Revolutionising Trigeminal Neuralgia Pain Relief using the Modified Kodeeswaran's Retro-gasserian Glycerol Rhizotomy (KRGR) Protocol and Technique in the management of Trigeminal Neuralgia 

Revolutionising Trigeminal Neuralgia Pain Relief using the Modified Kodeeswaran's Retro-gasserian Glycerol Rhizotomy (KRGR) Protocol and Technique in the management of Trigeminal Neuralgia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Revolutionising Trigeminal Neuralgia Pain Relief using the Modified Kodeeswaran's Retro-gasserian Glycerol Rhizotomy (KRGR) Protocol and Technique in the management of Trigeminal Neuralgia Kodeeswaran M, Chiraag Hiran.S, Ashwin Retnam, Priyadarshan K.P, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8057873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To evaluate the Modified Kodeeswaran’s Retro-gasserian Glycerol Rhizotomy (KRGR) protocol and technique of Glycerol Rhizotomy as a preferred treatment option for trigeminal neuralgia, by assessing its efficacy, impact on functional and social disability, psychiatric improvements, hospital stay, complications, and recurrence of pain. While various procedures exist for managing trigeminal neuralgia, evidence on PRGR is limited, particularly regarding its efficacy, safety, and suitability as a minimally invasive day-care procedure. Methods: A prospective study was conducted on 312 patients with trigeminal neuralgia involving the V1/V2/V3 branches. Pain duration ranged from 3 months to 20 years and assessed using World Trigeminal Neuralgia Foundation (WTNF) pain score. All patients underwent radiological evaluation for neurovascular conflict,anatomy and variations of foramen ovale. After informed consent, the modified KRGR was performed. Post-procedure assessments included pain relief, comparison of pre- and post-procedure scores, complications, and improvements in functional, social, and psychiatric status during the immediate and follow-up post-operative periods were noted. Results: Most patients were aged 51–60 years; 56% were female. Left-sided pain (54%) and V2V3 involvement (44%) were most common. 83.7% were medically refractory and 16.3% had recurrent pain (Failed Face Syndrome). Neurovascular conflict was seen in 73.7%. Immediate pain relief seen in 96.15%, and 86% had long-term relief over a 6-year mean follow-up. 17 patients required repeat injections. Minor complications occurred in 11.24% (facial numbness, injection site pain, transient hoarseness, herpes reactivation, facial palsy, and seizures); none were life-threatening. Conclusion: PRGR is a safe, cost-effective, and minimally invasive outpatient procedure with excellent immediate (96.15%) and long-term (86%) pain relief, low recurrence (14%) and a low treatment failure rate (3.85%). Only 11.24% experienced minor complications, along with improved social, functional and psychiatric outcomes post-operatively. Therefore KRGR should be considered a preferred and first-line therapy for trigeminal neuralgia relief. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Trigeminal neuralgia (TN) is a neuropathic disorder characterised with sharp and sudden paroxysmal lancinating pain resembling electric shock type of facial pain which lasts for few seconds. It is also known as TIC DOULOUREUX. It can be triggered by various cutaneous stimuli like cool breeze over the face, while brushing, talking, chewing and at times while shaving also. There are various pathogenesis behind the causation of trigeminal neuralgic pain and the most commonest being the vascular compression at the nerve root entry zone (Obersteiner Redlich zone) and the most common vessel causing it is the Superior Cerebellar artery. Various others being a posterior fossa tumour or plaques of multiple sclerosis. Still there has been speculations regarding the exact pathogenesis of an idiopathic TN. Although patients with trigeminal neuralgia, initially are managed with medical therapy but in course of time, these patients tend to wear-off from the efficacy of the drug. Such cases in which the side effects of drugs exceed the drawbacks and risks of surgery and they become refractory to medical management, they all require a percutaneous procedure or open surgery. Amongst the percutaneous procedures, the Percutaneous Retro-gasserian Glycerol Rhizotomy has still paved its way through the test of time. Hence this paper analyses a series of 312 patients, diagnosed with Trigeminal Neuralgia and treated with modified Kodeeswaran’s Retro-gasserian Glycerol Rhizotomy (KRGR), in terms of primary and secondary outcomes, shorter hospital stay, complications, safety in terms of no life threatening complications, recurrence and cost-effectiveness. Study Description A prospective study was conducted on a series of 312 patients. All of them came with complaints of either RIGHT or LEFT trigeminal neuralgic pain involving either of the three V1,V2,V3 distribution as a single or grouped involvement. The