Long-term results of Gasserian ganglion electrocoagulation JI~RGEN MENZEL, M.D., WOLFGANGPIOTROWSKI,M.D., AND HELMUT PENZHOLZ, M.D.
Department of Neurosurgery, University of Heidelberg, Heidelberg, Federal Republic of Germany v' This report is a follow-up study of 315 patients under 46 years old who suffered from trigeminal neuralgia and were treated by electrocoagulation of the Gasserian ganglion. The average follow-up period was 12.7 years, the maximum 33 years. Eighty percent had a return of pain, but 96.7% ultimately attained freedom from pain after repeat electrocoagulation.
KEy WORDS Gasserian ganglion electrocoagulation trigeminal neuralgia "
S
INCE trigeminal neuralgia generally strikes individuals about 60 years old, most follow-up studies that evaluate the success of conservative or operative treatment are necessarily restricted to a short period of time. The aim of this paper is to show the late results of electrocoagulation of the Gasserian ganglion in patients who suffered from trigeminal neuralgia earlier in life.
Clinical Material and Method The 315 patients included in this study were under 46 years old at the time of operation, between 1939 and 1971. The youngest patient in this group had his first attack at the age of 17 years, the eldest at 45. The sharp rise associated with increasing age, as noted by Zenker, 1~ Kirschner, 2 and Klar and Piotrowski) ,8 was not seen in this age group. The distribution of cases among various ages was constant (Fig. 1); however, the incidence 140
9
of operation shows a definite rise with increasing age (Fig. 2). The series was analyzed to determine the frequency with which the three divisions of the trigeminal nerve were affected. This analysis showed (Fig. 3) that in 80% the second division was involved, in 66.7% the third division, and in 43.3% both the second and third divisions. The ophthalmic nerve was affected in only 6.7%, and always in combination with the second or, more rarely, third divisions. All patients in this study were treated by the technique of electrocoagulation first tried by Kirschner 3,~ and continued by Bauer? The average follow-up period was 12.7 years, the maximum, 33 years (Fig. 4).
Results The most important follow-up criterion used was the "rate of recurrence," defined as including vestigial symptoms and operation
J. Neurosurg. / Volume 42 / February, 1975
Results of Gasserian ganglion electrocoagulation %
occasion. Trigeminal neuralgia was not influenced by electrocoagulation in the remaining 3.3% of the patients in the series. Another follow-up criterion was postoperative impairment of the ability to chew. In the total series of patients, 83.3% stated that they chewed on one side only, due to a lack of sensation. The same deficit led to occasional bite damage to the mucous membrane of the cheek. Although half of those examined had a masticatory paralysis, only 23.3% were aware of it. Saliva secretion was unchanged in 80% after the electrocoagulation; 16.7% experienced an increase, 3.3% a decrease. An increase of nasal secretion was noted by 23.3%, while 6.7% reported a decrease. In 70% of the cases nasal secretion remained unchanged. Impaired hearing due to a lesion of the tensor tympani muscle was diagnosed in 26.7% of the cases. Increased secretion of tears occurred in 16.7%, while 3.3% reported a pathological dryness of the eye. None of these cases had keratitis or keratitis neuroparalytica; this complication was not even observed when the first division was eliminated during the electrocoagulation. Disturbances of sensation, such as deafness, numbness, and burning, were reported by 93.7% of the patients; this confirmed the well-known fact that freedom from pain is only gained when the sensitivity in the branches afflicted with trigeminal neuralgia is
50 I.,,.,.
Z
23.3
25
23.3
23.3
I-,-
IW~'~: I~:~: : ' ~ ~ : ~
o,,.
0
23
28
32
36
1OO
40
~6 AGE
FIG. 1. Graph showing patients' age at first symptoms of trigeminal pain.
failures as well as genuine recurrence of pain. Unsuccessful operations that required second, third, or fourth coagulations were counted as the first, second, third, or fourth relapse even if the operations were carried out during the same hospital stay. The first coagulation was followed by a relapse in 80% of all cases; in 46.6% this occurred within the first 2 postoperative years (Fig. 5). A second relapse was experienced by 33% in the series (41.7% of those with one relapse) while 13.3% (40.0% of those with two relapses) had a third relapse. Fourth and fifth relapses occurred in 6.6% of the cases studied, and included 25% of the group with three relapses. No additional new attacks were observed. Actually, 96.7% of all patients were ultimately free of pain, although 36.7% still took analgesics on
75
%
75
%
56.8
m I-..
50
0
46.7
N 0
28 34
40
46
7
50
:::::::::::::::5
30.0 i!~iiiiiiiiiiii!i ................
