Percutaneous retrogasserian glycerol injection in the management of trigeminal neuralgia: long-term follow-up results

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1 J Neurosurg 73: , 1990 Percutaneous retrogasserian glycerol injection in the management of trigeminal neuralgia: long-term follow-up results TAKAMITSU FUJIMAKI, M.D., TAKANORI FUKUSHIMA, M.D., D.M.Sc., AND SHINICHIRO MIYAZAKI, M.D. Department of Neurosurgery, Mitsui Memorial Hospital, Tokyo, Japan v- The results in 122 patients with trigeminal neuralgia who underwent percutaneous retrogasserian glycerol injection are presented. Eighty patients were followed from 38 to 54 months. The recurrence rate at 54 months was 72% (Kaplan-Meier analysis), and the median pain-free interval was 32 months. Complications associated with the procedure were significantly high: 63% of the patients had definite hypesthesia of the face and 29% had unpleasant dysesthesias, including two cases of anesthesia dolorosa. Sensory disturbances were most frequent in patients who had received a previous alcohol block procedure. Among the patients without previous peripheral procedures, 50% developed sensory disturbances. Because of the high rates of recurrence and sensory disturbances, the authors prefer microvascular decompression for the management of trigeminal neuralgia. KEY WORDS " glycerol 9 rhizotomy 9 trigeminal nerve 9 trigeminal neuralgia S INCE its introduction by H~kanson 8 in 1981, percutaneous retrogasserian glycerol injection has become an increasingly popular form of therapy for trigeminal neuralgia. 1"2'4'11'13"16-j8'2~ Several authors have reported that this procedure avoids sensory loss and dysesthesia, s'13'26 The role of percutaneous retrogasserian glycerol injection in the treatment of trigeminal neuralgia is, however, still controversial because of the pain recurrence and significant sensory deficit associated with it. 2,3A6m'22 This report analyzes our results in 122 patients treated with this method and offers a prolonged follow-up review to explore potential complications such as sensory disturbance and recurrence. Summary of Cases Patient Population Between November, 1982, and February, 1985, 135 patients with trigeminal neuralgia underwent percutaneous retrogasserian glycerol injection at our institution. The procedure was performed successfully in 122 cases; 13 of the 135 patients did not receive the glycerol injection because of failure to visualize the trigeminal cistern. Of the 122 patients with the completed procedure, we followed 108 patients who achieved satisfac- tory pain relief. Four of these patients died within 4 years after percutaneous retrogasserian glycerol injection from causes not related to the procedure. Of those, three had recurrent pain and these patients were included in this study. Twenty-seven cases were lost to follow-up review, leaving a total of 80 cases (74%) available for analysis. All 80 patients were evaluated for duration of pain relief, the presence of sensory disturbances, and the rate of recurrence. The patients ranged in age from 41 to 92 years (average 71.7 years). There were 47 women and 33 men. Table 1 shows the trigeminal nerve divisions affected in these patients. Thirty-six patients (45%) had previously undergone one or more alcohol blocks. No patient had a history of peripheral neurotomy. Operative Technique Percutaneous retrogasserian glycerol injection was performed in patients suffering from trigeminal neuralgia who were not considered candidates for microvascular decompression because of medical complications or advanced age. All patients underwent high-resolution computerized tomography to exclude the presence of organic lesions. Puncture of the trigeminal cistern was achieved by an anterior percutaneous route via the 212 J. Neurosurg. / Volume 73/August, 1990