Duration of pain ranged from 3 months − 20 years. Out of 312 cases – 261 (83.7%) cases were medically refractory despite being on drugs for atleast 3 months or more and 51 (16.3%) cases had recurrent trigeminal neuralgic pain (post-interventional procedures) known as post-intervention recurrent patients or Falied Face Syndrome patients 1 . The intensity of pain was classified based on World Trigeminal Neuralgia Foundation (WTNF) Pain Intensity Score pre-operatively. Each case underwent radiological evaluation for any neurovascular conflict and amongst 312 cases – 230 (73.7%) cases had neurovascular conflict most commonly by the Superior cerebellar artery compressing or abutting the trigeminal nerve and 82 (26.3%) cases had none. All the cases underwent CT skull base with 3D reconstruction to delineate the shape, size and orientation of the foramen ovale for tailoring our entry into the retro-gasserian space (Fig. 1 ). The study patients were explained in detail about the condition, the benefits, and possible adverse effects of the procedure, as well as other treatment options available for their neuralgic pain. A written informed consent was obtained from all those patients involved in the study and were taken up for KRGR procedure. Ethics committee approval statement : Approval from the Institutional Ethics Committee was not required for this study, as it did not involve experimental interventions or procedures beyond standard clinical practice. Consent Written informed consent was obtained from each and every patient. Procedure : The patient was given supine with head neutral position. In some instances minimal neck extension with lateral rotation away from the side of pain Nasal oxygenation, vital monitoring and sedation was given. Under aseptic precautions, around 5 ml of 1% lignocaine (local anaesthesia) was injected just lateral to the angle of mouth at the side of pain and along the planned needle track. 3 points were marked (Fig. 2 a) 1st – 1.5 cm lateral to the angle of mouth 2nd – just in front of the tragus (external auditory meatus) 3rd – just below the inferior orbital rim along the mid-pupillary line The C-arm was projected in both sub-mentovertical position and lateral projection (Fig. 3 d), the c-arm was positioned at a 25–35 degree angle in postero-anterior axis (receiver positioned superiorly and tilted laterally to the side of pain and the emitter positioned inferiorly and tilted laterally away from the side of pain) and 15–35 degree angle in lateral angulation, and shots were taken until the foramen ovale was visualised. This view positions the foramen ovale between the lateral border of maxillary sinus and medial border of ramus of the mandible. (Fig. 3 a, 3 b) Needle insertion site − 1.5 cm lateral to the angle of the mouth of the side of pain. An 18G spinal needle was inserted at the above mentioned point and tunneled in the cheek for 2cm directing towards the ipsilateral tragus. Care must be taken to avoid needle entry into oral cavity. Further needle was manipulated superiorly towards the point marked at the inferior orbital rim along the mid-pupillary line and guided effectively downwards towards the skull base under C-arm guidance until foramen ovale breached. (Fig. 2 b) Confirmation of the needle's entrance into the trigeminal cistern within the Meckel's cave was ascertained by the presence of cerebrospinal fluid flow, a sign that may be absent, particularly after repeated percutaneous procedures. The needle’s pathway and tip was verified using C-arm fluoroscopy in lateral projection (Fig. 3 c). The needle was found passing in between the lower border of maxillary sinus and the upper part of 3rd molar teeth and through the foramen ovale, ensuring the needle tip remained inferiorly within a range of 0.5 to 1 cm from the point of convergence of line intersecting the floor of sella and clivus corresponding to mid-clival point. Following this, a volume of 0.5–1.5 ml of anhydrous glycerol was administered, after which the patient was promptly seated with neck flexion for approximately 2 hours to enhance the contact of glycerol with the trigeminal nerve root. Post procedure, the patients were monitored overnight in the hospital for primary outcomes such as immediate pain relief and immediate complications, and if none found and pain free, discharged the next day. The pain outcome was assessed based on WTNF pain intensity scores and was compared with the pre-operative score. Post discharge, the patients were followed up on OPD basis on regular intervals to assess the recurrence of pain and the medications were tapered and stopped after a week, if no recurrence. Results A total of 312 patients were included in the study and were successfully injected with Glycerol. Majority of the patients were in the 51–60 age group. Females constituted 56% (n = 175) and males constituted 44% (n = 137) of the study population (Fig. 4 c) Most common site involved