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Percutaneous Balloon Compression for the Treatment of Trigeminal Neuralgia
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background. Trigeminal neuralgia (TN) is a paroxysmal unilateral facial pain condition. That it is rather rare is of little comfort to those who are affected, as TN is often described as one of the worst pains known to mankind. Advanced age and multiple sclerosis (MS) are risk factors for developing TN. The first line of treatment is medical, primarily with carbamazepine. When medical treatment fails, as it does in many patients, there are several surgical options. One of the minimally invasive options, suitable for patients with comorbidity, is percutaneous balloon compression (PBC). Despite its introduction in the early 1980s, PBC is arguably the least well studied of the minimally invasive procedures for the treatment of TN.

Aims. The aim of this thesis was to evaluate the efficacy of PBC, both overall and in MS-TN patients specifically. Further, it intended to identify and evaluate pre- and intraoperative parameters associated with the efficacy of PBC. It also investigated changes in sensory function after PBC, and identified side effects and complications associated with PBC. Finally, it sought to evaluate how efficacy, side effects and complications differed between PBC and another minimally invasive technique; percutaneous retrogasserian glycerol rhizotomy (PRGR).

Methods. Cohorts of patients treated with PBC in Umeå and Stockholm, and with PRGR in Umeå, were followed retrospectively. Data from an existing database was combined with data from medical records, radiographs and telephone interviews.

Results. After PBC, 90 % of the patients were completely pain free without medication for TN. The median time to recurrence of pain was 28 months. In patients with concurrent MS, the initial success rate was 67 % and the median time to recurrence was 8 months. In patients without MS, who had not previously been treated surgically, the initial success rate was 91 % and the median time to recurrence was 48 months. The procedure could, however, be repeated with good results. A good compression, indicated by a pear-shaped balloon as seen on intraoperative lateral radiograph, was crucial to achieve good pain relief. Postoperative hypoesthesia was present in the majority of patients, but after 3-6 months, sensibility was partly or fully normalized in most patients. Severe complications were rare, but included transient cardiac arrest, meningitis and dysesthesia. The side effects profile was favorable to that of percutaneous retrogasserian glycerol rhizotomy, in that the latter produced more cases of dysesthesia and decreased corneal sensibility. The efficacy of the two treatments were, however, not significantly different.

Conclusions. PBC is an effective and relatively safe treatment option for patients with TN refractory to medical treatment. It deserves its place among the standard treatments for TN, and could be considered for those patients eligible for surgery for which open surgery is a less suitable option.

 

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 63
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2032
Keywords [en]
trigeminal neuralgia, multiple sclerosis, surgery, percutaneous balloon compression, percutaneous retrogasserian glycerol rhizolysis
National Category
Other Clinical Medicine
Research subject
Neurosurgery
Identifiers
URN: urn:nbn:se:umu:diva-158352ISBN: 978-91-7855-065-4 (print)OAI: oai:DiVA.org:umu-158352DiVA, id: diva2:1306782
Public defence
2019-05-17, Hörsal B, Unod T9, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2019-04-26 Created: 2019-04-24 Last updated: 2019-04-29Bibliographically approved
List of papers
1. Percutaneous retrogasserian balloon compression for trigeminal neuralgia: review of critical technical details and outcomes
Open this publication in new window or tab >>Percutaneous retrogasserian balloon compression for trigeminal neuralgia: review of critical technical details and outcomes
2013 (English)In: World Neurosurgery, ISSN 1878-8750, E-ISSN 1878-8769, Vol. 79, no 2, p. 359-368Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To describe percutaneous balloon compression (PBC) of the trigeminal rootlets as treatment for trigeminal neuralgia (TN), including history, operative techniques, outcomes, side effects, and some recent findings increasing the likelihood of a positive outcome.

METHODS: PBC is indicated in patients with TN in whom microvascular decompression is considered less suitable. The procedure is simplified by the use of biplanar fluoroscopy, although it is usually carried out with C-arm fluoroscopy to facilitate the introduction of the needle and the visualization of the inflated catheter. In the right position, a clearly defined pear shape usually appears after injection of 0.5-0.7 mL of contrast material. The balloon is kept inflated for 1.5-3 minutes. It is crucial to obtain a pear shape because this probably is the most significant factor for obtaining good, long-lasting pain relief.

RESULTS: An analysis of 100 consecutive PBC procedures showed an initial success rate of 90% and a median pain-free time without medication of 28 months. Subdividing these patients into primary TN (n = 77) and TN secondary to multiple sclerosis (a = 23), the median pain-free times were 33 months and 24 months (P = 0.2), indicating that the outcome may depend on the preoperative conditions.

CONCLUSIONS: Complications and side effects include cardiovascular stress during the procedure, local hemorrhages in the cheek, postoperative sensory disturbance, masseter weakness, infections, and transitory diplopia after surgery. Measures to minimize side effects are proposed. With meticulous technique, PBC is a straightforward, effective, and fast procedure that compares well with other percutaneous therapies for TN.

