Percutaneous balloon compression for primary trigeminal neuralgia in patients older than 80 years
© Du et al. 2015
Received: 29 April 2015
Accepted: 6 July 2015
Published: 18 September 2015
It has been demonstrated that the incidence of trigeminal neuralgia in elderly patients is higher and thus, neurosurgeons often encounter elderly patients with this disorder. However, for those with poor basic condition, the optimal surgical treatment remains controversial. In this study, the authors aimed to evaluate the safety and efficacy of percutaneous balloon compression (PBC) for primary trigeminal neuralgia in elderly patients older than 80 years.
From September 2009 to March 2013, a total of 68 patients older than 80 years underwent PBC, and a retrospective study of the clinical data of these patients was performed.
After PBC, pain relief was immediate in 66 (97.0 %) patients, 1 (1.5 %) patient had no pain relief, and 1 (1.5 %) patient had some pain that could be controlled with medication. With a mean length of follow-up of 40.1 months, ranging from 24 to 66 months after surgery, 55 (80.9 %) patients were still pain free. Of the 11 patients with recurrence, 9 cases had mild recurrence and 2 cases suffered severe recurrence. The mean time to recurrence was 18.9 months (1–64 months). Postoperative morbidity included common side effects such as facial numbness in 66 (97.1 %) patients, masseter muscle weakness in 19 (27.9 %) patients, paresthesia in 7 (10.3 %) patients, and diplopia secondary to abducens nerve weakness in 1 (1.5 %) patient. No corneal anesthesia, subarachnoid hemorrhage, or other serious surgical complications occurred in this study.
In this study, the authors reviewed data on a cohort of patient older than 80 years. The PBC procedure has advantages in that it is minimally invasive, safe, effective, and could be performed under general anesthesia. This makes it an optimized choice for elderly patients.
KeywordsTrigeminal neuralgia Percutaneous balloon compression Elderly Safety
Trigeminal neuralgia is a disorder characterized by sharp and paroxysmal pain within the trigeminal nerve distribution. With the aging population, the proportion of elderly patients is gradually increased . The etiology of trigeminal neuralgia is still controversial. Since Jannetta  refined and popularized microvascular decompression (MVD), it has become the first-line choice [3, 4], but it is nonetheless associated with some special risks such as cranial nerve injury, cerebellar hematoma, stroke, and death which are not seen with the commonly performed ablative procedures. So for the elderly patients older than 80 years, whether or not performing MVD is still controversial [5–7]. Percutaneous balloon compression (PBC) was first described by Mullan and Lichtor  in 1983. Because PBC is a minimally invasive, low-cost, safe, and effective procedure and could be simply performed with the patient under general anesthesia, it has become increasingly popular around the world. It has also been reported to provide longer pain relief than the other two percutaneous procedures and stereotactic radiosurgery (SRS) .
By now, no analysis regarding PBC for elderly patients has been reported. In this study, we aimed to evaluate the safety and efficacy of PBC for primary trigeminal neuralgia in elderly patients older than 80 years.
The demographic characteristics of these 68 patients
Age, year (range)
Sex (M:F), no
Disease duration, year (range)
Pain involvement, no (%)
3 (4.4 %)
13 (19.1 %)
15 (22.1 %)
V1 + V2
6 (8.8 %)
V2 + V3
29 (42.6 %)
V1 + V2 + V3
2 (2.9 %)
Side affected, no (%)
29 (42.6 %)
39 (57.4 %)
Clinical subtypes, no (%)
62 (91.2 %)
6 (8.8 %)
Previous operations, no (%)
28 (41.2 %)
The method we used was in accordance with the technique first described by Mullan and Lichtor  with modification. All PBCs were performed under a short-acting general anesthesia. During operation, the heart rate, ECGs, and blood pressure of the patients were closely monitored. The patients were placed in the supine position on the operating table, with slight extension and approximately 30° of rotation of the neck away from the ill side. The procedure was performed using C-arm image intensifier fluoroscope in order to obtain lateral images and location. The entry point was positioned at about 2.5 cm lateral to commissure of the lips, and the other two reference points were 3 cm anterior to the external auditory meatus along the zygomatic arch, and 1 cm inferior to the pupil and. A 14-gauge needle containing a blunt obturator was advanced until it penetrated the foramen ovale under lateral fluoroscopic imaging. The blunt obturator was then withdrawn, and a no. 4 Fogarty balloon catheter with a stainless steel stylet was advanced into Meckel’s cave under direct fluoroscopy. Then, the stylet was withdrawn. Under fluoroscopic control, the balloon was slowly inflated by adding undiluted contrast Omnipaque (300 mg iodine/mL) until it was proximal to the posterior fossa. Referring to the bony landmarks (clivus, sella, and petrous bones), the balloon shape and position were inspected. If necessary, the balloon was deflated and the catheter was repositioned until a pear-shaped balloon with a protrusion towards the posterior fossa was obtained. The balloon volume of this study was between 0.45 and 0.85 mL (depending on the individual’s volume of Meckel’s cave), and balloon compression time was between 3 and 8 min. After compression, the balloon was deflated, withdrawn with the catheter. The puncture wound was compressed for about 5 min. The total procedure usually lasted for less than 20 min.
