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Percutaneous electrocoagulation for tic douloureux
Mary Van Poole, RN
Percutaneous electrocoagulation for tic douloureux Trigeminal neuralgia (tic douloureux) was described as early as 1776 by John Fothergill.’ It is characterized by excruciating burning pain that radiates along one or more of the three divisions of the trigeminal, or fifth cranial nerve.
Mary Van Poole, R N , is assistant director of operating rooms, North Carolina Baptist Hospital, WinstonSalem, NC. A graduate of North Carolina Baptist Hospitals School of Nursing, she is secretary of the AORN Board of Directors. The author acknowledges the assistance of Eben Alexander, Jr, MD, professor and chairman of the department of neurosurgery, and Courtland H Davis, Jr, MD, professor of neurosurgery, at the Bowman Gray School o f Medicine, Wake Forest University, Winston-Salem, for department funding of illustrations.
The pain usi.:ally extends to the midline of the face and head because this is the extent of the tissue supplied by the offending nerve. There are areas along the course of the nerve known as “trigger points” where the slightest stimulation causes stabbing, agonizing pain that shoots across the victim’s face like jolts of burning electricity. Anything can set off the pain: eating, shaving, washing one’s face, brushing one’s teeth, swift movements, or being in drafts. In the past, drug therapy resulted in only short-term relief, and the patient spent most of his life trying desperately to avoid triggering the pain. A recent method to achieve lasting relief of pain with only partial destruction of the trigeminal nerve is by percutaneous electrocoagulation of the trigeminal nerve. By controlling the temperature during radiofrequency lesioning, the sensory portion of the trigeminal nerve is sufficiently destroyed to relieve pain but touch and motor function are preserved. This is possible because the small, poorly myelinated fibers that carry pain are more sensitive to thermal lesions and can be destroyed by the electric current while the better insulated, large fibers that mediate tactile and motor functions are less susceptible to injury. Percutaneous electrocoagulation may be done in the x-ray department,
AORN Journal, November 1976, Vol24, No 5
887
but it is best done in an operating room equipped to handle fluoroscopic procedures and provide rapid radiographic development. Here the patient can be adequately monitored and frequently reassured by a nurse, who is not always available in an x-ray department. It is most important that the nurse conduct a preoperative interview to learn about the patient’s history and physical status. The nurse must realize that the patient suffering from trigeminal neuralgia is an apprehensive individual who fears being approached by anyone who does not
understand his ailment. He needs to be told in detail what will happen during the procedure, that the time element can be lengthy, and that his cooperation is of utmost importance. He gains assurance by knowing that one who is familiar with his problem will be present during the procedure. Prior to the procedure, the patient receives nothing by mouth for at least five hours and is given adequate preoperative medication at least one hour preoperatively. In the operating room, the patient is placed on the operating table in a supine position with his head sup-
The trigeminal, or fifth cranial nerve, innervates the face, mucous membranes, other internal structures of the head, and the motor nerve of the muscles of mastication. It emerges from the pons and divides into three divisbns at the trigeminal ganglion. Trigeminal neuralgia is sudden, severe, laminating pain in one or more divisions of the trigeminal nerve. 888
AORN Journal, November 1976, Vol24, No 5
Inf. orbital fissure Needle in foramen ovale Ext. auditory meatus
Fig 1. A. Landmarks for puncture of the foramen ovale. B. Guiding finger in pterygoid fOSSa. (Illustrations by George Lynch, director and medical illustrator, departmenr ot audiovisual resources, Bowman Gray School of Medicine, Wake Forest
Universify. Winston-Salem, NC.)
vI
Fig 2. The trigeminal ganglion is coagulated at its three divisions.
Trigerninol ganglion
Trigerninol cistern
5 rnrn needle -(Tip uninsulated)
AORN Journal, November 1976, Val 24, No 5
889
Fig 3. Regions of analgesia obselved after selective lesioning in a V2, V2, V3 division of the trigeminal ganglion.
