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For confirming the correct location of the radiofrequency electrode before creation of a lesion, percutaneous CT-guided trigeminal tractotomy-nucleotomy is most commonly performed with the patient prone and awake. However, for patients whose facial pain and hypersensitivity are so severe that the patients are unable to rest their face on a support (as required with prone positioning), awake CT-guided tractotomy-nucleotomy might not be feasible. The authors describe 2 such patients, for whom percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia was successful. One patient was a 79-year-old man with profound left facial postherpetic neuralgia, who was unable to tolerate awake CT-guided tractotomy-nucleotomy, and the other was a 45-year-old woman with intractable hemicranial pain that developed after a right frontal lesionectomy for epilepsy. Each patient underwent a percutaneous intraoperative CT-guided tractotomy-nucleotomy under general anesthesia. No complications occurred, and each patient reported excellent pain relief for up to 6 and 3 months after surgery, respectively. Percutaneous intraoperative CT-guided tractotomy-nucleotomy performed on anesthetized patients is effective for facial postherpetic neuralgia and postoperative hemicranial neuralgia.

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Trigeminal neuralgia is a type of facial pain that is difficult to treat. The pain can be excruciating and debilitating. The wide range of treatments currently used for trigeminal neuralgia is ample evidence that there is no simple answer to how it should be managed. This review will evaluate the current surgical procedures used for the treatment of trigeminal neuralgia. A critical analysis of the evidence-based studies to date was done to evaluate and compare the efficacy of the different surgical procedures. Arguments for and against the use of surgery for trigeminal neuralgia are presented. In addition, the surgical procedures were compared with other treatments for trigeminal neuralgia.

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In 1987 to 1997, open ultrasonic vertical trigeminal nucleotractotomy was performed in 46 patients with drug-resistant facial pain syndromes. There were 29 patients with deafferentation pain, 14 with migraine-induced neuralgia and 3 with trigeminal neuralgia due to multiple sclerosis. The operation included unilateral suboccipital craniotomy, C1 hemilaminectomy and vertical destruction of the trigeminal nucleus and descending tract with an ultrasonic microsurgical needle. The rostral limit of trigeminal nucleotractotomy depended on the site of facial pain. In the early postoperative period, there were good (relief of baseline pain or mild pain requiring no medical therapy) in 44 (96%) patients and poor results in 2 (4%). Late results of follow-ups lasting 1 to 11 years (mean 6.1 years) were known in 39 patients. Good, fair (pain control with medication), and bad results were preserved in 25 (64%), 4 (10%), and 10 (26%) patients. Trigeminal nucleotractotomy is effective in relieving intractable facial pain.

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The many procedures performed for the treatment of trigeminal neuralgia require an extensive knowledge of the brainstem and spinal nuclei anatomy and physiology, their projections, central and peripheral connections, the trigeminal autonomic elements, and autonomic effects of trigeminal injury. Recent advances in the understanding of the anatomy and physiology complex as presented in the neuroscience literature are reviewed.

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New radiofrequency lesion dorsal root entry zone (DREZ) electrodes for relief of facial pain were designed based on a neuroanatomic study in man of the trigeminal nucleus caudalis at the cervicomedullary junction. The human brainstems of 3 normal postmortem specimens were sectioned with measurements and relationships of the trigeminal nucleus caudalis, segmental tracts, spinocerebellar tracts and dorsal columns. Two right-angle DREZ electrodes were made by Radionics for producing DREZ lesions in the trigeminal nucleus caudalis to treat deafferentation facial pain.

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The authors report of a case with a pituitary macroadenoma which was associated with a persistent trigeminal artery. The tumour was removed by transsphenoidal microsurgical approach to the sella turcica. To recognise the developmental anomaly is very important to avoid complications during operation.