Keywords
Balloon compression, Review, Trigeminal neuralgia
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-71110 (URN)10.1016/j.wneu.2012.03.014 (DOI)000317537000041 ()22480980 (PubMedID)2-s2.0-84875896123 (Scopus ID)
Available from: 2013-06-11 Created: 2013-05-20 Last updated: 2019-04-25Bibliographically approved
2. The predictive power of balloon shape and change of sensory functions on outcome of percutaneous balloon compression for trigeminal neuralgia
Open this publication in new window or tab >>The predictive power of balloon shape and change of sensory functions on outcome of percutaneous balloon compression for trigeminal neuralgia
2010 (English)In: Journal of Neurosurgery, ISSN 0022-3085, E-ISSN 1933-0693, Vol. 113, no 3, p. 498-507Article in journal (Refereed) Published
Abstract [en]

The authors have demonstrated that using a pear-shaped balloon when performing percutaneous balloon compression for trigeminal neuralgia results in longer pain relief than non-pear-shaped balloons. Other surgical parameters seemed less important with respect to pain relief. Balloon compression also, in many cases, results in hypesthesia.

Keywords
trigeminal neuralgia, balloon compression, balloon shape, sensory function, outcome predictor, sensimetric testing
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-42290 (URN)10.3171/2010.2.JNS091466 (DOI)20345223 (PubMedID)
Available from: 2011-04-07 Created: 2011-04-07 Last updated: 2019-04-25Bibliographically approved
3. Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia
Open this publication in new window or tab >>Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia
2016 (English)In: Neurosurgery, ISSN 0148-396X, E-ISSN 1524-4040, Vol. 78, no 3, p. 421-428Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Despite >30 years of clinical use, the literature is still sparse when it comes to comparisons between percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizolysis (PRGR) as treatments for trigeminal neuralgia.

OBJECTIVE: To perform a retrospective cohort comparison between PBC and PRGR with regard to therapeutic effect, side effects, and complications.

METHODS: Medical records and follow-up data from 124 primary PRGRs performed from 1986 to 2000 and 82 primary PBCs performed from 2000 to 2013 were reviewed. All patients had undergone clinical sensory testing and assessment of sensory thresholds. Analyses were performed to compare duration of pain relief, frequency of sensory disturbances, and side effects.

RESULTS: Median duration of pain relief was 21 months after PRGR and 20 months after PBC. Both methods carried a high risk of hypesthesia/hypalgesia (P < .001) that was partly reversed with time. Decreased corneal sensibility was common after PRGR (P < .001) but not after PBC. Dysesthesia was more common after PRGR (23%) compared after PBC (4%; P < .001). Other side effects were noted but uncommon.

CONCLUSION: PBC and PRGR are both effective as primary surgical treatment of trigeminal neuralgia. Both carry a risk of postoperative hypesthesia, but in this series, the side effect profile favored PBC. Furthermore, PBC is technically less challenging, whereas PRGR requires fewer resources. Between these 2 techniques, we propose PBC as the primary surgical technique for percutaneous treatment of trigeminal neuralgia on the basis of its lower incidence of dysesthesia, corneal hypesthesia, and technical failures.

ABBREVIATIONS: MS, multiple sclerosisPBC, percutaneous balloon compressionPRGR, percutaneous retrogasserian glycerol rhizotomyTN, trigeminal neuralgiaThis is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work, provided it is properly cited. The work cannot be changed in any way or used commercially.

Keywords
Balloon compression, Glycerol rhizotomy, Trigeminal neuralgia
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-113954 (URN)10.1227/NEU.0000000000001059 (DOI)000370438000028 ()26465639 (PubMedID)
Available from: 2016-01-08 Created: 2016-01-08 Last updated: 2019-04-24Bibliographically approved
4. One hundred eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis
Open this publication in new window or tab >>One hundred eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis
Show others...
2019 (English)In: Operative neurosurgery, ISSN 2332-4252Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: Trigeminal neuralgia associated with multiple sclerosis (MS-TN) is comparatively rare and larger series of percutaneous balloon compression (PBC) in such cases are few in the literature.

OBJECTIVE: To evaluate the results after PBC for MS-TN with regards to therapeutic effect, side effects, and complications.

METHODS: One hundred eleven procedures with PBC performed in 66 cases of MS-TN were analyzed. Therapeutic effect was measured as postoperative time to pain recurrence without medication. All complications were compiled and the sensory function was evaluated in a subgroup of cases.

RESULTS: The initial pain free rate was 67% and the median time to pain recurrence was 8 mo. Thirty-six patients were treated with PBC only, and among them, the results were worse if treated 3 to 4 times before, compared to first treatment (P = .009-.034). Patients who had several PBCs had worse results already after the first surgery (P < .001). A significant number of patients had impaired sensation to light touch directly after surgery, which was normalized at the late follow-up. Sensimetric testing showed raised thresholds for perception and pain directly after surgery (P = .004-.03), but these were also normalized at the late follow-up.

CONCLUSION: PBC is a treatment that can be effective for many patients with MS-TN. Repeated previous surgeries is a risk factor for an unsatisfactory outcome. However, the patients with multiple surgeries had less satisfactory results already at the first procedure, indicating that a therapy resistant disease can be predicted after the first two PBCs. Postoperative sensory deficits were common but not lasting.

Place, publisher, year, edition, pages
Oxford University Press, 2019
Keywords
Balloon compression, Multiple sclerosis, Trigeminal neuralgia
National Category
Other Clinical Medicine Neurology Surgery
Research subject
Neurosurgery
Identifiers
urn:nbn:se:umu:diva-158351 (URN)10.1093/ons/opy402 (DOI)30690631 (PubMedID)
Available from: 2019-04-24 Created: 2019-04-24 Last updated: 2019-04-25

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