ported on a donut headrest. An intravenous infusion is started in the left arm, and blood pressure and electrocardiograph are monitored by the anesthetist. An x-ray technician is available with fluoroscopy equipment. The circulating nurse has in readiness the sterile tic kit, radiofrequency generator, and other necessary supplies. The setup includes four special 19gauge cannulae with varying tip exposures of 2, 5, 7, and 10 mm openings; short-beveled, sharp-tipped cannulae with matching stylets; a 22-gauge temperature monitoring electrode; and a flush adapter for cleansing the cannula of cerebrospinal fluid. An ample supply of surgeon’s gloves are available because the surgeon changes gloves frequently throughout the procedure. Preliminary films are taken to identify the foramen ovale or nerve opening and adjacent anatomical landmarks. Surface landmarks the surgeon uses for electrode insertion are: 1. a point 3 cm anterior to the external auditory meatus 890
2. a point 2.5 cm lateral to the oral commissure 3. a point corresponding to the line defined by the pupillary center (Fig 1 A).2 The patient’s face is prepped and draped with towels. Lidocaine 1% is injected into the right cheek. The surgeon chooses the exposed cannula tip he plans to use. The insulated cannula with uninsulated tip is chosen according to the number of trigeminal nerve divisions to be coagulated; 5 mm for one division (Fig 2), 7 mm for two or three divisions, and 10 mm for three divisions. Placing his gloved right index finger inside the patient’s mouth into the pterygoid fossa, the surgeon uses his left hand to guide the cannula through the patient’s cheek (Fig 1 B) into the foramen ovale. The patient experiences painful paresthesia in the mandibular division when the foramen ovale is penetrated. Fluoroscopy and x-ray confirm needle placement. The needle is advanced until cerebrospinal fluid can be seen from holes in the cannula hub. This
AORN Journal, November 1976, Vol24, No 5
indicates that the tip of the needle has reached the trigeminal cistern. An indifferent electrode connection is made by inserting a spinal needle about 7 cm in length under the scalp near the forehead in preparation for stimulation and radiofrequency electrocoagulation of the trigeminal nerve. The nerve is coagulated with a radiofrequency generator. Stimulation is then attempted by using unipolar stimulator pulses of one millisecond duration. Stimulation voltage is raised to between 0.2 and 0.5 volts until the patient reports paresthesia in the trigeminal division responsible for pain and the trigger zone. The electrode penetration is increased to provoke paresthesia in the third, second, and first divisions of the trigeminal nerve. The patient is watched carefully for eye movement and facial contraction during each penetration to avoid overdestruction and objectionable side effects. The patient is then given a rapid intravenous injection of fentanyl to achieve somnolence and amnesia during destruction of nerve fibers. The first thermal lesion is made when the electrode tip heated to 60 C (140 F) is applied to the nerve fiber for 60 seconds. The power is then turned back to zero. In two to three minutes, the patient awakens, and sensory testing is performed by the surgeon. The goal is analgesia to pinpricking in the division causing the pain. Successive heat lesions are made. Each time the patient is given fentanyl and awakened rapidly with sensory testing. This process is repeated until analgesia of the entire area is accomplished (Fig 3). Usually three lesions are made a t a temperature of 60 C (140 F) to 80 C (176 F) with a 5 C (9F) temperature increase for each l e ~ i o n . ~ After each lesion is made and while the patient is fully awake, the surgeon checks corneal and cilia reflexes and
facial sensation. Erythema occurs in the facial zone when maximal coagulation has been administered. This indicates destruction has occurred in that division. The patient is returned to his room following the procedure. An ice pack is applied to the operated jaw for four hours. Methylcellulose drops are instilled in the eye on the operated side four times daily. The patient is given a soft diet with instructions not to chew on the operated side until paresthesia has diminished. After the procedure, the patient is insensitive to pain on the affected side. At discharge, instruct the patient and his family to observe the affected eye carefully for redness and to avoid rubbing or touching it. Explain that the cornea will be insensitive to pain and not serve its usual function as a n indicator of pain or irritation. If blurred vision or conjunctival erythema is noted, the patient should contact his physician immediately. The patient should also be told to visit his dentist routinely to detect dental caries on the affected side because he will not feel pain associated with them. This procedure has afforded relief for many patients suffering from trigeminal neuralgia. In some cases, it may need to be repeated because a less than ideal lesion may have been achieved due to the age of the patient, mental status, and fear of pain. He may say his pain was relieved when, in fact, it was not. In these cases, the procedure may need to be repeated from a day to several months later. 0 Notes 1. Stanley Jablonski, //lustrated Dictionary of Eponymic Syndromes and Diseases and Their Synonyms (Philadelphia: W B Saunders, 1969) 108. 2. John M Tew, Radionics Procedure Technique Series (Burlington, Mass: Radionics, Inc, 1974). 3. /bid, 10.
