 2 mm away from the clival line in the lateral view, when the needle pierces the medial part of the FO toward the medial part of the trigeminal impression in the petrous ridge, and no more than 4 mm in the lateral part. The 40°/45° inferior transfacial-20° oblique radiographic projection visualized 96.2% of the FOs in dry skulls, and the remainder were not visualized in any other projection of the radiograph. Patients with V1 involvement experienced postoperative pain more frequently than did patients with V2 or V3 involvement. Anatomical targeting of V1 in specimens was more efficiently achieved by inserting the needle in the medial third of the FO; for V2 targeting, in the middle of the FO; and for V3 targeting, in the lateral third of the FO.

Knowledge of the extracranial and intracranial anatomical relationships of the FO is essential to understanding and avoiding complications during FO puncture. These data suggest that better radiographic visualization of the FO can improve lesioning accuracy depending on the part of the FO to be punctured. The angles and safety distances obtained may help the neurosurgeon minimize complications during FO puncture and TN lesioning 8).


Koizuka et al., presented a new method for percutaneous radio-frequency thermocoagulation of the Gasserian ganglion, in which computed tomography (CT) fluoroscopy is used to guide needle placement.

In the present study, 15 patients with trigeminal neuralgia underwent percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy.

RESULTS: Trigeminal neuralgia was improved in all patients after treatment without any severe complications. Moderate dysesthesia occurred in only one case.

CT fluoroscopy-guided percutaneous radio-frequency thermocoagulation of the Gasserian ganglion was safe, quick, and effective for patients with intractable idiopathic trigeminal neuralgia 9).


1)

Mendes PD, Martins da Cunha PH, Monteiro KKO, Quites LV, Fonseca Filho GA. Percutaneous Foramen Ovale Puncture: Usefulness of Intraoperative CT Control, in the Eventuality of a Narrow Foramen [published online ahead of print, 2020 Sep 16]. Stereotact Funct Neurosurg. 2020;1-4. doi:10.1159/000509821
2)

Oertel MF, Sarnthein J, Regli L, Stieglitz LH. Peroral Trigeminal Rhizotomy Using a Novel 3-Dimensional Printed Patient-Specific Guidance Tool. Oper Neurosurg (Hagerstown). 2021 Aug 30:opab299. doi: 10.1093/ons/opab299. Epub ahead of print. PMID: 34460929.
3)

Zdilla MJ, Fijalkowski KM. The Shape of the Foramen Ovale: A Visualization Aid for Cannulation Procedures. J Craniofac Surg. 2016 Dec 23. doi: 10.1097/SCS.0000000000003325. [Epub ahead of print] PubMed PMID: 28027173.
4)

Kaplan M, Erol FS, Ozveren MF, Topsakal C, Sam B, Tekdemir I. Review of complications due to foramen ovale puncture. J Clin Neurosci. 2007 Jun;14(6):563-8. Epub 2006 Dec 13. PubMed PMID: 17169562.
5)

Guo W, Shi H, Wen X, Qian T. A Simple Method for Foramen Ovale Puncture Based on Preoperative Image Simulation in Percutaneous Microcompression of the Trigeminal Ganglion. Oper Neurosurg (Hagerstown). 2022 Mar 3. doi: 10.1227/ONS.0000000000000123. Epub ahead of print. PMID: 35240674.
6)

Guo Z, Wu B, Du C, Cheng M, Tian Y. Stereotactic Approach Combined with 3D CT Reconstruction for Difficult-to-Access Foramen Ovale on Radiofrequency Thermocoagulation of the Gasserian Ganglion for Trigeminal Neuralgia. Pain Med. 2016 Sep;17(9):1704-16. doi: 10.1093/pm/pnv108. Epub 2016 Feb 13. PubMed PMID: 26874883.
7)

Ding W, Chen S, Wang R, Cai J, Cheng Y, Yu L, Li Q, Deng F, Zhu S, Yu W. Percutaneous radiofrequency thermocoagulation for trigeminal neuralgia using neuronavigation-guided puncture from a mandibular angle. Medicine (Baltimore). 2016 Oct;95(40):e4940. PubMed PMID: 27749549; PubMed Central PMCID: PMC5059051.
8)