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Persistent trigeminal neuralgia, herpes zoster neuralgia of the first division of the trigeminal nerve and pain caused by cancer situated in the head and neck pose frustrating problems for patients and physicians. Tractotomy and/or partial vertical nucleotomy of the subnucleus caudalis nervi trigemini offers a logical approach to the treatment of such pain, since these structures contain fibres of the Vth nerve, as well as the somatosensory fibres of the VIIth, IXth and Xth nerve. Tactile and some thermal sensitivity of the face is preserved and anaesthesia dolorosa and keratitis neuroparalytica is avoided. Over the past 30 years 370 patients with therapy-refractory trigeminal pain, pain due to cancer of the head and neck and herpes zoster trigeminal pain were treated by means of tractotomy (personal series of V. Grunert), including 30 patients who underwent partial vertical nucleotomy. The mean age of the patients was 68 years (range 54-84 years). The mortality in this series was 0.9% (4 patients; one operative mortality due to air embolism, one postoperative cardiac failure following myocardial infarction and two intracerebral haematomas). 60% of the patients with persistent trigeminal neuralgia were pain-free and 28% improved, whereas 12% were unchanged or suffered from recurrent pain. Of the patients with cancer who complained of pain derived from the Vth, VIIth, IXth and Xth nerve, 40% demonstrated marked pain relief and 60% showed no improvement. Tractotomy and partial vertical nucleotomy offer a valuable method in experienced hands for relieving pain where other methods have failed.

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This study includes 127 patients treated for typical trigeminal neuralgia, 74 of whom underwent a percutaneous microcompression (PMC), 33 a radiofrequency thermocoagulation (RFT) and 20 were explored for microvascular decompression (MVD). A mean follow-up of 24 months was reached by all the groups. Pain relief was evaluated as an 'all or none' effect. At hospital discharge, pain had disappeared in 93.2% of the patients treated with PMC, in 81.8% of those treated with RFT, and in 85% of the MVD group. At 24 months the effect was maintained by 57.2% of the PMC group, 57.6% of the RFT, and by 75% of the MVD group. Marked dysesthesia was reported by 6.7% of the patients treated with PMC, and by 24.2% of those who received a RFT. Impairment of masticatory function was observed in 10% of the PMC patients. Ipsilateral hypoacusia and transient IV nerve palsy in 1 patient was the only major complication after MVD.

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The experiment was designed to determine the pathway taken to the brain stem by periodontal afferents responsible for the digastric jaw-opening reflex induced by tooth-tapping. Cutting the trigeminal sensory roots of anesthetized decerebrate cats eliminated the ipsilateral periodontally-induced reflex, although the stretch reflexes of the jaw-closing muscles were undiminished. These results suggest that periodontal afferents causing the jaw-opening reflex reach the brainstem through the Vth sensory root, and confirm that muscle spindle afferents travel through the Vth motor root.

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Pontine stereotactic tractotomy was performed on 13 patients for the relief of intractable pain. The results of electrical stimulation performed to localise target sites and confirm electrode trajectory are described. Stimulation sites included the cerebellum, cerebellar peduncle, trigeminal nucleus, facial nucleus, cochlear and vestibular nuclei and the trigeminal descending quintothalamic and spinothalamic tracts. Particular attention was given to facial sensory responses. Stimulation of the trigeminal nucleus produced discrete sensations, but quintothalamic stimulation gave more general ipsilateral facial sensation. Medullary trigeminal nucleotomy is recommended for facial deafferentation pain because it interrupts intranuclear trigeminal connections in the caudal trigeminal nucleus where the point of neuronal hyperactivity and stimulus convergence lies.

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Substance P, a putative neurotransmitter peptide present in a subpopulation of small sensory neurons, was measured in the walls of feline cranial arteries and systemic veins and arteries using a sensitive and specific radioimmunoassay. Substance P immunoreactivity exhibited a retention time identical to that of synthetic substance P when vessel extracts were subjected to reverse phase high performance liquid chromatography. Levels in cephalic arteries (453-1083 fmol/mg protein) were at least twice as high as amounts in systemic arteries and veins, and were significantly higher than those measured in the cornea and lip. Unilateral excision of the trigeminal ganglion decreased the peptide by 44 to 86 per cent in ipsilateral intracranial and extracranial arteries (e.g. external and internal maxillary, lingual, temporal, anterior, middle and posterior cerebral, superior cerebellar and posterior communicating arteries). Extracranial arteries were decreased on average by 78 per cent, whereas intracranial arteries were reduced by 55 per cent. Unilateral removal of the superior cervical sympathetic ganglion was without effect. The described pattern of sensory innervation provides a possible explanation for the referral of pain to the forehead and anterior scalp during attacks of migraine, and with arteritis and thrombosis involving vascular structures within the posterior fossa, the circle of Willis and the external carotid system of man.