AORN Journal, November 1976, Vol24, No 5
891
Percutaneous electrocoagulation for tic douloureux Trigeminal neuralgia (tic douloureux) was described as early as 1776 by John Fothergill.’ It is characterized by excruciating burning pain that radiates along one or more of the three divisions of the trigeminal, or fifth cranial nerve.
Mary Van Poole, R N , is assistant director of operating rooms, North Carolina Baptist Hospital, WinstonSalem, NC. A graduate of North Carolina Baptist Hospitals School of Nursing, she is secretary of the AORN Board of Directors. The author acknowledges the assistance of Eben Alexander, Jr, MD, professor and chairman of the department of neurosurgery, and Courtland H Davis, Jr, MD, professor of neurosurgery, at the Bowman Gray School o f Medicine, Wake Forest University, Winston-Salem, for department funding of illustrations.
The pain usi.:ally extends to the midline of the face and head because this is the extent of the tissue supplied by the offending nerve. There are areas along the course of the nerve known as “trigger points” where the slightest stimulation causes stabbing, agonizing pain that shoots across the victim’s face like jolts of burning electricity. Anything can set off the pain: eating, shaving, washing one’s face, brushing one’s teeth, swift movements, or being in drafts. In the past, drug therapy resulted in only short-term relief, and the patient spent most of his life trying desperately to avoid triggering the pain. A recent method to achieve lasting relief of pain with only partial destruction of the trigeminal nerve is by percutaneous electrocoagulation of the trigeminal nerve. By controlling the temperature during radiofrequency lesioning, the sensory portion of the trigeminal nerve is sufficiently destroyed to relieve pain but touch and motor function are preserved. This is possible because the small, poorly myelinated fibers that carry pain are more sensitive to thermal lesions and can be destroyed by the electric current while the better insulated, large fibers that mediate tactile and motor functions are less susceptible to injury. Percutaneous electrocoagulation may be done in the x-ray department,
AORN Journal, November 1976, Vol24, No 5
887
but it is best done in an operating room equipped to handle fluoroscopic procedures and provide rapid radiographic development. Here the patient can be adequately monitored and frequently reassured by a nurse, who is not always available in an x-ray department. It is most important that the nurse conduct a preoperative interview to learn about the patient’s history and physical status. The nurse must realize that the patient suffering from trigeminal neuralgia is an apprehensive individual who fears being approached by anyone who does not
understand his ailment. He needs to be told in detail what will happen during the procedure, that the time element can be lengthy, and that his cooperation is of utmost importance. He gains assurance by knowing that one who is familiar with his problem will be present during the procedure. Prior to the procedure, the patient receives nothing by mouth for at least five hours and is given adequate preoperative medication at least one hour preoperatively. In the operating room, the patient is placed on the operating table in a supine position with his head sup-
The trigeminal, or fifth cranial nerve, innervates the face, mucous membranes, other internal structures of the head, and the motor nerve of the muscles of mastication. It emerges from the pons and divides into three divisbns at the trigeminal ganglion. Trigeminal neuralgia is sudden, severe, laminating pain in one or more divisions of the trigeminal nerve. 888
AORN Journal, November 1976, Vol24, No 5
Inf. orbital fissure Needle in foramen ovale Ext. auditory meatus
Fig 1. A. Landmarks for puncture of the foramen ovale. B. Guiding finger in pterygoid fOSSa. (Illustrations by George Lynch, director and medical illustrator, departmenr ot audiovisual resources, Bowman Gray School of Medicine, Wake Forest
Universify. Winston-Salem, NC.)
vI
Fig 2. The trigeminal ganglion is coagulated at its three divisions.
Trigerninol ganglion
Trigerninol cistern
5 rnrn needle -(Tip uninsulated)
AORN Journal, November 1976, Val 24, No 5
889
Fig 3. Regions of analgesia obselved after selective lesioning in a V2, V2, V3 division of the trigeminal ganglion.