was the left constituting about 54% (n = 169) and right was about 45% (n = 140) and 1% (n = 3) of the study population had bilateral involvement. (Fig. 4 b) The dermatomal pattern of pain in our study was as follows : 31 patients (10%) in V1 region only ; 12 patients (4%) in V2 region only; 17 patients (5.3%) in V3 region only; 75 patients (24%) in V1V2 regions; 137 patients (44%) in V2V3 regions and 40 patients (12.7%) in V1V2V3 regions. (Fig. 4 a) Also there was improvemen in secondary outcome in terms of functional and social disability, anxiety and suicidal ideation when compared between the Pre-operative and post-operative period. (Fig. 4 d) Amongst 312 patients involved in our study, almost 261 (83.7%) patients were on medical management and 51 (16.3%) cases had underwent previous open surgical or minimally invasive procedures which are available for the management of trigeminal neuralgia and such patients were categorised Failed Face Syndorme. 1 Table 1 Previous treatment details of the study population Number of patients Percentage of patients MEDICAL MANAGEMENT 1 drug 11 3.7% 2 drugs 115 36.7% 3 drugs 135 43.3% SURGICAL PROCEDURE MVD 23 7.3% Botox injections 4 1.3% Percutaneous procedures – RFA, PRGR 24 7.7% Out of 312 patients, 300 patients (96.15%) had complete pain relief immediately post procedure. Seventeen patients (5.45%) had continued occasional pain with reduced intensity on 1 st follow up and hence not requiring medications. On further follow ups ,out of 17 patients, 14 underwent 2 nd injection and 3 patients required 3 rd injection. The mean follow-up duration was 6 years. Of the 312 patients, 12 patients (3.85%) who had no immediate pain relief (treatment failure rate) were lost to follow-up and 5 patients died due to an unrelated medical cause, hence a follow up of 295 patients was done. The mean follow-up duration was 6 years. Thus, immediate pain relief was seen in 96.15% ( n = 300 of 312 patients), long-term pain relief in 86% ( n = 254 of 295 patients). During the follow-up period, the efficacy of the pain relief decreased from 96.15% to 86%. All the complications encountered were mild and not life-threatening. Table 2 Treatment success and failure rate. TREATMENT SUCCESS RATE 1 ST INJECTION 2 ND INJECTION 3 RD INJECTION TREATMENT FAILURE RATE TOTAL 300 283 14 3 12 312 96.15% 90.7% 4.45% 1% 3.85% 100% Table 3 World Trigeminal Neuralgia Foundation (WTNF) pain intensity score in the pre-operative, immediate post-operative and follow-up period. Score Description Medication Use Pre-operative Immediate post-operative Follow-up period (Mean-6 years) I No pain None - 283 254 II Occasional mild pain None - 17 24 III Mild pain, not requiring daily medication Occasional - - - IV Moderate pain, controlled with regular medication Regular 94 - 17 V Moderate–severe pain despite medication Regular 170 4 - VI Severe, disabling pain uncontrolled by medication having suicidal tendency Regular (ineffective) 48 8 - Total 312 312 295 Table 4 Number of cases showing complications COMPLICATION NUMBER % Pain, at injection site Immediate upto 3 hours 213 68.3% 3 hours – 48 hours 99 31.7% Post 48 hours 0 0 Transient Numbness over face upto 48 hours 194 62.3% Persistent numbness over face - on 1st follow up (14th day post procedure) 19 6% Corneal anaesthesia 0 0 Herpes reactivation 5 1.6% Transient Facial palsy 8 2.67% Transient hoarseness of voice 1 0.33% Seizure 2 0.64% Meningitis, life-threatening complications 0 0 Discussion Trigeminal neuralgia (TN) is a neuropathic disorder characterized with sharp and sudden paroxysmal lancinating pain (electric shock pain) which lasts for few seconds. It is also known as TIC DOULOUREUX. The main characteristic of the trigeminal neuralgic pain is having multiple episodes, remissions and exacerbations. 2 The main pathophysiology over years was considered to be due to EHAPTIC TRANSMISSION in trigeminal nerve from the A fibres (partially de-myelinated larger diameter) to the A-Delta (thinly myelinated) and C (nociceptive) fibres. Peter Jannetta explained the concept of vascular compression at the root entry zone of trigeminal nerve either by arterial loops or veins. 3,4 Most common involvement was by the Superior Cerebellar Artery (80%). 5 Although studies by Ramesh and Premkumar suggested that vascular compression at the trigeminal root entry zone is also seen in normal individuals, questioning its causative role in trigeminal neuralgia (TN). 6 Alternative theories, including axonal or myelin alterations by Loeser et al 7 and the ignition hypothesis 8 , attempt to explain TN. However, its unclear etiopathogenesis creates ambiguity in selecting optimal treatment for refractory cases. The main goal of the procedures available for the management of trigeminal neuralgia, is always and will be alleviation of pain with an acceptable level of side effects of the procedure. Amongst the percutaneous procedures available, PRGR is preferred by many neuro-surgeons for primary as well as refractory TN. Anhydrous glycerol used in our study, works by chemically ablating the pathological areas on the axons. While the exact mechanism behind its ability to relieve neuralgic attacks without causing the intense anesthesia typically remains unclear. 