Percutaneous Retrogasserian Glycerol Rhizolysis
Neurosurgery. 2000 Feb;46(2):363-8; discussion 368-70.
Percutaneous retrogasserian glycerol rhizolysis for treatment of chronic intractable cluster headaches: long-term results.
Pieper DR, Dickerson J, Hassenbusch SJ.
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
OBJECTIVE: To analyze the long-term effectiveness and safety of percutaneous retrogasserian glycerol rhizolysis (PRGR) in the treatment of medically refractive chronic cluster headache (CH). The current mainstay of surgical intervention for these patients is percutaneous radiofrequency retrogasserian rhizotomy (PRFR). However, when performed for V1 distribution pathology, PRFR can lead to corneal anesthesia, which places the patient at risk for future visual loss. It also increases the risk of facial dysesthesia.
METHODS: In a prospective, consecutive series, 18 patients with intractable CH were followed for a mean of 5.2 years (range, 40-78 mo) after they had undergone PRGR, performed using a standard technique. The significance of this technique as an alternative to PRFR is that it should result in a lower rate of both corneal and facial anesthesia and provide an acceptable degree of pain relief.
RESULTS: Fifteen patients (83%) obtained immediate pain relief after one or two injections; the majority of them experienced relief after the first injection. CH recurred in seven patients (39%) over the course of the study. Two of these patients received a second injection, and both met with equal success. Two other patients underwent PRFR. Excluding those who underwent PRFR, the overall daily headache frequency decreased from 3.5 +/- 0.3 attacks per day preoperatively to 0.6 +/- 0.2 attacks per day at last follow-up. The severity of these headaches, as assessed by verbal pain scales, also decreased from 10 preoperatively to 4.4 +/- 1.4 at follow-up. None of the patients, including those who required a second procedure, experienced corneal anesthesia or facial dysesthesia.
CONCLUSION: This study provides the first long-term evaluation of PRGR for the treatment of medically refractive chronic CH and lends support to both the safety and long-term efficacy of this procedure. Further investigations are needed to compare directly the relative efficacy and safety of PRGR and PRFR.
PMID: 10690725
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Neurosurgery. 1991 Oct;29(4):504-8.
Trigeminal cisternal injection of glycerol for treatment of chronic intractable cluster headaches.
Hassenbusch SJ, Kunkel RS, Kosmorsky GS, Covington EC, Pillay PK.
Department of Neurosurgery, Cleveland Clinic Foundation, Ohio.
Medical treatment of chronic cluster headaches (cluster headaches that occur frequently without remission) can be very difficult. In many patients, the pain remains severe despite all medication trials. For these patients, previous reports recommend radiofrequency trigeminal rhizotomy, which risks corneal anesthesia and subsequent corneal decompensation. As a safer, yet effective, treatment, retro-Gasserian injections of glycerol were given to eight patients having intractable chronic cluster headaches. Needle penetration into the trigeminal cistern, glycerol amount (0.55 ml), and length of patient elevation after the procedure (80-90 degrees upright for 10 h) were modified for maximal exposure of the V1 division. Three patients required one additional injection, and one patient required two additional injections. Verbal pain scales (means +/- 1 standard error of the mean) were: 9.1 +/- 0.30 (preoperative), 2.6 +/- 1.10 (1 mo postoperative), and 2.1 +/- 0.64 (1 yr postoperative). Daily headache frequency decreased from 6.0 +/- 2.0 (preoperative) to 0.2 +/- 0.09 (i.e., one headache every 5 days) (1 yr postoperative). Three of the eight patients had no headaches after 1 year. There were no instances of corneal or facial anesthesia. One year postoperatively, five patients required no medication, and three remained on low doses of medication for headache treatment. In contrast to previous limited reports of glycerol injections for cluster headaches, results with these patients having chronic cluster headaches support the use of glycerol injections as a viable treatment alternative, with significant pain relief and corneal safety.
PMID: 1944829
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Cephalalgia. 1987 Mar;7(1):21-7.
Retro-Gasserian glycerol injection in the treatment of chronic cluster headache.
Ekbom K, Lindgren L, Nilsson BY, Hardebo JE, Waldenlind E.
Seven therapy-resistant patients with cluster headache (six of whom were chronic) were treated by percutaneous retro-Gasserian glycerol injections under general anesthesia. In four of the patients immediate and complete relief of attacks was obtained. There was a close correlation between pain relief and the degree of ophthalmic sensory loss. Quantitative estimation of thresholds for thermal perception and pain showed a good correlation to clinically evaluated sensory loss. As the analgesia waned, headaches returned, and the glycerol injections had to be repeated. Two patients were still considerably improved after 5 1/2 and nearly 3 years, respectively. In the other patients the results were less satisfactory at long-term follow-up study. Pure glycerol is highly hypertonic, and the damage of the trigeminal nerve root may be due to this property.
PMID: 3495342
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