Peris-Celda M, Graziano F, Russo V, Mericle RA, Ulm AJ. Foramen ovale puncture, lesioning accuracy, and avoiding complications: microsurgical anatomy study with clinical implications. J Neurosurg. 2013 Nov;119(5):1176-93. doi: 10.3171/2013.1.JNS12743. Epub 2013 Apr 19. PubMed PMID: 23600929.
9)

Koizuka S, Saito S, Sekimoto K, Tobe M, Obata H, Koyama Y. Percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy. Neuroradiology. 2009 Sep;51(9):563-6. doi: 10.1007/s00234-009-0541-8. Epub 2009 Jun 5. PubMed PMID: 19499214.

Trigeminal nerve-related pathology

Trigeminal nerve-related pathology

The trigeminal nerve (TGN) is the largest cranial nerve and can be involved in multiple inflammatory, compressive, ischemic, or other pathologies.

see Trigeminal neuralgia.

Postherpetic neuralgia in 20% of cases involves the trigeminal nerve (with a predilection for the ophthalmic division, called herpes zoster ophthalmicus).

Trigeminal trophic syndrome

see Trigeminal neuropathy.

Lesions in the cavernous sinus involve cranial nerves III, IV, VI, and V1 & V2 (ophthalmic and maxillary divisions of the trigeminal nerve), and spare II and V3.

Superior orbital fissure syndrome: dysfunction of nerves III, IV, VI and V1.

Orbital apex syndrome: involves II, III, IV, VI and partial V1.

Raeder’s paratrigeminal neuralgia.

In Sturge-Weber syndrome: Ipsilateral port-wine facial nevus (nevus flammeus) usually in the distribution of 1st division of trigeminal nerve (forehead and/or eyelid) (rarely bilateral): not always present, alternatively sometimes in V2 or V3 regions 1).


Postoperative trigeminal nerve symptoms occur transiently in 22% and permanently in 11% following microsurgery, similar to the results of SRS 2).


Basilar impression: trigeminal nerve anesthesia.


In vestibular schwannoma or cerebellopontine angle meningioma, trigeminal nerve involvement may occur with tumors > 3 cm (check corneal reflex), with tic douloureux-like symptoms being unusual.


Osteopetrosis

Microvascular decompression for trigeminal neuralgia

Microvascular decompression for trigeminal neuralgia


Microvascular decompression is a first-line neurosurgical approach for classical trigeminal neuralgia with neurovascular conflict, but can show clinical relapse despite proper decompression. Second-line destructive techniques like radiofrequency thermocoagulation have become reluctantly used due to their potential for irreversible side effects. Subcutaneous peripheral nerve field stimulation (sPNFS) is a minimally invasive neuromodulatory technique which has been shown to be effective for chronic localised pain conditions.

The most frequently used surgical management of trigeminal neuralgia is Microvascular decompression (MVD), followed closely by stereotactic radiosurgery (SRS). Percutaneous stereotactic rhizotomy (PSR) , despite being the most cost-effective, is by far the least utilized treatment modality 1).

Microvascular decompression (MVD) via lateral suboccipital approach is the standard surgical intervention for trigeminal neuralgia treatment.

Teflon™ and Ivalon® are two materials used in MVD for TN. It is an effective treatment with long-term symptom relief and recurrence rates of 1-5% each year. Ivalon® has been used less than Teflon™ though is associated with similar success rates and similar complication rates 2)

Although microvascular decompression (MVD) is the most effective long-term operative treatment for TN, its use in older patient populations has been debated due to its invasive nature. The symptoms and surgical findings presented in a cohort for young-onset TN are similar to those reported in elderly adults. MVD appears to be a safe and effective treatment for young patients with TN 3).

see Microvascular decompression for trigeminal neuralgia and multiple sclerosis

see Awake Microvascular Decompression for Trigeminal Neuralgia.

see also Endoscope assisted microvascular decompression for trigeminal neuralgia.