0
0
28
34 40 46
FIG. 2. Graphs showing patients' age at operation. Left." Age at first operation. operation.
J. Neurosurg. / Volume 42 / February, 1975
AGE
Right." Age at last 141
J. Menzel, W. Piotrowski and H. Penzholz 100
greatly reduced or eliminated. In 60% of the cases complete lack of pain was linked with hypesthesia and anesthesia. Discrete pain was associated with increased sensitivity, while pains as severe as those prior to operation were found when the sensitivity had been only slightly reduced. Anesthesia dolorosa was observed in five cases.
80.0 75
~66.7
v) 5O
Discussion
Z UJ
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Q., 25
I II III BRANCH Fro. 3. Graph showing frequency with which three divisions of trigeminal nerve were affected.
% 501
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4o.~
23.3
o
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1 5 10 15 20 25 30 33 YEARS FIG. 4. Graph showing follow-up time for patients in this series.
75 to) I-Z
%
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5th
23.0 25
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1 2 3 4 ov.4 YEARS Fro. 5. Graph illustrating lapse of time between first operation and recurrence of symptoms. 142
We were surprised by the high incidence of relapses (80%), which greatly exceeded those in all other reports, such as Kirschner, 2 22%; Kubanyi, 7 22.9%; Klar, 5 18.2%; and Schiirmann and Butz, 8 23%. We believe the primary reason for this difference is the long period of follow-up, which obviously covered the late relapses not reported in shorter time periods. Besides this, the term "relapse" included vestigial symptoms and operation failures besides the genuine recurrence of pain. The aim of the operation, ultimate freedom from pain, was attained in 96.7% of all cases studied. TSnnis and KreisseP reported cessation of pain in 84.8%, Kla? in 95.4%, and Schiirmann and Butz 8 in 98%. We believe it significant that no cases of keratitis neuroparalytica and only five of anesthesia dolorosa occurred in our series. After weighing all the advantages and disadvantages revealed by this investigation, we believe the following advantages support electrocoagulation: 1. Minimal operative strain on the patient (operative mortality rate, 0%) 2. Ease of repeating the procedure many times 3. Short period of hospitalization 4. Simplicity of operative equipment 5. Ultimately high rate of success. References
1. Bauer KH: Unsere Technik der Koagulation des Ganglion Gasseri. Zentralbl Chir 14:816-819, 1939 2. Kirschner M: Zur Behandlung der Trigeminusneuralgie. Med Wochenschr (Munich) 89:235-239, 1974 3. Kirschner M: Zur Elektrokoagulation des Ganglion Gasseri. Zentralbl Chir 47: 2841-2843, 1932 4. Kirschner M: Die Punktionstechnik und die Elektrokoagulation des Ganglion Gasseri: tiber gezielte Operationen. Langenbecks Arch Chir 176:581-620, 1933 J. Neurosurg. / Volume 42 / February, 1975
Results of Gasserian ganglion electrocoagulation 5. Klar E: (lber Erfahrungen mit Elektrokoagulation bei Trigeminusneuralgie an der Heidelberger Universiditsklinik. Langenbecks Arch Chit 294:713-723, 1960 6. Klar E, Piotrowski W: Die Electrokoagulation des Ganglion Gasseri im Greisenalter, in Proceedings of the International Association of Gerontology, Wien, 1966, pp 311-316, 1966 7. Kubanyi E: Trigeminusneuralgie: die Ditferentialdiagnose und Therapie der Gesichtsschmerzen. Wien, Verlag Urban und Schwarzenberg, 1956 8. Schiirmann K, Butz M: Retroganglion~ire Trigeminuswurzelresektion durch temporale Sch~idelerSffnung oder kontrollierte partielle Elektrover~Sdung des Ganglion Gasseri in der operativen Behandlung der idiopathischen Trigeminusneuralgie. Zentralbl Neurochir 29:139-152, 1968
J. Neurosurg. / Volume 42 / February, 1975
9. T~nnis W, Kreissel H: Die Bedeutung einer sorgf'~dtigen Differentialdiagnose fiir die chirurgische Behandlung der Trigeminusneuralgie. Dtsch Med Wochenschr 76:1202-1205, 1951 10. Zenker R: Die Behandlung der Trigeminusneuralgic unter besonderer Beriicksichtigung der Grundlagen, der Ausffihrung und der Ergebnisse der Punktion und Elektrokoagulation des Ganglion Gasseri nach Kirschner. Ergeb Chir Orthop 31:1-82, 1939
Address reprint requests to: Jiirgen Menzel, M.D., Department of Neurosurgery, University of Heidelberg, Heidelberg, Federal Republic of Germany.
