Percutaneous Trigeminal Rhizotomy
Three techniques are available: radiofrequency, glycerol injection, and balloon compression. The basis of these techniques is that controlled heat (69–90°C), a neurotoxin or ischemic and mechanical pressure, respectively, will damage trigeminal neurons. Advantages to percutaneous techniques include shorter procedure duration and minimal anesthesia risk. A recent pooled analysis revealed that 55%–80% of patients are pain free at 4–11 years after balloon compression, 26%–82% after radiofrequency thermocoagulation, and 19%–58% after glycerol injection. Initial pain relief (around 90%) across these is approximately equal, but each one is associated with different rates of recurrence and complications.[194–199]
With the large difference in success rates reported across centers for the same procedures, it is hard to unequivocally recommend a superior intervention. Radiofrequency thermocoagulation reaches high rates of pain relief but is associated with high frequencies of facial and corneal numbness. Radiofrequency does allow for somatotopic nerve mapping and selective division lesioning. Multiple treatments not only improve outcomes but also increase morbidity. Balloon compression is similar in outcomes with potentially high, long-term success rates. Glycerol injection offers similar pain-free outcomes, but complication rates have been reported as higher (25% vs. 16%) and lower (11% vs. 23%) compared with balloon compression. Median time to recurrence was 21 months for the balloon procedure and 16 months for the glycerol procedure. In summary, data suggest that these procedures may be dependent on patient selection and/or may be surgeon sensitive.
Headache. 2021;61(6):817-837. © 2021 Blackwell Publishing