Compared with the standard microscope-assisted techniques, the 3D exoscopic endoscope-assisted MVD offers an improved visualisation without compromising the field of view within and outside the surgical field 4).

97 patients with primary trigeminal neuralgia (PTN) underwent fully endoscopic microvascular decompression (MVD) via keyhole approach in Capital Medical University Affiliated Beijing Shijitan Hospital from December 2014 to February 2019 was collected. During fully endoscopic MVD in PTN via keyhole approach, performer use natural clearance without grinding except developed rock bone crest or excessive retraction of the brain tissue, visually and panoramically observe and evaluate the CPA area, accurately identify the responsible vessels, to avoid the omission of responsible vessels or insufficient decompression. And the use of preplaced technology, bridging technology and submersible technology, ensure the efficacy of surgery and reduce the surgical side injuries. Barrow Neurological Institute Pain Intensity Score was used to evaluate the efficacy and identify the recurrence. The surgical efficacy was analyzed. The offending vessels were identified under endoscope in 96 cases. Among them, arterial compression was found in 77 cases, venous compression in 6 cases, and both arterial and venous compression in 13 cases. About the pain outcomes, 87 cases had immediate and complete relief of pain, 5 cases had almost relief of pain, 4 cases had partial relief of pain, and still needed medication control, but the dose was lower than that before operation, and 1 case had no obvious relief of pain. About complications, there were 4 cases of temporary facial numbness, 1 case of temporary hearing loss, both of them recovered after symptomatic treatment. There was no cerebral infarction or hemorrhage, intracranial or incision infection. All cases were followed up for 3.0-38.0 months with a median period of(22.4±2.2) months. During the follow-up periods, postoperative recurrence occurred in 3 cases. Fully endoscopic MVD for PTN through keyhole approach, provides panoramic view to avoid omission of offending vessels and reduce complications, seemed to be a safe and effective surgical method 5).

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMedCochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors.

Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67).

Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict a more favorable outcome. These results may improve patient selection and provider expectations 6).

Microvascular decompression for trigeminal neuralgia technique.

Microvascular decompression for trigeminal neuralgia outcome.

Microvascular decompression for trigeminal neuralgia complications

Microvascular decompression for trigeminal neuralgia case series.


1)

Sivakanthan S, Van Gompel JJ, Alikhani P, van Loveren H, Chen R, Agazzi S. Surgical management of trigeminal neuralgia: use and cost-effectiveness from an analysis of the medicare claims database. Neurosurgery. 2014 Sep;75(3):220-6. doi: 10.1227/NEU.0000000000000430. PubMed PMID: 24871139.
2)

Pressman E, Jha RT, Zavadskiy G, Kumar JI, van Loveren H, van Gompel JJ, Agazzi S. Teflon™ or Ivalon®: a scoping review of implants used in microvascular decompression for trigeminal neuralgia. Neurosurg Rev. 2019 Nov 30. doi: 10.1007/s10143-019-01187-0. [Epub ahead of print] Review. PubMed PMID: 31786660.
3)

Yu F, Yin J. Young-onset trigeminal neuralgia: a clinical study and literature review. Acta Neurochir (Wien). 2021 Apr 17. doi: 10.1007/s00701-021-04848-6. Epub ahead of print. PMID: 33864143.
4)

Li Ching Ng A, Di Ieva A. How I do it: 3D exoscopic endoscope-assisted microvascular decompression. Acta Neurochir (Wien). 2019 May 29. doi: 10.1007/s00701-019-03954-w. [Epub ahead of print] PubMed PMID: 31144166.
5)

Peng WC, Guan F, Hu ZQ, Huang H, Dai B, Zhu GT, Mao BB, Xiao ZY, Zhang BL, Liang X. [Efficacy analysis of fully endoscopic microvascular decompression in primary trigeminal neuralgia via keyhole approach]. Zhonghua Yi Xue Za Zhi. 2021 Mar 30;101(12):856-860. Chinese. doi: 10.3760/cma.j.cn112137-20200630-02002. PMID: 33789367.
6)

Holste K, Chan AY, Rolston JD, Englot DJ. Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis. Neurosurgery. 2020 Feb 1;86(2):182-190. doi: 10.1093/neuros/nyz075. PubMed PMID: 30892607.