2 Glycerol injection for trigeminal neuralgia FIG. 1. Initial and early follow-up results of percutaneous retrogasserian glycerol injection in patients with trigeminal neuralgia (typical 105, atypical 17). Long follow-up data obtained in 80 patients demonstrate a high recurrence rate. Excellent: complete pain relief; good: pain improved, some sensory disturbance; poor: persistent pain. TABLE l Distribution of pain in 80 cases with trigeminal neuralgia Trigeminal Nerve Division No. of Cases! , , ,2,3 5 foramen ovale, as described by Hfikanson. 8 Following premedication with atropine, the patient was placed on a radiographic table in the position described by Perl and Ecker. 15 Under local anesthesia, a No. 20 spinal needle was inserted 3 cm lateral to the corner of the mouth and the foramen ovale was punctured under fluoroscopic control. After drainage of cerebrospinal fluid (CSF), the patient was placed in a semi-sitting position. The depth of needle penetration was confirmed by lateral fluoroscopy, then 0.5 ml metrizamide (300 mg/ml) was injected into the trigeminal cistern. After adequate positioning of the needle tip had been verified, 0.3 to 0.5 ml of pure sterile glycerol was injected slowly. The patient was kept in the sitting or semi-sitting position for 3 to 4 hours. Surgical Results The initial, early follow-up, and long-term follow-up results are shown in Fig. 1. The final outcome (as of April, 1988) shows that 21 patients (26 %) reported longlasting pain relief (Group A); 13 patients (62%) in this group had slight-to-moderate sensory disturbance. Eleven patients (14%) experienced complete pain relief or improved original pain but painful dysesthesia or anesthesia dolorosa remained (Group B). Forty-eight patients (60%) developed recurrent pain (Group R); 25 (52%) of these subsequently underwent microvascular decompression. The pain-free interval for this series, calculated by the Kaplan-Meier method, is shown in Fig. 2. The median pain-free interval was 32 months and only 28.4% of patients were pain-free at 54 months. Complications relating to percutaneous retrogasserian glycerol injection were unexpectedly frequent. Of 80 patients followed for 38 to 54 months, 50 patients (63%) had definite hypesthesia and 23 (29%) suffered from unpleasant paresthesia or dysesthesia, including two cases of anesthesia dolorosa. Of the 36 patients who had previously received an alcohol block, 28 patients ( 77.8 %) developed sensory disturbance; of the 44 patients who had not received previous peripheral procedures, 22 patients (50%) developed sensory disturbance (Fig. 3). Patients in Groups B and R were more likely to have undergone previous block procedures (Fig. 3). Discussion In his initial description of percutaneous retrogasserian glycerol injection, Hfikanson 8 reported a high success rate in relieving trigeminal neuralgia while sparing facial sensory function. He noted a 60% incidence of slight sensory disturbance in the face, but the numbness faded after several weeks and no patient described the altered sensation as unpleasant. Lunsford and coworkers ~'j3'14 also reported a 37% incidence of mild sensory disturbance and a 7% incidence of annoying paresthesia. Apfelbaum found an 8.2% incidence of J. Neurosurg. / Volume 73/August,

3 I T. Fujimaki, T. Fukushima, and S. Miyazaki Recurrence free ratio (Kaplan-Meier) I, L., i= "1, t m ul I (~ If '6 4'2 48 5=4 Months FIG. 2. Kaplan-Meier analysis of the probability of pain-free ratio in 108 patients. Rates of pain-free patients at 12, 24, 36, 48, and 54 months were 0.71, 0.55, 0.48, 0.35, and 0.28, respectively. A) cases previous block and s-=nsory disturbance (+) (_.') *P<0.02 ~r sensory disturb. cases B) previous block and recurrence R m I~! previous alcohol block,//////j "///////, A,////HJ 20-,//////, 20- D /HHH, 78% B!5; :///Mh /i/i/h/ y////// FIG. 3. A: Sensory disturbance in patients with (+) or without (-) previous block procedures. The rate of sensory disturbance is significantly higher in patients who had received previous blocks. Statistical significance was calculated using the chi-square test (p < 0.02). Sensory disturbance developed in 50% of those who had not received a previous block procedure. B: Patients in Group B (sensory disturbance) and Group R (recurrence) frequently had had previous blocks, but the differences were not statistically significant (p > 0.03). Group A had excellent results with complete relief. substantial sensory loss (Lunsford and Apfelbaum12); in contrast, other authors reported a 37% to 52% incidence of sensory disturbance. 