| Background:Percutaneous Radiofrequency Thermocoagulation(RFT)is one of the methods for the treatment of Trigeminal Neuralgia(TN).The vast majority of surgeons use manual puncture to complete RFT.RFT is a relatively difficult operation.During the cannulation of the foramen ovale(FO),there may be some risks and various accidents,such as:intraoperative hemorrhage caused by mistakenly puncturing the foramen ovale venous plexus and foramen conduit,acute epidural hematoma caused by puncturing the middle meningeal artery through the foramen spinosa,intracranial infection caused by multiple punctures,and cardiovascular and cerebrovascular accidents caused by severe trigeminocardiac reflex(TCR).RFT with the aid of neuronavigation,stereotaxic and other auxiliary guidance equipment is more labor-intensive than bare-hand puncture,and the patient’s economic expenditure is more expensive.However,for neurosurgeons who are novice in RFT,from the perspective of avoiding surgical risks,the application of percutaneous stereotactic radiofrequency(PSR)is a relatively safe choice.In 2012,our team started to use the PSR method to treat TN patients.Objective:On the basis of the previous work about the application of PSR in the treatment of TN,to further improve the long-term efficacy of PSR in patients with TN,especially those who are difficult to puncture.Methods:(1)Improved PSR technology,including:(a)3D CT skull reconstruction imaging technology was used to observe FO in 438 non-TN patients and 57 TN patients who underwent PSR,and determine whether the Pterygoid Process Ridge(PPR)is a novel critical factor affecting the preset accuracy of the FO target(FOT)at the middle 1/2 point of the FO transverse diameter and the inner 1/3point of the FO transverse diameter;(b)Retrospectively analyze the clinical data of30 cases of TN patients with pre-set conventional and unconventional facial puncture points(Unconventional Facial Entry Point,UFEP)to complete PSR surgery,and judge the necessity that the pre-set individualized UFEP is suitable for patients with various puncture difficult factors for PSR;(c)For patients with extreme puncture difficult factors,a method of determining the puncture trajectory based on bidirectional guidance--Air-to-Air meeting technology was invented to solve the problem of accurately using all the data in the preoperative plan.(d)For patients with extremely limited puncture path,3D CT/MR fusion technology is used to display the location of the target area of??the Gasserian ganglion,which provides an accurate basis for judging whether such patients are suitable for PSR surgery.(2)By observing the indicators of operation and efficacy with improved PSR technology(improved group,40 cases)and with early PSR technology(early group,44 cases),including:intraoperative FOT puncture times,intraoperative adjustment times of searching for Gasserian ganglion target(GGT),the intraoperative electrophysiological sensory test value of searching for GGT,the occurrence of postoperative complications during pre-operation and follow up after surgery(before surgery,3 days after surgery,surgery after 1 month,3 months,6months,1 year and 2 years),the effective rate of treatment and the recurrence rate of1 year and 2 years after surgery.Results:(1)The proportion of FO obscured by PPR was 7.3%and 8.8%in non-TN patients and TN patients,respectively(P>0.05);among TN patients,the actual transverse diameter of FO was obscured by PPR in 4 cases,and the proportion was 19.2%-39.7%,there was 1 rare patient whose FO transverse diameter was completely obscured by PPR;it is worth noting that,through the observation of FO in 438 non-TN patients,it was found that:about 1/4(if V3 was involved)to 1/3(if V1 and/or V2 were involved)FOT preset positions were affected by PPR.(2)The conventional puncture point group and the unconventional puncture point group accounted for 73.3%and 26.7%of all patients,respectively;the unconventional puncture point group contained significantly more types of puncture difficulty than the conventional puncture point group(P<0.01);There was no significant difference in the number of foramen ovale puncture between the unconventional puncture point group(1.25±0.7071)and the conventional puncture point group(1.1818±0.3947)(P>0.05);there was no statistically significant the postoperative effective rate and the incidence of complications between the two groups(P>0.05).(3)Using the Air-to-Air meeting technology,the 3D data in the preoperative plan(X,Y,Z values??of FOT measured on axial CT)and 2D data(the distance from the facial puncture point to the corner of the mouth,the arc angle value of needle insertion)can be completely implemented in PSR.(4)For a patient with a facial puncture point range of only 1 mm~2and a single available puncture trajectory,the 3D CT/MR fusion images provided an exact basis for judging whether the patient was suitable for PSR surgery.(5)The effect of applying the improved PSR technology:compared with the early group,there was no significant difference in the number of FOT punctures and the voltage value of the intraoperative electrophysiological sensory test;the adjustment times for finding GGT of improvement group was significantly less than the early group(P=0.003);the number of postoperative common complications in the improvement group was less than that in the early group;the postoperative hospital stay in the improvement group was significantly shorter than that in the early group(P<0.001);Compared with the early group,there was no significant difference in the one-year treatment effective rate and recurrence rate;the improvement group was significantly higher than the early group in the two-year postoperative treatment effective rate,and the recurrence rate was significantly lower than that in the early group(P=0.045).Conclusion:PPR is a bony variant that affects the planning of preoperative puncture target FOT and is of vital importance;FEPs are preset in preoperative planning,especially for puncturing difficult-to-access foramen ovale.The UFEP is preset for patients with difficult factors,which is helpful for the successful completion of PSR surgery;the Air-to-Air meeting technology we invented is suitable for all patients treated with PSR,and all the data in the preoperative plan can be accurately applied.CT/MR fusion technology can provide an exact basis for judging whether patients with extremely difficult-to-access FO are suitable for PSR surgery;the application of improved PSR technology helps the puncture needle to reach the GGT position smoothly during operation,reduce the occurrence rate of complications,the hospitalization time and the relapse rate of patients.It can also improve the long-term treatment effect of PSR on TN patients effectively. |
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