Neuropathic dental pain

Neuropathic dental pain

Dental pain may have another origin than teeth. It may be caused by myofascial, neurovascular, cardiac, neurological, sinusal or psychological factors.

A high percentage of patients that are surgically treated for trigeminal neuralgia consult their dentist first and receive possibly unjustified dental treatment. Differential diagnoses include odontogenic pain syndromes as well as atypical orofacial pain. The present literature acknowledges difficulties in correctly diagnosing trigeminal neuralgia, but seems to underestimate the extent 1).

It is notoriously difficult to treat. To date, there are no deep brain stimulation (DBS) studies on this specific pain condition and no optimal target or “sweet spot” has ever been defined.

To determine the optimal thalamic target for improving this condition by utilizing the steering abilities of a directional DBS electrode (Vercise CartesiaTM Model DB-2202-45, Boston Scientific).

literature search and review of the database identified 3 potential thalamic targets. A directional lead was implanted in a patient with NDP and its current steering used to test the effects in each nucleus. The patient reported her pain after 2 wk of stimulation in a prospective randomized blinded clinical trial of one. Quality of life measurements were performed before and after 3 mo on their best setting.

They identified 3 potential nuclei: the Centromedian nucleus (CM), Ventral posteromedial nucleus (VPM), and Anterior pulvinar nucleus. The best results were during VPM stimulation (>90% reduction in pain) and CM stimulation (50% reduction). Following 3 mo of VPM-DBS in combination of lateral CM stimulation, their pain disability index dropped (from 25 to 0) and short form 36 improved (from 67.5 to 90).

VPM stimulation in combination with CM stimulation is a promising target for NDP. DBS electrode directionality can be used to test multiple targets and select a patient specific “sweet spot” for NDP treatment 2).

Case reports

Imholz et al. discuss 2 rare cases of patients who presented with a cerebellopontine angle tumor, who initially manifested with symptoms of dental pain.

The first patient, male, 44 years of age presented to his dentist with toothache (47), which led to its extraction. Five months later, a second painful episode, more characteristic, revealed the presence of a vestibular schwannoma, which was successfully treated and led to the disappearance of the pain. The second case, a 43-year-old female presented to her dentist with toothache (46), which lead the dentist perform a root filling. Two years later, with a 3rd episode of dental pain, more relevant of a trigeminal nevralgia, a epidermoid cyst of the right cerebellopontine angle was identified and successfully treated leading to the disappearance of the pain.

Cerebellopontine angle tumors of this type may lead, in exceptional cases to symptoms of dental pain. Therefore, in face of atypical tooth or facial pain, both a detailed medical history and a detailed examination are necessary, in order to investigate any neurological signs and symptoms, before undertaking any non-essential dental treatment, which may be detrimental for the patients 3).


1)

von Eckardstein KL, Keil M, Rohde V. Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurg Rev. 2015 Apr;38(2):355-60; discussion 360. doi: 10.1007/s10143-014-0591-1. Epub 2014 Nov 25. PubMed PMID: 25418511.
2)

Krüger MT, Avecillas-Chasin JM, Heran MKS, Naseri Y, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Directional Deep Brain Stimulation Can Target the Thalamic “Sweet Spot” for Improving Neuropathic Dental Pain. Oper Neurosurg (Hagerstown). 2021 May 6:opab136. doi: 10.1093/ons/opab136. Epub ahead of print. PMID: 33956987.
3)

Imholz B, Lombardi T, Scolozzi P. [Toothache: At what point has a pontocerebellar angle tumor to be evoked?]. Rev Stomatol Chir Maxillofac Chir Orale. 2015 May 19. pii: S2213-6533(15)00068-3. doi: 10.1016/j.revsto.2015.04.002. [Epub ahead of print] French. PubMed PMID: 26001346.