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Canadian Journal of Anesthesia 51:990-992 (2004)
© Canadian Anesthesiologists' Society, 2004
Regional Anesthesia and Pain

A new guidance device facilitates percutaneous puncture of the foramen ovale in human cadavers

[Un nouveau guidage facilite la ponction percutanée du foramen ovale chez les cadavres humains]

Martin Hinteregger*, Fritz Zschiegner*, Philipp Lirk, MD*,{dagger}, Eugen Ladner, MD*, Albert Goeschl, MB*, Othmar Gaber, MD{ddagger}, Patrizia Moser, MD§, Ingo Lorenz, MD* and Christian Kolbitsch, MD DEAA*

* From the Departments of Anesthesiology and Critical Care Medicine, and
§ Pathology, and
{ddagger} the Institute of Anatomy, Histology & Embryology, Medical University of Innsbruck, Innsbruck, Austria; and
{dagger} the Department of Anesthesiology, Medical College of Wisconsin, Wisconsin, USA.

Address correspondence to: Dr. Philipp Lirk, Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria. Phone: 43-512-504-80479; Fax: 43-512-504-22450; E-mail: philipp.lirk{at}uibk.ac.at


   Abstract
TOP
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 References
 
Purpose: Trigeminal neuralgia is the most common neurological cause for facial pain. Contemporary interventional treatment relies on surgical microvascular decompression or, alternatively, percutaneous interventions targeting the semilunar ganglion via the foramen ovale. For the latter approach, only free-hand punctures using fluoroscopy devices have been reported. Therefore, the present study aimed to evaluate a new fluoroscopy-based guidance device for transforaminal puncture.

Methods: Two experienced examiners punctured the foramen ovale bilaterally free-hand, and using a guidance device in human cadavers (n = 9). The number of attempts for puncture was recorded. A new attempt was counted each time the needle had to be retracted for redirection.

Results: As compared to the free-hand puncture of the foramen ovale (4.44 ± 2.79), the new guidance device significantly reduced the number of trials needed (1.37 ± 0.69).

Conclusion: The employment of a guidance device facilitated percutaneous transforaminal puncture and resulted in a significantly decreased number of puncture attempts as compared to free-hand techniques in human cadavers.


   Introduction
TOP
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 References
 
TRIGEMINAL neuralgia (TN) is the most common neurological cause for facial pain.1 It is characterized by recurrent paroxysmal severe pain in the area supplied by the fifth cranial nerve.1 Contemporary interventional treatment of TN relies on microvascular decompression or, alternatively, percutaneous interventions targeting the semilunar ganglion.1

The latter regimen has been found to offer a decreased rate of complications as compared to posterior fossa operations, and may be employed in idiopathic and secondary TN alike.1

Major adverse effects of percutaneous ganglionic procedures such as fistula formation between the carotid artery and the sinus cavernosus are attributed to misguided puncture.1 Currently, percutaneous puncture of the semilunar ganglion is performed free-hand under fluoroscopy control. No guided trigeminal punctures using fluoroscopy-guidance devices have been described. Yet, guidance devices may decrease the number of puncture attempts and thus contribute to increased patient safety and comfort. Therefore, the present study aimed to evaluate a new fluoroscopy-guided puncture device in human cadavers.


   Materials and methods
TOP
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 References
 
After Institutional approval was obtained, human cadavers (n = 9) preserved as previously published2 were investigated. Two examiners experienced in the percutaneous transforaminal technique punctured the foramen ovale (FO) bilaterally free-hand and using a newly designed guidance device for the needle (diameter 1.18 mm).

Unguided puncture was performed as previously described.3 In brief, a radiopaque marker was placed 3 cm lateral to the labial commissure. The radiographic image of the marker and the FO on screen of a fluoroscopy device (BV 25, Philipps, Hamburg, Germany) were brought in line and puncture was performed free-hand following the path of radiation.

For guided puncture, a device not described previously was used (FigureGo). It consists of a mounting ring that can be adapted to fit most standard fluoroscopy devices, to which is attached a needle holder on a flexible sliding bar, allowing for axial adjustment of the device to patient and table. The needle holder is made of Plexiglas, such that the path of radiation is not obstructed. In contrast to a free-hand approach, this device firmly fixes the needle used for puncture in the centre of the radiation path. In the radiographic appearance on the fluoroscopy screen, this causes the needle to be depicted as a radiopaque dot. Two linear laser beams are mounted on the guidance device such that their intersection indicates the centre of the path of radiation on the skin of the patient in order to predict the site of skin puncture at any time.



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  		FIGURE Schematic drawing of guidance device mounted on fluoroscopy apparatus: 1) radiation source; 2) detector; 3) flexible sliding bar; 4) needle holder arrow path of radiation.

 
The sequence during the guided puncture first involved location of the skin puncture site using the intersection of the two laser beams. Subsequently, the radiographic appearances of the needle and the FO were aligned, thus giving the optimal entry route, and the puncture was performed through the needle holder canal.

Verification of the needle position in both the guided and unguided puncture was accomplished using a second fluoroscopy device (OEC-9800 Cardiac, General Electric Medical Inc., Salt Lake City, UT, USA) positioned perpendicular to the device positioned in the line of puncture. Furthermore, computed tomography scans were taken to verify correct position of the needle.

The number of attempts for puncture was recorded. A new attempt was counted each time the needle had to be retracted for redirection.