143
Department of Neurosurgery, University of Heidelberg, Heidelberg, Federal Republic of Germany v' This report is a follow-up study of 315 patients under 46 years old who suffered from trigeminal neuralgia and were treated by electrocoagulation of the Gasserian ganglion. The average follow-up period was 12.7 years, the maximum 33 years. Eighty percent had a return of pain, but 96.7% ultimately attained freedom from pain after repeat electrocoagulation.
KEy WORDS Gasserian ganglion electrocoagulation trigeminal neuralgia "
S
INCE trigeminal neuralgia generally strikes individuals about 60 years old, most follow-up studies that evaluate the success of conservative or operative treatment are necessarily restricted to a short period of time. The aim of this paper is to show the late results of electrocoagulation of the Gasserian ganglion in patients who suffered from trigeminal neuralgia earlier in life.
Clinical Material and Method The 315 patients included in this study were under 46 years old at the time of operation, between 1939 and 1971. The youngest patient in this group had his first attack at the age of 17 years, the eldest at 45. The sharp rise associated with increasing age, as noted by Zenker, 1~ Kirschner, 2 and Klar and Piotrowski) ,8 was not seen in this age group. The distribution of cases among various ages was constant (Fig. 1); however, the incidence 140
9
of operation shows a definite rise with increasing age (Fig. 2). The series was analyzed to determine the frequency with which the three divisions of the trigeminal nerve were affected. This analysis showed (Fig. 3) that in 80% the second division was involved, in 66.7% the third division, and in 43.3% both the second and third divisions. The ophthalmic nerve was affected in only 6.7%, and always in combination with the second or, more rarely, third divisions. All patients in this study were treated by the technique of electrocoagulation first tried by Kirschner 3,~ and continued by Bauer? The average follow-up period was 12.7 years, the maximum, 33 years (Fig. 4).
Results The most important follow-up criterion used was the "rate of recurrence," defined as including vestigial symptoms and operation
J. Neurosurg. / Volume 42 / February, 1975
Results of Gasserian ganglion electrocoagulation %
occasion. Trigeminal neuralgia was not influenced by electrocoagulation in the remaining 3.3% of the patients in the series. Another follow-up criterion was postoperative impairment of the ability to chew. In the total series of patients, 83.3% stated that they chewed on one side only, due to a lack of sensation. The same deficit led to occasional bite damage to the mucous membrane of the cheek. Although half of those examined had a masticatory paralysis, only 23.3% were aware of it. Saliva secretion was unchanged in 80% after the electrocoagulation; 16.7% experienced an increase, 3.3% a decrease. An increase of nasal secretion was noted by 23.3%, while 6.7% reported a decrease. In 70% of the cases nasal secretion remained unchanged. Impaired hearing due to a lesion of the tensor tympani muscle was diagnosed in 26.7% of the cases. Increased secretion of tears occurred in 16.7%, while 3.3% reported a pathological dryness of the eye. None of these cases had keratitis or keratitis neuroparalytica; this complication was not even observed when the first division was eliminated during the electrocoagulation. Disturbances of sensation, such as deafness, numbness, and burning, were reported by 93.7% of the patients; this confirmed the well-known fact that freedom from pain is only gained when the sensitivity in the branches afflicted with trigeminal neuralgia is
50 I.,,.,.
Z
23.3
25
23.3
23.3
I-,-
IW~'~: I~:~: : ' ~ ~ : ~
o,,.
0
23
28
32
36
1OO
40
~6 AGE
FIG. 1. Graph showing patients' age at first symptoms of trigeminal pain.
failures as well as genuine recurrence of pain. Unsuccessful operations that required second, third, or fourth coagulations were counted as the first, second, third, or fourth relapse even if the operations were carried out during the same hospital stay. The first coagulation was followed by a relapse in 80% of all cases; in 46.6% this occurred within the first 2 postoperative years (Fig. 5). A second relapse was experienced by 33% in the series (41.7% of those with one relapse) while 13.3% (40.0% of those with two relapses) had a third relapse. Fourth and fifth relapses occurred in 6.6% of the cases studied, and included 25% of the group with three relapses. No additional new attacks were observed. Actually, 96.7% of all patients were ultimately free of pain, although 36.7% still took analgesics on
75
%
75
%
56.8
m I-..
50
0
46.7
N 0
28 34
40
46
7
50
:::::::::::::::5
30.0 i!~iiiiiiiiiiii!i ................
0
0
28
34 40 46
FIG. 2. Graphs showing patients' age at operation. Left." Age at first operation. operation.