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The partial vertical nucleotomy is presented as a new neurosurgical method for the treatment of therapy-resistant pain in the spreading area of the N. trigeminus. Strict indications are laid down which are mainly restricted to therapy-resistant pain in the above mentioned spreading area in the presence of diffusely growing malignant tumours, after traumas and infections and predominantly in forms of idiopathic trigeminal neuralgia that has been treated without any results over a period of many years. In the experimental part of the article; material and method as well as results of anterograde transport on the efferent trigeminal pathways in rabbits by means of horseradish peroxi- dase (HRP) and its representation by means of tratramethylbenzidine (TMB) are discussed. Furthermore fibre preparations of the tractus and nucles spinalis nervi trigemini and the radiating fibres of the Nervus vagus are shown.

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Eleven Macaque monkeys underwent a variety of lesions in the trigeminal afferent system; namely, tractotomy, rhizotomy, and radiofrequency destruction of various components of the bulbospinal trigeminal nuclear complex. Behavioral responses were evaluated before and after the lesions using a quantitative paradigm which measured lever-pressing in response to electrical stimulation of the dental pulp or facial skin, and by assessing adversive responses to facial cutaneous and intraoral pin-scratch. Thresholds for lever-pressing in response to cutaneous facial stimulation were elevated by tractotomy, elevated further by a combination of tractotomy and rhizotomy of the seventh, ninth, and 10th cranial nerves and cervical dorsal roots C1-3, and maximally elevated by complete radiofrequency destruction of the trigeminal nucleus caudalis. These lesions also abolished adversive responses to cutaneous facial pin-scratch. None of these lesion combinations, however, altered lever-pressing responses to dental pulp stimulation. Radiofrequency destruction of the trigeminal nuclei principalis, oralis, and interpolaris caused elevations of lever-pressing thresholds in response to dental pulp stimulation, and also smaller but statistically significant elevations on cutaneous electrical stimulation. Mild reductions in adversive responses to cutaneous pin-scratch were also produced by these rostral nuclear lesions, suggesting analgesia. The experiments suggest that primary afferent fibers for dental pain perception travel only in the trigeminal nerve and that these fibers relay via the trigeminal brain-stem nuclei principalis, oralis, and interpolaris. Primary afferent fibers for cutaneous facial pain perception travel in the trigeminal, facial, glossopharyngeal, and vagus nerves, and the upper cervical dorsal and ventral roots, and these afferents relay mainly in the trigeminal nucleus caudalis.

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The treatment of pain due to malignancy in the head and neck is difficult, and the pain doctor must take a special responsibility in selecting the appropriate treatment. Specialized and often combined surgical procedures may still offer the best chance of relief, particularly when tumours involve the paranasal sinuses and the petrous bone. Peripheral and central destructive procedures can prove effective, and perhaps thalamotomy is deserving of greater usage. Chronic intrathecal analgesic administration can undoubtedly prove effective, and while the unwanted features may yet have to be established, it provides a welcome additional option in the management of pain in this difficult area.

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The trigeminal nuclear complex and its spinal tract extend throughout the greater part of the brain-stem and at medullary levels form the target site for producing stereotactic lesions. This paper describes a method for three-dimensional drawings of this nuclear complex. A stereotactic atlas of the human brain-stem and cerebellar nuclei has formed the data base. The two-dimensional composite transverse sections, at 1-mm intervals have been digitized using an X-Y coordinate plotting microscope. Computer programs have been written to generate drawings of a single transverse hemisection as well as regeneration of the opposite hemibrain-stem section. Specific programs were used to reconstruct serial transverse section outlines and incorporate the trigeminal nuclear complex with and without hidden line removal techniques and colour graphic display facilities. Rotation about the x, y and z axes was possible and permits any view of the reconstructed specimen to be computer-generated. A further program for reconstructing structures as stereopairs is presented.

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owing to an enormous development in the operative technical possibilities, percutaneous surgical methods are available today for both destructive and functional pain interventions, so that the surgical risk can be reduced to a minimum and also patients in a poor general condition and of advanced age can tolerate these interventions at any time.

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