4'16'22'26 In the present series, sensory disturbance was observed in 50 (63%) of the 80 patients studied over the long term. This is higher than the figure in other reports but, when the data were restricted to patients who had received no previous alcohol block (44 patients), the incidence was 50% and comparable to other series. Annoying sensory disturbance or painful dysesthesia was noted in 29% of the present cases. Saini 2~ reported a 4.7% incidence of anesthesia dolorosa (26 patients). In our series, two patients (1.6%) developed anesthesia dolorosa. Rappaport and Gomori ~7 also found a 5% incidence of painful dysesthesia after primary injection and a significantly higher (14.3%) incidence after a second procedure. Lunsford and Bennett ~s reported one (5.3%) of 19 patients who developed dysesthesia after a secondary procedure. Recurrence rates and sensory disturbances in published series are shown in Table 2. Although only a few series have been published describing long-term followup results of percutaneous retrogasserian glycerol injection, the recurrence rates reported in several studies are quite significant. Saini 2~ reported recurrence in 41% of cases in 2 years and 83% in 5 years. Hhkanson 8 initially reported an 18% recurrence rate in patients followed from 2 months to 4 years. He subsequently reported 100 patients followed for 1 to 6 years with a 31% recurrence rate. v In experimental studies, glycerol has been shown to be a neurolytic agent which produces demyelination and axonolysis) 4'~9 As with any other procedure that produces damage to a nerve root, one would expect a certain incidence of deafferentation pain following trigeminal rhizolysis. From their experimental results, Rengachary, et al., 19 predicted that the recurrence rate might increase with longer follow-up periods. Repeat percutaneous retrogasserian glycerol in- 214 J. Neurosurg. / Volume 73/August, 1990

4 Glycerol injection for trigeminal neuralgia Authors & Year TABLE 2 Summary of percutaneous retrogasserian glycerol injection results reported in the literature No. of Cases Initial Results Pain Relief H~kanson, % Sweet, ~ al., % Lunsford, % H~kanson, % Lunsford& Bennett, % Apfelbaum, 1985" 73 86% Lunsford, 1985" % Rappaport & Magora, % Waltz, et al., % Arias, % Beck, et al., % Rappaport, % Dieckmann, et al., % Saini, % (2 yrs), 17% (5 yrs) Burchiel, % Rappaport & Gomori, % Young, % Fujimaki, et al., % Recurrence * Apfelbaum and Lunsford reported their clinical data separately in a joint communication/z Sensory Disturbance Rate Period Minor Major 18% 2 mos-4 yrs 60% 18.5% 31% 1-6 yrs 60% 9.8% < 6 mos 25.9% 1.8% 7.1% -> 6 mos 23% 8.2% 35% -< 3 yrs 6% 73% 27% 17% -< 24 mos 67% 16% 10% 6-36 mos 70% 17% 2% 25% -> 1 yr 37.5% 34% 12% 1-2 yrs 40% 92% 6 yrs 16% 50% _< 18 mos 72% 22% 28% 18.5% 6-67 mos 72% 3% 72% mos 63% 29% jection for recurrent trigeminal neuralgia may cause more sensory disturbances. This is also true in patients who have received a previous alcohol block. Injection of glycerol into the trigeminal cistern may lead to narrowing of the cisternal CSF space. A higher incidence of sensory deficit and dysesthetic pain will occur following repeat percutaneous retrogasserian glycerol injection in this setting. 2~ It appears that this procedure has a high risk of recurrence and of minor and major sensory disturbances. The risk of sensory disturbance is even higher when compared to conventional radiofrequency rhizotomy 23,24 in which the lesion can be more accurately controlled. Both percutaneous retrogasserian glycerol injection and radiofrequency rhizotomy are destructive procedures and do not remove the cause of pain. On the other hand, microvascular decompression surgery 9 has been established as the definitive treatment for trigeminal neuralgia. Jannetta ~~ reported that 90% of patients were pain-free or improved over long follow-up periods. Our experience with microvascular decompression for the past 9 years has also demonstrated excellent pain relief in a majority of patients with trigeminal neuralgia. 