Percutaneous balloon compression trigeminal rhizotomy case series

Between March 2018 and February 2021, 20 peroral balloon compression rhizotomy procedures with a 3D-PSGT were performed in 18 consecutive trigeminal pain patients (13 female, mean age 58 yr). We registered the procedure duration, side effects, complications, and trigeminal function. The therapeutic effect was gauged from reduction of TP and use of analgesics.

Results: All catheter insertions and rhizotomy procedures were successful at the first attempt. Apart from fluoroscopy, no auxiliary material was necessary. The average length of surgery was 19 min (range, 11-27 min). In total, 8 patients indicated complete analgesia and 6 patients pain relief; in 4 patients, persistence of TP was observed during follow-up examinations of up to 20 mo. In total, 6 patients reported of new mild to moderate facial hypesthesia affecting the trigeminal branches V2, V3, or V1-3. No masticatory musculature or corneal affections and device-related complications occurred.

The peroral 3D-PSGT trigeminal rhizotomy is straightforward for the neurosurgeon. This operative approach allows for rapid, safe, and simple foramen ovale puncture cannulation in TP patients and reduces the use of additional equipment, radiation exposure, and procedure time 1).

A total of 120 patients who underwent PTCG for trigeminal neuralgia were randomly assigned to control group-intravenous saline pretreatment before PCTG puncture and anesthesia targeted to bispectral index (BIS) 40 to 60 throughout, and study group-intravenous propofol 1 to 2 mg/kg pretreatment to deepen anesthesia to BIS<40 before PCTG. Mean arterial pressure, heart rate (HR), cardiac output, system vascular resistance, and BIS were measured at 9 time points during the procedure, and the incidence of the TCR was observed at T5 and T6.

BIS was lower in the study group compared with the control after pretreatment with propofol or saline, respectively. Compared with the control group, mean arterial pressure was lower in the study group at several points during the procedure, but there was no difference in HR between the 2 groups at any point. Cardiac output was higher and system vascular resistance lower in the study compared with the control group. In the control group, 42 (70.0%) and 52 (86.7%) of patients developed a TCR at the 2 points, and 37 (67.1%) and 45 (75.0%) in the study group. There was no difference in the incidence of TCR between the 2 groups.

Increasing the depth of propofol anesthesia partially attenuated PTCG-related elevation of blood pressure but did not modify the abrupt reduction in HR.

One hundred eleven procedures with Percutaneous balloon compression (PBC) performed in 66 cases of Multiple sclerosis related trigeminal neuralgia (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.

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.

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 2).


A retrospective review of patients with trigeminal neuralgia who underwent PBC in Istanbul Faculty of Medicine Neurosurgery Department between January 1st, 2007, and January 1st, 2016, was undertaken. Of the 105 patients who underwent balloon compression, 27 patients who received surgical treatment for the first time for typical trigeminal neuralgia were included in the study. Follow-ups, clinical features, and 3-Tesla MRI findings were analyzed retrospectively. MRI findings and clinical features of patients with and without recurrence were compared. The correlation between fractional anisotropy (FA) values and recurrence was investigated.

Nine (33%) patients had recurrence during follow-up. The patients with recurrence had longer duration of symptoms (p=0.032), higher FA difference (ΔFA) (p=0.042) and a higher FA difference rate (p̂FA) (p=0.023). A trend towards early recurrence was found in patients with higher p̂FA, although not significant (p=0.051, R=0.319).

Symptom duration was longer and the microstructural changes were more apparent in patients with recurrence. Symptom duration and FA values obtained with 3-Tesla MRI might be a valuable input in surgical decision besides age, co-morbidities and other clinical and radiographic features 3).


Medical records and follow-up data from 124 primary Percutaneous glycerol trigeminal rhizotomy (PRGR) performed from 1986 to 2000 and 82 primary percutaneous balloon compression (PBC) 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.

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.

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 4).

Oertel MF, Sarnthein J, Regli L, Stieglitz LH. Peroral Trigeminal Rhizotomy Using a Novel 3-Dimensional Printed Patient-Specific Guidance Tool. Oper Neurosurg (Hagerstown). 2021 Aug 30:opab299. doi: 10.1093/ons/opab299. Epub ahead of print. PMID: 34460929.
Asplund P, Linderoth B, Lind G, Winter J, Bergenheim AT. One hundred eleven Percutaneous Balloon Compressions for Trigeminal Neuralgia in a Cohort of 66 Patients with Multiple Sclerosis. Oper Neurosurg (Hagerstown). 2019 Jan 23. doi: 10.1093/ons/opy402. [Epub ahead of print] PubMed PMID: 30690631.
Unal TC, Unal OF, Barlas O, Hepgul K, Ali A, Aydoseli A, Aras Y, Sabanci PA, Sencer A, Izgi N. Factors determining the outcome in trigeminal neuralgia treated with percutaneous balloon compression. World Neurosurg. 2017 Jul 29. pii: S1878-8750(17)31232-9. doi: 10.1016/j.wneu.2017.07.132. [Epub ahead of print] PubMed PMID: 28765027.
Asplund P, Blomstedt P, Bergenheim AT. Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia. Neurosurgery. 2016 Mar;78(3):421-8. doi: 10.1227/NEU.0000000000001059. PubMed PMID: 26465639; PubMed Central PMCID: PMC4747977.
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