Statistical analysis
Data are presented as mean (± SD). The Wilcoxon signed rank test was employed. Statistical significance was assumed at P ≤ 0.05. SPSS® 9.0.0 for Windows (Chicago, IL, USA) was used for all statistical analyses.


   Results
TOP
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 References
 
Examiner 1 needed 3.2 ± 1.9 (left side) and 4.0 ± 1.7 (right side) free-hand attempts to enter the FO, whereas 1.3 ± 0.7 (left) and 1.37 ± 0.7 (right) attempts were required using the guidance device. Similarly, examiner 2 performed 7.7 ± 6.2 (left) and 2.9 ± 1.3 (right) free-hand attempts as compared to 1.7 ± 1 (left) and 1.1 ± 0.4 (right) attempts using the guidance device. As compared to the free-hand puncture of the FO, the new guidance device significantly reduced the number of trials needed for each examiner both on the left and right side (P < 0.05). Between the two examiners, the number of free-hand trials and of guidance device-based trials was comparable. Finally, no statistically significant difference between left- and right-side puncture could be found either free-hand or under guidance.


   Discussion
TOP
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
References
 
A newly designed device for fluoroscopy-guided transforaminal puncture of the fifth cranial nerve ganglion significantly reduced the attempts needed for successful puncture as compared to free-hand.

TN is a debilitating syndrome characterized by recurrent paroxysmal pain attacks. Some 85% of TN are nowadays classified as idiopathic, and in only 15%, an underlying pathology, such as tumours or multiple sclerosis, is diagnosed.1 One of the most widely used techniques in the interventional treatment of TN is a percutaneous intervention targeting the semilunar ganglion, which is in part located in the meckelian cavity, formed by the dura mater near the apex of the petrous part of the temporal bone.4 Most frequently, the ganglion is subsequently subjected to a radiofrequency thermal rhizotomy, glycerol rhizotomy, or balloon microcompression. The major advantages of percutaneous techniques are the possibility to employ them also in secondary cases, e.g., in multiple sclerosis patients, and the higher safety considering the elevated mean age of TN patients.1,5,6

The major adverse events associated with percutaneous semilunar ganglion puncture are anesthesia dolorosa (4%), mastication muscle weakness (in up to 40% of destructive techniques involving the mandibular branch of the trigeminal nerve), intrathecal spread of neurolytic drugs, and sensory losses.5 Furthermore, the possibility of missed or impossible puncture exists, and the accidental puncture of adjacent anatomical structures such as the carotid artery has been reported to potentially elicit fistula formation in the sinus cavernosus.5 Considering the small distances between the theoretical puncture canal used for the percutaneous approach to the semilunar ganglion and, e.g., the carotid artery, and sinus cavernosus, it becomes obvious that the narrower the puncture canal is defined, and the less deviation in any direction is allowed, the smaller the chances are that vital adjacent structures are damaged.

The present study demonstrates that a newly designed device for fluoroscopy-guided transforaminal puncture significantly reduced the number of puncture attempts as compared to a free-hand approach. This may not only improve patient safety by reducing the likelihood of injury to adjacent structures, but also patient satisfaction by reducing the number of attempts at puncturing the FO.

Finally, some limitations of the present study should be noted. The present cadaver study was performed in cadavers conserved for a minimum of one year, which leads to more rigid connective and muscular tissue. This would - in theory - impair transforaminal puncture of the FO, and thus emphasizes the positive results obtained in the present study, as the mean number of puncture attempts was less than two with either examiner using the guidance device. Moreover, the assumption that multiple puncture attempts cause an increased incidence of adverse events due to damage caused to the abundance of neighbouring structures seems obvious, but has, to our knowledge, not been validated by clinical studies. The employment of a second fluoroscopic device seems unfeasible in clinical practice, and was used in the present study to allow for digital recordings. Simple adjustments would allow for a temporary rotation of the main device to allow for ascertainment of puncture depth without compromising the needle guidance.

In conclusion, the employment of a guidance device facilitated percutaneous transforaminal puncture and resulted in a significantly decreased number of puncture attempts as compared to free-hand techniques. Guided transforaminal puncture should enhance patient safety and comfort.


   Acknowledgments
 
We acknowledge the kind assistance of Joshua Colvin MB in the preparation of the manuscript, and the excellent technical expertise of Fritz Zschiegner and Martin Hinteregger in the design of the device.


   Footnotes
 
Accepted for publication Aprul 8, 2004. Revision accepted August 2, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
1 Zakrzewska JM. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain 2002; 18: 14–21.[Medline]

2 Platzer W, Putz R, Poisel S. New system for the preservation and storage of anatomical matter (German). Acta Anat (Basel) 1978; 102: 60–7.[Medline]

3 Gomori JM, Rappaport ZH. Transovale trigeminal cistern puncture: modified fluoroscopically guided technique. AJNR Am J Neuroradiol 1985; 6: 93–4.[Abstract]

4 Gray H. Gray’s Anatomy, 20th ed. New York: Bartleby; 2000.

5 Gorge HH. Operative treatment of trigeminal neuralgia (German). Schmerz 2001; 15: 48–58.[Medline]

6 Delzell JE Jr, Grelle AR. Trigeminal neuralgia. New treatment options for a well-known cause of facial pain. Arch Fam Med 1999; 8: 264–8.[Abstract/Free Full Text]





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