ported on a donut headrest. An intravenous infusion is started in the left arm, and blood pressure and electrocardiograph are monitored by the anesthetist. An x-ray technician is available with fluoroscopy equipment. The circulating nurse has in readiness the sterile tic kit, radiofrequency generator, and other necessary supplies. The setup includes four special 19gauge cannulae with varying tip exposures of 2, 5, 7, and 10 mm openings; short-beveled, sharp-tipped cannulae with matching stylets; a 22-gauge temperature monitoring electrode; and a flush adapter for cleansing the cannula of cerebrospinal fluid. An ample supply of surgeon’s gloves are available because the surgeon changes gloves frequently throughout the procedure. Preliminary films are taken to identify the foramen ovale or nerve opening and adjacent anatomical landmarks. Surface landmarks the surgeon uses for electrode insertion are: 1. a point 3 cm anterior to the external auditory meatus 890
2. a point 2.5 cm lateral to the oral commissure 3. a point corresponding to the line defined by the pupillary center (Fig 1 A).2 The patient’s face is prepped and draped with towels. Lidocaine 1% is injected into the right cheek. The surgeon chooses the exposed cannula tip he plans to use. The insulated cannula with uninsulated tip is chosen according to the number of trigeminal nerve divisions to be coagulated; 5 mm for one division (Fig 2), 7 mm for two or three divisions, and 10 mm for three divisions. Placing his gloved right index finger inside the patient’s mouth into the pterygoid fossa, the surgeon uses his left hand to guide the cannula through the patient’s cheek (Fig 1 B) into the foramen ovale. The patient experiences painful paresthesia in the mandibular division when the foramen ovale is penetrated. Fluoroscopy and x-ray confirm needle placement. The needle is advanced until cerebrospinal fluid can be seen from holes in the cannula hub. This
AORN Journal, November 1976, Vol24, No 5
indicates that the tip of the needle has reached the trigeminal cistern. An indifferent electrode connection is made by inserting a spinal needle about 7 cm in length under the scalp near the forehead in preparation for stimulation and radiofrequency electrocoagulation of the trigeminal nerve. The nerve is coagulated with a radiofrequency generator. Stimulation is then attempted by using unipolar stimulator pulses of one millisecond duration. Stimulation voltage is raised to between 0.2 and 0.5 volts until the patient reports paresthesia in the trigeminal division responsible for pain and the trigger zone. The electrode penetration is increased to provoke paresthesia in the third, second, and first divisions of the trigeminal nerve. The patient is watched carefully for eye movement and facial contraction during each penetration to avoid overdestruction and objectionable side effects. The patient is then given a rapid intravenous injection of fentanyl to achieve somnolence and amnesia during destruction of nerve fibers. The first thermal lesion is made when the electrode tip heated to 60 C (140 F) is applied to the nerve fiber for 60 seconds. The power is then turned back to zero. In two to three minutes, the patient awakens, and sensory testing is performed by the surgeon. The goal is analgesia to pinpricking in the division causing the pain. Successive heat lesions are made. Each time the patient is given fentanyl and awakened rapidly with sensory testing. This process is repeated until analgesia of the entire area is accomplished (Fig 3). Usually three lesions are made a t a temperature of 60 C (140 F) to 80 C (176 F) with a 5 C (9F) temperature increase for each l e ~ i o n . ~ After each lesion is made and while the patient is fully awake, the surgeon checks corneal and cilia reflexes and
facial sensation. Erythema occurs in the facial zone when maximal coagulation has been administered. This indicates destruction has occurred in that division. The patient is returned to his room following the procedure. An ice pack is applied to the operated jaw for four hours. Methylcellulose drops are instilled in the eye on the operated side four times daily. The patient is given a soft diet with instructions not to chew on the operated side until paresthesia has diminished. After the procedure, the patient is insensitive to pain on the affected side. At discharge, instruct the patient and his family to observe the affected eye carefully for redness and to avoid rubbing or touching it. Explain that the cornea will be insensitive to pain and not serve its usual function as a n indicator of pain or irritation. If blurred vision or conjunctival erythema is noted, the patient should contact his physician immediately. The patient should also be told to visit his dentist routinely to detect dental caries on the affected side because he will not feel pain associated with them. This procedure has afforded relief for many patients suffering from trigeminal neuralgia. In some cases, it may need to be repeated because a less than ideal lesion may have been achieved due to the age of the patient, mental status, and fear of pain. He may say his pain was relieved when, in fact, it was not. In these cases, the procedure may need to be repeated from a day to several months later. 0 Notes 1. Stanley Jablonski, //lustrated Dictionary of Eponymic Syndromes and Diseases and Their Synonyms (Philadelphia: W B Saunders, 1969) 108. 2. John M Tew, Radionics Procedure Technique Series (Burlington, Mass: Radionics, Inc, 1974). 3. /bid, 10.
AORN Journal, November 1976, Vol24, No 5
891