5'6 Because of the high incidence of pain recurrence and annoying sensory disturbances associated with the percutaneous retrogasserian glycerol injection procedure, we believe that microvascular decompression is the better treatment modality for trigeminal neuralgia. Acknowledgment The authors thank Dr. Benjamin Gelber of Lincoln, Nebraska, for his help and advice in editing the manuscript. References 1. Arias M J: Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia. A prospective study of 100 cases. J Neurosurg 65:32-36, Beck DW, Olson J J, Urig E J: Percutaneous retrogasserian glycerol rhizotomy for treatment of trigeminal neuralgia. J Neurosurg 65:28-3 l, Burchiel K J: Percutaneous retrogasserian glycerol rhizolysis in the management of trigeminal neuralgia. J Neurosurg 69: , Dieckmann G, Varas G, Sogabe K: Retrogasserian glycerol injection or percutaneous stimulation in the treatment of typical and atypical trigeminal pain. Neurol Res 9:48-49, Fukushima T: Brain protection by keyhole microsurgery, in Isamat F, Ferrer E (eds): 8th European Congress of Neurosurgery. Barcelona: European Congress of Neurosurgery, 1987, p 10 (Abstract) 6. Fukushima T: Decompression vasculaire micro-chirurgicale du trijumeau pour le traitement du "tic douloureux', in: Les Algies Cranio-Faciales. Journee d'oto-neuro- Ophtalmologie. 1988, pp HSkanson S: Retrogasserian glycerol injection as a treatment of tic douloureux, in Bonica J J, Lindblom U, Iggo A, et al (eds): Advances in Pain Research and Therapy. New York: Raven Press, 1983, Vol 5, pp HSkanson S: Trigeminal neuralgia treated by the injection of glycerol into the trigeminal cistern. Neurosurgery 9: , Jannetta P J: Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26: , Jannetta PJ: Trigeminal neuralgia: treated by microvascular decompression, in Wilkins RH, Rengachary SS (eds): Nenrosurgery. New York: McGraw-Hill, 1985, Vol 3, pp J. Neurosurg. / Volume 73/August,

5 T. Fujimaki, T. Fukushima, and S. Miyazaki 11. Lunsford LD: Treatment of tic douloureux by percutaneous retrogasserian glycerol injection. JAMA 284: , Lunsford LD, Apfelbaum RI: Choice of surgical therapeutic modalities for treatment of trigeminal neuralgia. Clin Neurosurg 32: , Lunsford LD, Bennett MH: Percutaneous retrogasserian glycerol rhizotomy for tic douloureux. Part 1. Technique and results in 112 patients. Neurosurgery 14: , Lunsford LD, Bennett MH, Martinez AJ: Experimental trigeminal glycerol injection. Electrophysiologic and morphologic effects. Arch Neuroi 42: , Perl T, Ecker A: Roentgenologically controlled placement of the needle in the trigeminal root for the treatment of tic douloureux. A JR 82: , Rappaport ZH: Percutaneous retrogasserian glycerol injection for trigeminal neuralgia: one year follow-up. Pain Clin 1:57-61, Rappaport ZH, Gomori JM: Recurrent trigeminal cistern glycerol injections for tic douloureux. Aeta Neurochir 90: 31-34, Rappaport ZH, Magora F: Trigeminal glycerol rhizolysis in the treatment of tic douloureux. Eur J Anaesthesiol 2: 53-57, Rengachary SS, Watanabe IS, Singer P, et al: Effect of glycerol on peripheral nerve: an experimental study. Neu- rosurgery 13: , Saini SS: Retrogasserian glycerol injection therapy in trigeminal neuralgia. J Neurol Neurosurg Psychiatry 50: , Sweet WH: The treatment of trigeminal neuralgia (tic douloureux). N Engl J Med 315: , Sweet WH, Poletti CE, Macon JB: Treatment of trigeminal neuralgia and other facial pains by retrogasserian injection of glycerol. Neurosurgery 9: , Tew JM Jr, Maxfield FH: Trigeminal neuralgia: a new surgical approach (percutaneous electrocoagulation of the trigeminal nerve). Laryngoscope 83: , van Loveren H, Tew JM Jr, Keller JT, et al: A 10-year experience in the treatment of trigeminal neuralgia. Comparison of percutaneous stereotaxic rhizotomy and posterior fossa exploration. J Neurosurg 57: , Waltz TA, Dalessio DJ, Ott KH, et al: Trigeminal cistern glycerol injections for facial pain. Headache 25: , Young RF: Glycerol rhizolysis for treatment of trigeminal neuralgia. J Neurosurg 69:39-45, 1988 Manuscript received September 8, Address reprint requests to: Takamitsu Fujimaki, M.D., c/o I. Josh Fidler, D.V.M., Ph.D., Department of Cell Biology, University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 173, Houston, Texas J. Neurosurg. / Volume 73~August, 1990