Tag: glycerol injection

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Revisiting Härtel’s technique for percutaneous transoval glycerol injection

Acta Neurochirurgica (2025) 167:126

The study revisits Härtel’s technique for percutaneous transoval glycerol injection in treating trigeminal neuralgia. It identifies an optimal entry point in the cheek, 2 mm below the horizontal plane, to improve procedural success and reduce complications, emphasizing the importance of precise needle guidance.

• Purpose: The study revisits Härtel’s technique for percutaneous transoval glycerol injection (GI) to treat trigeminal neuralgia, aiming to identify optimal needle entry points and trajectories using imaging-based simulations.

• Methods: CT and MRI-based simulations were conducted on eleven patients to determine optimal entry points and trajectories through the foramen ovale (FO) to reach Meckel’s cave.

• Findings: The optimal entry point is 2 mm below the horizontal plane through the angle of the mouth, providing better access to Meckel’s cave in most cases.

• Conclusion: Technical results of GI can be improved by selecting the optimal entry point and guiding the needle through the medial part of FO under fluoroscopy.

• Historical Context: Härtel’s technique, developed in 1912, provided a systematic approach to reach the trigeminal ganglion through FO.

• Variability in Techniques: Different variations of GI techniques have led to variable outcomes, highlighting the importance of standardizing the procedure.

• Simulation Insights: 3D simulations help in identifying reliable entry points and can be useful in cases with anatomical variations.

• Clinical Implications: The study suggests that lowering the entry point in the cheek could improve the success rate of GI procedures.

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Surgical treatment of trigeminal neuralgia. Results from the use of glycerol injection, microvascular decompression, and rhizotomia

Acta Neurochir (2010) 152:2125–2132. DOI 10.1007/s00701-010-0840-1

The study aims to assess the efficacy and safety of surgical treatment of trigeminal neuralgia (TN) in our department and to identify prognostic factors.

Methods Seventy patients receiving surgical treatment for TN during the period 2003–2004 were included in this retrospective study. The surgical procedures used were glycerol injection (GI), microvascular decompression (MVD), or rhizotomia (RIZ). All patients were divided into spontaneous onset TN type1 (brief lancinating pain) or TN type 2 (continuous pain component). Two patients had bilateral TN; each side was regarded as a separate case. These 70 patients had a total of 160 interventions (110 GI, 40 MVD, and ten RIZ) performed in the period 1998–2007. Data were obtained by chart review and telephone interview. Patients provided information about pre- and postoperative pain characteristics including subtype, duration, intensity, and the use of antiepileptic drugs. Outcome was evaluated using a pain vector diagram.

Results To quantify self-reported pain, we developed a new vector-based pain diagram. The subtype of TN was shown to be a very important prognostic factor. One year after MVD, 90% of patients with type 1 TN still had positive effect, whereas this was only true in 73% of patients with type 2 TN. After RIZ, the results were 71% and 33% for types 1 and 2, respectively. For comparison, GI had a significant lower effect but if the treatment led to hypoesthesia, 41% continued to have a positive effect 1 year after surgery, compared to only 24% if postoperative sensation was normal. Type 2 TN was found to be dominated by women with left-sided TN outside the V2 dermatome and with a lower probability of a neurovascular conflict. As expected, 1/5 of the cases developed postoperative hypoesthesia in the face following a nerve destructive procedure (RIZ and GI). Using MVD, the risk of serious side effects was about 4%. Complementary and alternative treatment had no general or permanent effect in the investigated population—quite the contrary.

Conclusions Regarding prognosis and outcome, we find that it is very important to classify TN in subgroups (types 1 and 2). Dealing with medically treatment-resistant type 1 TN, MVD and RIZ are reasonably safe and effective interventions. The surgical results dealing with type 2 TN are still very poor. All patients with medically treatmentresistant TN should be offered referral to a neurosurgical unit with experience in treating this painful disease. We recommend using a vector-based pain diagram when evaluating the outcome of multiple interventions.

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Comparison of percutaneous balloon compression and glycerol rhizotomy for the treatment of trigeminal neuralgia

J Neurosurg 113:486–492, 2010.DOI: 10.3171/2010.1.JNS091106

The aim of this study was to compare percutaneous balloon compression (PBC) and percutaneous retrogasserian glycerol rhizotomy (PRGR) in terms of effectiveness, complications, and technical aspects.

Methods. Sixty-six consecutive PBC procedures were performed in 45 patients between January 2004 and December 2008, and 120 PRGR attempts were performed in 101 patients between January 2006 and December 2008. The PRGR procedures were not completed due to technical reasons in 19 cases. Five patients in the Balloon Compression Group and 9 patients in the Glycerol Group were lost to follow-up and were excluded from the study. The medical records and the intraoperative fluoroscopic images from the remaining cases were retrospectively examined, and the follow-up was completed with telephone contact, when necessary. The 2 groups were compared in terms of initial effect, duration of effect, and rates of complications as well as severity and type of complications.

Results. The rates for immediate pain relief were 87% for patients treated with glycerol injection and 85% for patients treated with balloon compression. The Kaplan-Meier plots for the 2 treatment modalities were similar. The 50% recurrence time was 21 months for the balloon procedure and 16 months for the glycerol procedure. When the groups were broken down by the “previous operations” criterion, the 50% recurrence time was 24 months for the Glycerol First Procedure Group, 6 months for the Balloon First Procedure Group, 8 months for the Glycerol Previous Procedures Group, and 21 months for the Balloon Previous Procedures Group. The rates of complications (excluding numbness) were 11% for PRGR and 23% for PBC, and this difference was statistically significant (chi-square test, p = 0.04).

Conclusions. Both PRGR and PBC are effective techniques for the treatment of trigeminal neuralgia, with PRGR presenting some advantages in terms of milder and fewer complications and allowing lighter anesthesia without compromise of analgesia. For these reasons the authors consider PRGR as the first option for the treatment of trigeminal neuralgia in patients who are not suitable candidates or are not willing to undergo microvascular decompression, while PBC is reserved for patients in whom the effect of PRGR has proven to be short or difficult to repeat due to cisternal fibrosis.

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