Trigeminal Neuralgia-Step-by-Step DYNA-Computed Tomography-Assisted Balloon Compression Rhizotomy

Trigeminal nerve balloon compression (TNBC)1-3 can provide immediate thera-peutic relief to patients suffering from trigeminal neuralgia. This is a particularly effective treatment option for patients who are not eligible for surgical pro-cedures (i.e., elderly patients or patients with multiple comorbidities) or for patients who have had an insufficient response to microvascular decompres-sion. TNBC can also be used as a bridge treatment before stereotactic radio -surgery. Use of intraoperative computed tomographyLlike images using a C-arm system (DYNA-CT) imaging facilitates the TNBC procedure.4,5 Three-dimensional DYNA-CT imaging with needle guidance allows for precise needle advancement and insertion through the foramen ovale. DYNA-CT enables the direct visuali-zation and avoidance of vascular structures such as the carotid or internal maxillary arteries and results in decreased procedure times and complications. The authors present a step-by-step video demonstrating the use of intraoperative DYNA-CT needle guidance for TNBC (Video 1). A Siemens Artis Zee Biplane system is used for the procedure. A comprehensive description of all elements of the procedure is provided including balloon preparation, needle trajectory planning, needle advancement, 3-dimensional confirmation of the needle's depth and path, balloon placement, balloon inflation, and balloon removal. Tips and optimal strategies are presented.Advantages of using DYNA-CT for needle guidance include the reduction of fluoroscopy dose and fluoroscopy time. The average dose area product during conventional percutaneous balloon compression in prior studies was 1137 mGycm2, with a mean fluoroscopic time of 62 seconds.6 In our experience, the mean fluoroscopy dose is 274 mGycm2 and the total fluoroscopic time is about 45 seconds. Furthermore, during the DYNA-CT acquisition, the neurointerven-tional team stays outside the room during the DYNA-CT, which reduces the cumulative radiation to the operator.DYNA-CT needle guidance facilitates precise advancement of the needle into the foramen ovale and positioning of the balloon in the Meckel cave during TNBC. It is a safe and feasible technique that allows for the visualization and avoidance of important structures such as the internal carotid artery or the in-ternal maxillary artery, resulting in decreased procedure times and complications.