9 Amongst the treatment modalities available for trigeminal neuralgia management, each one have their share of recurrence of pain and complications. In 1994, Walchenbach et al conducted a study which reported recurrence of trigeminal neuralgia after MVD in 58 patients, to be 29% on a 5 year long term follow-up period. 10 In the year 2000, Lee et al performed MVD in TN patients and found a recurrence rate of 31% and the etiology behind the recurrence as venous compression. 11 A study done by Kanpolat et al in the year 2001, in which 1,600 patients with idiopathic trigeminal neuralgia after RF-TR were analyzed after a follow-up period of 1 to 25 years and reported a recurrence rate of 17.4%. 12 Karam et al in the year 2014, showed results of gamma-knife radiosurgery to be about 32% free from any pain and 63% free from severe pain and hence a recurrence rate of around 37% on a 5 year follow up period. 13 Kondziolka and Lunsford (2005) reviewed their experience of Percutaneous Retrogasserian Glycerol rhizotomy (PRGR) in 1174 cases and reported a recurrence rate of about 23%. 14 Another study conducted by Kodeeswaran et al (2015), in which PRGR was performed in 93 patients and the recurrence rate was found to be 11% on an average period of 18.8 months follow-up. 15 In comparison with other procedures and their study in the published literatures, our study shows that PRGR is better in terms of immediate and long term pain relief and also recurrence of pain is minimal. [Table 5 ] Table 5 Comparison of various studies of treatment modalities available for management of trigeminal neuralgia with our current study in terms of immediate pian relief, long-term pain relief, recurrence and follow-up period STUDY IMMEDIATE RELIEF LONG-TERM RELIEF RECURRENCE FOLLOW-UP Current study 96.15 86 14 6 years RFA, Singh et al, 2014 16 77.8 66.7 16.7 1.5 years PRGR, Tew and Taha, 1995 17 80 60 28 Retrospective MVD, Campero et al, 2014 18 88 11.1 36 months Balloon compression, Mullan and Lichtor, 1983 19 88 77 12 3.6 years Gamma Knife radiosurgery, Kondziolka et al, 1988 20 77 62 36 4 years As per the technique of the PRGR with our modified KRGR protocol and technique, we are able to attain good results due to few modifications done. One such modification is that the procedure is performed in supine position. We also use 100% anhydrous glycerol and no contrast is being used. Also there is significant variation in the size, shape and orientation of the foramen ovale. Hence we have made it compulsory as a protocol to do CT skull base with 3D reconstruction in order to delineate the shape, size and orientation of the foramen ovale for tailoring our entry into the retro-gasserian space and reduces the incidence of failures. Most importantly, once the glycerol is injected, the patient is immediately made to sit upright with neck flexion for approximately 2 hours after the procedure and this facilitates contact of glycerol in the retro-gasserian space without seepage into the posterior fossa cisterns. Also with the technique elaborated in detail above, we have achieved perfection of needle entry into the foramen ovale by confirming step by step on lateral x ray revealing the needle entry to first enter below the lower border of maxillary sinus and above the upper part of third molar, next at the skull base into the foramen ovale and lastly the needle tip at the mid-clival point. These are the modifications and pearls of our modified KRGR protocol and technique. The most common complications of PRGR are minor like development of a local hematoma, reactivation of labial herpetic lesions, transient injection site pain and anesthesia dolorosa (transient numbness over face). Rarest complications include transient facial palsy, transient hoarseness of voice, seizure and severe complications like chemical meningitis and infectious meningitis were nil. PRGR showed no life-threatening complications, in our study as well as in the available published literature, in comparison to a study done by Yong Yue et al. 21 The study showed 7 cases with life-threatening complications. One was cerebellar infarction with acute hydrocephalus, one was cerebellum and the brain stem infarction with acute hydrocephalus, 2 cases had cerebellar hematoma, one was multiple hemorrhage with acute hydrocephalus, one was supratentorial subdural hematoma, and one was cerebellar swelling with acute hydrocephalus. After therapy, one patient died, one was in a persistent vegetative state, and five were discharged from the hospital upon recovery. In brief, life-threatening complications accompanying MVD are present but rare, hence requires attention. Conclusion