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Abstract
Introduction/purpose Facial pain is a debilitating disease with 15,000 new TN cases and 500 GPN cases reported each year, and is often refractory to medical treatment. Minimally invasive rhizotomy is an excellent treatment but requires reaching a deep skull base target with a needle for radiofrequencey (RF) treatment. In this report, we highlight a combined flat panel dynaCT and fluoroscopic guidance system to target the V3 through foramen ovale, V2 through foramen rotundum, and glossopharyngeal nerve adjacent to the styloid process for RF-based therapies, with step-by-step instruction as highlighted by representative cases.
Materials and methods Eighteen patients with Trigeminal Neuralgia (TN) and 2 patients with classical Glossopharyngeal Neuralgia (GPN) were enrolled. Among the 18 TN patients, 15 presented with atypical Trigeminal Neuralgia (ATN) and 3 presented with classical Trigeminal Neuralgia (CTN). Numeric Rating Scale (NRS) scores for facial pain pre-treatment, immediate post-treatment, post procedure day 1, and months 1 and 3 were recorded documenting primary clinical outcome (pain relief with 50% or more reduction in NRS) and adverse clinical outcome (hematoma, facial numbness, masticatory weakness, corneal involvement, and difficulty swallowing).
Results The technical success rate is 100%, confirmed by dynaCT and electrostimulatory testing in awake patients. GPN and CTN groups show excellent immediate and sustained pain relief (2/2 (100%) and 3/3 (100%) with NRS reduction >50% up to 3 months). The ATN group is variable, with 6/15 (40%) having good immediate and sustained pain relief, while the other 9 (60%) patients experienced sub-optimal response (NRS reduction <50% and/or duration <3 months). Complications were mild and well-tolerated, including mild to moderate facial numbness in the TN group (10/18, 56%), mild throat numbness in the GPN group (1/2, 50%), and mild masticatory weakness (1/18, 6%). There was no hematoma, corneal problem, or dysphagia.
Conclusion We present a step-by-step method using representative examples targeting V3, V2, and the glossopharyngeal nerve, as well as our single-center experience with dyna-CT guided RF ablation of chronic facial pain. Using this multidisciplinary approach, we demonstrate 100% technical success with needle guidance to difficult locations. Treatment results are excellent for CTN and GPN (100% NRS reduction >50% up to 3 months), with more variable results in ATN (40% NRS reduction >50% up to 3 months), which is known to be more refractory to therapies.
Disclosures N. Telischak: None. J. Heit: None. O. Choudhri: None. H. Do: None. X. Qian: None.