J. Neurosurg. / Volume 42 / February, 1975
AGE
Right." Age at last 141
J. Menzel, W. Piotrowski and H. Penzholz 100
greatly reduced or eliminated. In 60% of the cases complete lack of pain was linked with hypesthesia and anesthesia. Discrete pain was associated with increased sensitivity, while pains as severe as those prior to operation were found when the sensitivity had been only slightly reduced. Anesthesia dolorosa was observed in five cases.
80.0 75
~66.7
v) 5O
Discussion
Z UJ
I---
Q., 25
I II III BRANCH Fro. 3. Graph showing frequency with which three divisions of trigeminal nerve were affected.
% 501
25
4o.~
23.3
o
o
3.3
1 5 10 15 20 25 30 33 YEARS FIG. 4. Graph showing follow-up time for patients in this series.
75 to) I-Z
%
1st [---1
2ndl~
kid
< Q,.
50
--i3! __ Z
3
3rdk~ 4~
5th
23.0 25
i
I
io.o io.o
1 2 3 4 ov.4 YEARS Fro. 5. Graph illustrating lapse of time between first operation and recurrence of symptoms. 142
We were surprised by the high incidence of relapses (80%), which greatly exceeded those in all other reports, such as Kirschner, 2 22%; Kubanyi, 7 22.9%; Klar, 5 18.2%; and Schiirmann and Butz, 8 23%. We believe the primary reason for this difference is the long period of follow-up, which obviously covered the late relapses not reported in shorter time periods. Besides this, the term "relapse" included vestigial symptoms and operation failures besides the genuine recurrence of pain. The aim of the operation, ultimate freedom from pain, was attained in 96.7% of all cases studied. TSnnis and KreisseP reported cessation of pain in 84.8%, Kla? in 95.4%, and Schiirmann and Butz 8 in 98%. We believe it significant that no cases of keratitis neuroparalytica and only five of anesthesia dolorosa occurred in our series. After weighing all the advantages and disadvantages revealed by this investigation, we believe the following advantages support electrocoagulation: 1. Minimal operative strain on the patient (operative mortality rate, 0%) 2. Ease of repeating the procedure many times 3. Short period of hospitalization 4. Simplicity of operative equipment 5. Ultimately high rate of success. References
1. Bauer KH: Unsere Technik der Koagulation des Ganglion Gasseri. Zentralbl Chir 14:816-819, 1939 2. Kirschner M: Zur Behandlung der Trigeminusneuralgie. Med Wochenschr (Munich) 89:235-239, 1974 3. Kirschner M: Zur Elektrokoagulation des Ganglion Gasseri. Zentralbl Chir 47: 2841-2843, 1932 4. Kirschner M: Die Punktionstechnik und die Elektrokoagulation des Ganglion Gasseri: tiber gezielte Operationen. Langenbecks Arch Chir 176:581-620, 1933 J. Neurosurg. / Volume 42 / February, 1975
Results of Gasserian ganglion electrocoagulation 5. Klar E: (lber Erfahrungen mit Elektrokoagulation bei Trigeminusneuralgie an der Heidelberger Universiditsklinik. Langenbecks Arch Chit 294:713-723, 1960 6. Klar E, Piotrowski W: Die Electrokoagulation des Ganglion Gasseri im Greisenalter, in Proceedings of the International Association of Gerontology, Wien, 1966, pp 311-316, 1966 7. Kubanyi E: Trigeminusneuralgie: die Ditferentialdiagnose und Therapie der Gesichtsschmerzen. Wien, Verlag Urban und Schwarzenberg, 1956 8. Schiirmann K, Butz M: Retroganglion~ire Trigeminuswurzelresektion durch temporale Sch~idelerSffnung oder kontrollierte partielle Elektrover~Sdung des Ganglion Gasseri in der operativen Behandlung der idiopathischen Trigeminusneuralgie. Zentralbl Neurochir 29:139-152, 1968
J. Neurosurg. / Volume 42 / February, 1975
9. T~nnis W, Kreissel H: Die Bedeutung einer sorgf'~dtigen Differentialdiagnose fiir die chirurgische Behandlung der Trigeminusneuralgie. Dtsch Med Wochenschr 76:1202-1205, 1951 10. Zenker R: Die Behandlung der Trigeminusneuralgic unter besonderer Beriicksichtigung der Grundlagen, der Ausffihrung und der Ergebnisse der Punktion und Elektrokoagulation des Ganglion Gasseri nach Kirschner. Ergeb Chir Orthop 31:1-82, 1939
Address reprint requests to: Jiirgen Menzel, M.D., Department of Neurosurgery, University of Heidelberg, Heidelberg, Federal Republic of Germany.
143