We would like to conclude through our case series of 312 patients ,that the percutaneous retro-gasserian glycerol rhizotomy (PRGR) is relatively safe as the major complication found in our series was injection site pain and numbness over face which over period of time improved and there was no life-threatening complications. The 51 (16.3%) cases diagnosed as recurrent post-interventional patients or Failed face syndrome patients were treated with PRGR and showed ablation of the neuralgic pain with single injection without any recurrence so far. PRGR can be done just under local anaesthesia with sedation, as an outpatient procedure and the patient gets back to his/her normal routine within few days hence acts as a day care procedure. In comparison to other procedures in the management of trigeminal neuralgia, PRGR is better in terms of immediate (96.15%) and long term (86%) pain relief and also recurrence of pain (14%) is minimal. The efficacy of PRGR in management of trigeminal neuralgia through our case series was found to be 86% with treatment failure rate of just 3.85%. Hence PRGR is to be considered as preferred treatment of choice in the management of trigeminal neuralgia. Declarations Acknowledgments: The authors wish to thank Mr.Loganathan for the illustrations included in this article Funding : The authors declare that no funds, grants, or other support were received during the preparation of this manuscript Conflict of interest : The authors have no relevant financial or non-financial interests to disclose . Author Contributions : All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr.Kodeeswaran.M, Dr.Chiraag Hiran.S and Dr.Ashwin Retnam. The first draft of the manuscript was written by Dr.Chiraag Hiran.S and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript Ethics approval : Approval from the Institutional Ethics Committee was not required for this study, as it did not involve experimental interventions or procedures beyond standard clinical practice Consent to participate : Informed consent was obtained from all individual participants included in the study References Kodeeswaran M, Gaurav R, Dhoka KP, Priyadharshan SS, Padmanaban V, Sathyabal R, Fathima K, Dhinesh Kumar (2024) Om Saran Kodeeswaran, Vishal Chadva, Bipin Chaurasia, Failed Face Syndrome: Understanding and Addressing the Challenges of Persistent Facial. Pain After Trigeminal Neuralgia Procedures,World Neurosurgery Saini SS (1987) Retrogasserian anhydrous glycerol injection therapy in trigeminal neuralgia: Observations in 552 patients. 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J Neurosurg 59:1007–1012 Kondziolka D, Perez B, Flickinger JC, Habeck M, Lunsford LD (1998) Gamma knife radiosurgery for trigeminal neuralgia: Results and expectations. Arch Neurol 55:1524–1529 Campero A, Ajler P, Campero AA (2014) Microvascular decompression for trigeminal neuralgia, report of 36 cases and literature review. Surg Neurol Int 5(Suppl 11):S441–S445 Yue Y, Zhao ZR, Liu DC, Liu HJ, Lu DL, Zhang H, Jin P (2021) Life-threatening complications after microvascular decompression procedure: Lessons from a consecutive series of 596 patients. J Clin Neurosci 86:64–70 Epub 2021 Jan 29 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:13:42","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89592,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/fb7e2225db95604d79b409ff.html"},{"id":96693636,"identity":"c9f6405c-c206-42e9-b8f5-4674ae96a404","added_by":"auto","created_at":"2025-11-25 07:13:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":913100,"visible":true,"origin":"","legend":"\u003cp\u003eImages of CT skull base with 3D reconstruction of various foramen ovales with significant variation in the size, shape and orientation of the foramen ovale\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/588ae8c538b8d1dec992c81e.png"},{"id":96693638,"identity":"5015e14b-c77a-464a-a6ff-d0e430ceea0e","added_by":"auto","created_at":"2025-11-25 07:13:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":465365,"visible":true,"origin":"","legend":"\u003cp\u003ea - Three landmarks to be marked for the needle guidance ; b - Pathway (Red) of the needle navigating towards and into the foramen ovale\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/002269cb77925509040ab75c.png"},{"id":96710240,"identity":"0aa63277-9273-455d-b7fe-2150b10bd8ea","added_by":"auto","created_at":"2025-11-25 10:10:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1004799,"visible":true,"origin":"","legend":"\u003cp\u003eC-arm images – A , B : Submento-vertical view of foramen ovale showing Foramen ovale (black arrow) between the lateral border of maxillary sinus (Red) and medial border of ramus of mandible (yellow) ; C - lateral projection revealing the pathway of the needle. Starting from below upwards and left to right of the image - red circle showing needle passing between the upper half of 3\u003csup\u003erd\u003c/sup\u003e