Technical considerations and outcome assessment in retrogasserian balloon compression for treatment of trigeminal neuralgia. Series of 901 patients

Abstract

Background: The aim of our study was to describe the retrogasserian balloon compression (RGBC) procedure with some personal tricks and to assess the long-term results.

Methods: Between 1985 and 2012, 901 patients, suffering from refractory trigeminal neuralgia (TN), underwent RGBC procedure in our department. Concerning the surgical technique, the introducer was in close contact with the posterior extremity of the horizontal plate of the palatine bone and had the direction of the bisector of the angle clivus-superior edge of the petrous bone on an X-rays sagittal view. No metallic material was inserted intracranially. The balloon was inflated with 0.7 cc of contrast medium for 6 min.

Results: At 1 month follow up, appreciable pain relief was obtained in 835 patients (92.7%). At 1 year, results were excellent in 605 patients (67.1%), satisfactory in 109 patients (12.1%), poor in 57 patients (6.3%), fair in 66 patients (7.3%), whereas recurrences were observed in the remaining 64 patients (7.2%). At mean follow up of 16,5 years, 559 (62%) patients remained pain free. Twenty six patients (2,8%) continued to experience severe pain. Recurrences occurred in two hundred and fifty patients (27,8%). Fifty two of them were operated on a third time and 22 underwent four procedures.

Conclusion: RGBC IS AN APPROPRIATE AND EFFECTIVE PROCEDURE FOR TREATMENT OF REFRACTORY TN, ENSURING A LONG LASTING PAIN RELIEF PREDICTED ON THREE FACTORS: pear shape of the balloon, its volume, and duration as mentioned earlier.

Keywords: Balloon compression; foramen oval; percutaneous approaches; recurrences; trigeminal neuralgia.

Figure 1

The three landmarks of the Hartel's route on the right hemiface: The first corresponds to location of the skin puncture: 2.5 cm lateral to the angle lip. The second is on the inferior edge of the zygomatic arch, 3 cm anterior to the external auditory canal. The third is on the line joining the first point to the pupil on the inferior edge of the orbit

Figure 2

Skin puncture for balloon compression in a patient under intubation and general anesthesia

Figure 3

Three-dimensional volume computerized tomography depicting the vessels in the pterygo maxillary fossa, especially the internal maxillary artery (short white arrow), the foramen oval (long yellow arrow) after resection of the zygomatic arch and the coronoid process of the mandible (black arrows)

Figure 4

Sagittal X-rays showing the metallic hollow introducer (HI) in close contact with the posterior extremity of the horizontal plate of the palatine bone (thin white arrow) and at the level of the foramen oval (thick white arrow). In black lines: The clivus and the superior edge of the petrous bone

Figure 5

Lateral view X-rays revealing the thin silicone catheter (SC) and the ideal pear shape of the balloon

Figure 6

Graph analysis demonstrating duration of pain relief in 901 patients after percutaneous balloon compression. X-axis denotes pain free survival in years and Y-axis denotes rates of pain-free patients

Figure 7

Lateral view X-rays revealing an unacceptable shape of the balloon despite the close contact of the silicone catheter (SC) with the posterior extremity of the horizontal plate of the palatine bone (black arrow)