Follow-up and effect evaluation
Barrow Neurological Institute (BNI) pain intensity scale score
No pain, no medication
Occasional pain, not requiring medication
Some pain, adequately controlled with medication
Some pain, not adequately controlled with medication
Severe pain/no pain relief
The outcomes of the 68 patients after PBC
BNI pain score
Immediately after PBC, number of patients (%)
During the postoperative period, number of patients (%)
The complications of the 68 patients after PBC
Masseter muscle weakness
Trigeminal neuralgia is a disorder which has a tendency to occur in the older patients , with a mean age of 51.5 years at diagnosis . With the aging population, the proportion of elderly patients has gradually increased . Since Jannetta  refined and popularized MVD, it has become the first-line choice [3, 4], but it is nonetheless associated with some special risks such as cranial nerve injury, cerebellar hematoma, stroke, and death which are not seen with the commonly performed ablative procedures. Many authors have reported the safety and efficacy for the elderly patients treated with MVD. The age cutoffs range from 60 to 75 years [10–15]. So for the elderly patients older than 80 years, MVD is still controversial [5–7]. Yang et al.  reported outcomes on 59 patients older than 65 years, and they found that the acute pain relief after surgery was 93.2 % and the recurrence rate was 8.9 % with a mean length of follow-up of 42 months. Complications after surgery included headaches, nausea, and vomiting; there were no severe morbidities and mortalities. Günther et al.  reported the results of 112 patients older than 65 years (mean 70.35 years), the pain-free and recurrence rate were 75 and 14 %, respectively, with a mean length of follow-up of 90 months, and complications included hypesthesia in 6.25 % of the patients, hypacusis in 5.4 % of patients, and partial facial nerve palsy, complete hearing loss, and vertigo in 0.89 % each. One patient suffered meningitis and cerebrospinal fluid leak . In Sekula et al.’s report , the acute pain relief was achieved in 96 % of the 25 patients older than 75 years, with an average follow-up of 44 months; 78 % of the patients remained pain free. So far, several published studies [10–15] suggested that the safety and efficacy of MVD in elderly patients have no difference with the younger ones. But these studies were small sample sizes, and Sekula et al. summarized these studies in a meta-analysis . Ruqhani et al.  utilized a large national data set and found that the risk of pulmonary, cardiac, cerebrovascular, and thromboembolic complications was higher in older patients. So for the elderly patients, MVD remains a controversial surgical option, and postoperative morbidities do tend to gradually increase in tandem with an advanced age . So gamma knife or percutaneous procedures might be the first surgical option for the elderly patients with poor fitness.
PBC was first described by Mullan and Lichtor  in 1983. Because PBC is a minimally invasive, low-cost, safe, and effective procedure and could be simply performed with the patient under general anesthesia, it has become increasingly popular around the world. It has also been reported to provide longer pain relief than the other two percutaneous procedures and SRS . Several studies [4, 8, 17–23] had proved the safety and efficacy of PBC. In their 20-year follow-up study of 496 patients, Skirving and Dan  reported that the acute pain relief was 99.8 %, recurrence rate was 19.2 % within 5 years, and 31.9 % over a mean length of follow-up of 10.7 years. Baabor and Perez-Limonte  reported the outcomes on 206 patients; the initial pain relief was 93 %, and the recurrence rate was 15 % after a 3-year follow-up. Lichtor and Mullan  reported their experience on 100 patients; the successful rate was 97 %, and the recurrence rate was 20 % for 5 years. In the present study, we found that the pain relief was immediate in 97.0 % of the patients, with a mean length of follow-up of 40.1 months; 80.9 % of the patients were still pain free. Our efficacy was similar with the published studies. Nine cases had mild recurrence; of these, three cases did not require medication, six cases could adequately be controlled with medication, and most of them were satisfied with the results. PBC was repeated a second time in the two patients who suffered severe recurrence.
Postoperative complications of PBC series (%)
Masseter muscle weakness
Brown et al.
Skirving et al.
Stomal et al.
Chen et al.
Campos et al.
One patient in our study suffered diplopia secondary to abducens nerve weakness and recovered within 4 months. Several studies have reported that diplopia was a relatively rare complication [19–23], and all of them recovered within 3–6 months. As it could be seen, all cases of diplopia described in the published studied were transient. It is unlike what happens in radiofrequency rhizotomy, which might cause permanent diplopia .
In this study, the authors reviewed data on a cohort of patient older than 80 years. The PBC procedure has advantages in that it is minimally invasive, safe, effective, and could be performed under general anesthesia. This makes it an optimized choice for elderly patients or physically unstable patients which present some special risks for MVD.
percutaneous balloon compression
Barrow Neurological Institute
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