molar and lower border of maxillary sinus , yellow circle depicting the needle passing into foramen ovale , blue circle showing the needle tip at midclival point; D : Projections of the C-arm\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/780a3f53bcf188da130b1539.png"},{"id":96693643,"identity":"16aa9282-f680-415a-9c42-2fef169a866b","added_by":"auto","created_at":"2025-11-25 07:13:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":111217,"visible":true,"origin":"","legend":"\u003cp\u003eA: Site of pain distribution , B : Rate of Side commonly involved , C : Male : Female ratio , D : Pre-operative and post-operative comparison of improvement in secondary outcome in terms of functional and social disability, anxiety and suicidal ideation.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/e19f18c5395166aa6b89173b.png"},{"id":104781668,"identity":"02644ff2-4569-4ce6-85e5-33440ecd9c4a","added_by":"auto","created_at":"2026-03-17 07:56:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3638677,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8057873/v1/de4c9bb0-c1ed-45c6-a64e-f2ccddf6c154.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Revolutionising Trigeminal Neuralgia Pain Relief using the Modified Kodeeswaran's Retro-gasserian Glycerol Rhizotomy (KRGR) Protocol and Technique in the management of Trigeminal Neuralgia ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTrigeminal neuralgia (TN) is a neuropathic disorder characterised with sharp and sudden paroxysmal lancinating pain resembling electric shock type of facial pain which lasts for few seconds. It is also known as TIC DOULOUREUX. It can be triggered by various cutaneous stimuli like cool breeze over the face, while brushing, talking, chewing and at times while shaving also. There are various pathogenesis behind the causation of trigeminal neuralgic pain and the most commonest being the vascular compression at the nerve root entry zone (Obersteiner Redlich zone) and the most common vessel causing it is the Superior Cerebellar artery. Various others being a posterior fossa tumour or plaques of multiple sclerosis. Still there has been speculations regarding the exact pathogenesis of an idiopathic TN. Although patients with trigeminal neuralgia, initially are managed with medical therapy but in course of time, these patients tend to wear-off from the efficacy of the drug. Such cases in which the side effects of drugs exceed the drawbacks and risks of surgery and they become refractory to medical management, they all require a percutaneous procedure or open surgery. Amongst the percutaneous procedures, the Percutaneous Retro-gasserian Glycerol Rhizotomy has still paved its way through the test of time. Hence this paper analyses a series of 312 patients, diagnosed with Trigeminal Neuralgia and treated with modified Kodeeswaran\u0026rsquo;s Retro-gasserian Glycerol Rhizotomy (KRGR), in terms of primary and secondary outcomes, shorter hospital stay, complications, safety in terms of no life threatening complications, recurrence and cost-effectiveness.\u003c/p\u003e"},{"header":"Study Description","content":"\u003cp\u003eA prospective study was conducted on a series of 312 patients. All of them came with complaints of either RIGHT or LEFT trigeminal neuralgic pain involving either of the three V1,V2,V3 distribution as a single or grouped involvement.\u003c/p\u003e\u003cp\u003eThe Duration of pain ranged from 3 months \u0026minus;\u0026thinsp;20 years. Out of 312 cases \u0026ndash; 261 (83.7%) cases were medically refractory despite being on drugs for atleast 3 months or more and 51 (16.3%) cases had recurrent trigeminal neuralgic pain (post-interventional procedures) known as post-intervention recurrent patients or Falied Face Syndrome patients\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The intensity of pain was classified based on World Trigeminal Neuralgia Foundation (WTNF) Pain Intensity Score pre-operatively. Each case underwent radiological evaluation for any neurovascular conflict and amongst 312 cases \u0026ndash; 230 (73.7%) cases had neurovascular conflict most commonly by the Superior cerebellar artery compressing or abutting the trigeminal nerve and 82 (26.3%) cases had none. All the cases underwent CT skull base with 3D reconstruction to delineate the shape, size and orientation of the foramen ovale for tailoring our entry into the retro-gasserian space (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study patients were explained in detail about the condition, the benefits, and possible adverse effects of the procedure, as well as other treatment options available for their neuralgic pain. A written informed consent was obtained from all those patients involved in the study and were taken up for KRGR procedure.\u003c/p\u003e\u003cp\u003eEthics committee approval statement : Approval from the Institutional Ethics Committee was not required for this study, as it did not involve experimental interventions or procedures beyond standard clinical practice.