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Interventional Procedures for Trigeminal Neuralgia

Interventional Procedures for Trigeminal Neuralgia. Dr. Edmond Chung Pain Team QEH. Contents. Methods Theory Indications Limitations Contraindications Anatomy Set up Equipments. Contents (cont’d). Technique Side Effects & Complications Efficacy What if the pain recurs ?

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Interventional Procedures for Trigeminal Neuralgia

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  1. Interventional Procedures for Trigeminal Neuralgia Dr. Edmond Chung Pain Team QEH

  2. Contents • Methods • Theory • Indications • Limitations • Contraindications • Anatomy • Set up • Equipments

  3. Contents (cont’d) • Technique • Side Effects & Complications • Efficacy • What if the pain recurs ? • Peripheral nerve blocks

  4. Methods • Chemical – Glycerol • Radiofrequency thermocoagulation of Trigeminal Ganglion • Maxillary & Mandibular nerve blocks • Peripheral nerve blocks of the branches of Trigeminal nerve – supraorbital, infraorbital, mental nerve blocks

  5. Indications • Trigeminal Neuralgia refractory to non-invasive means of Rx – V1, V2 or V3 dermatomes

  6. Contraindications • Space-occupying lesions or microvascular compression in brain, esp brainstem (Check CT or MRI first!) • Coagulopathy • Infection • Uncooperative patient • Patient refusal

  7. Anatomy • Middle cranial fossa • Dorsal & cranial to foramen ovale • Medial to the gasserian ganglion is the carotid artery & cavernous sinus • V1 (ophthalmic part) – most medial & greatest distance to the foramen ovale • V2 (maxillary part) – central • V3 (mandibular part) – most lateral & superficial

  8. Limitations • Pts who want to avoid numbness of face as result of RF • Pain in V1 dermatome

  9. Equipments • RF generator • RF cannulae • RF probes • RF ground electrode • X-ray Image Intensifier (C-arm)

  10. Set Up

  11. Technique - landmark

  12. Technique • Pt on horizontal recumbent position • Head fixed on a radiolucent head rest by adhesive bandage • Under MAC (using TCI / TIVA technique) • Fluoroscopic guidance • Essential to obtain an optimal picture of foramen ovale • C-arm 45 deg caudal / cranial & 15-20 deg sideways

  13. Technique (cont’d) • 22G 10cm RF needle with a 2mm free tip inserted along the direction of radiation beam (tunnel-vision technique) • N.B. beware piercing of oral mucosa • Needle advanced towards foramen ovale • Once needle enters the foramen, a clear “give” perceived • Check with lateral view on the depth of penetration – intersection of clivus & ospetrosum

  14. Technique (cont’d) • Sensory Stimulation • Freq : 100 Hz • Voltage : 0.1-0.5V • The aim : to elicit paresthesia or pain in the division of trigeminal nerve, which you wish to lesion • Motor Stimulation • Freq : 2 Hz • Voltage : less than 1V • If you see contractions of masseter muscle, advance the needle deeper into the foramen ovale.

  15. Technique (cont’d) • Lesion mode (additional bolus of IV propofolfirst) : • Lesion at 60 deg C for 60 sec • Allow to wake up after 1st lesion  retest with pin prick or sensory stimulation • Adjust position of needle or advance further accordingly • Re-institute GA • Repeat lesioning in 5 deg C increments for 60 sec each • At each stage, allow pt to wake up & retest with pin prick or sensory stimulation • Check corneal reflex

  16. Results • Long term (years) success rates vary from 80 – 90%

  17. Complications • Corneal anesthesia / hyperesthesia – 13.7% • Dysesthesia in the treated area 5-7% • Masseter weakness 1-2%

  18. Morbidity & Mortality • Low morbidity • Can be performed on an out-patient basis • Mortality has not been reported

  19. What if the pain recurs ? • For repeated RF • To review with CT or MRI brain at intervals to exclude SOL • Refer to Neurosurgery for consideration of Gamma Knife or Radiosurgery

  20. Maxillary or Mandibular Nerve Blocks

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