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from each and every patient.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eProcedure :\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe patient was given supine with head neutral position. In some instances minimal neck extension with lateral rotation away from the side of pain\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNasal oxygenation, vital monitoring and sedation was given.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUnder aseptic precautions, around 5 ml of 1% lignocaine (local anaesthesia) was injected just lateral to the angle of mouth at the side of pain and along the planned needle track.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e3 points were marked (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e1st \u0026ndash; 1.5 cm lateral to the angle of mouth\u003c/p\u003e\u003cp\u003e2nd \u0026ndash; just in front of the tragus (external auditory meatus)\u003c/p\u003e\u003cp\u003e3rd \u0026ndash; just below the inferior orbital rim along the mid-pupillary line\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe C-arm was projected in both sub-mentovertical position and lateral projection (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed), the c-arm was positioned at a 25\u0026ndash;35 degree angle in postero-anterior axis (receiver positioned superiorly and tilted laterally to the side of pain and the emitter positioned inferiorly and tilted laterally away from the side of pain) and 15\u0026ndash;35 degree angle in lateral angulation, and shots were taken until the foramen ovale was visualised. This view positions the foramen ovale between the lateral border of maxillary sinus and medial border of ramus of the mandible. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eNeedle insertion site \u0026minus;\u0026thinsp;1.5 cm lateral to the angle of the mouth of the side of pain.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAn 18G spinal needle was inserted at the above mentioned point and tunneled in the cheek for 2cm directing towards the ipsilateral tragus. Care must be taken to avoid needle entry into oral cavity. Further needle was manipulated superiorly towards the point marked at the inferior orbital rim along the mid-pupillary line and guided effectively downwards towards the skull base under C-arm guidance until foramen ovale breached. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConfirmation of the needle's entrance into the trigeminal cistern within the Meckel's cave was ascertained by the presence of cerebrospinal fluid flow, a sign that may be absent, particularly after repeated percutaneous procedures.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe needle\u0026rsquo;s pathway and tip was verified using C-arm fluoroscopy in lateral projection (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). The needle was found passing in between the lower border of maxillary sinus and the upper part of 3rd molar teeth and through the foramen ovale, ensuring the needle tip remained inferiorly within a range of 0.5 to 1 cm from the point of convergence of line intersecting the floor of sella and clivus corresponding to mid-clival point.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFollowing this, a volume of 0.5\u0026ndash;1.5 ml of anhydrous glycerol was administered, after which the patient was promptly seated with neck flexion for approximately 2 hours to enhance the contact of glycerol with the trigeminal nerve root.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePost procedure, the patients were monitored overnight in the hospital for primary outcomes such as immediate pain relief and immediate complications, and if none found and pain free, discharged the next day. The pain outcome was assessed based on WTNF pain intensity scores and was compared with the pre-operative score.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePost discharge, the patients were followed up on OPD basis on regular intervals to assess the recurrence of pain and the medications were tapered and stopped after a week, if no recurrence.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 312 patients were included in the study and were successfully injected with Glycerol. Majority of the patients were in the 51\u0026ndash;60 age group. Females constituted 56% (n\u0026thinsp;=\u0026thinsp;175) and males constituted 44% (n\u0026thinsp;=\u0026thinsp;137) of the study population (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003ec)\u003c/p\u003e\n\u003cp\u003eMost common site involved was the left constituting about 54% (n\u0026thinsp;=\u0026thinsp;169) and right was about 45% (n\u0026thinsp;=\u0026thinsp;140) and 1% (n\u0026thinsp;=\u0026thinsp;3) of the study population had bilateral involvement. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eb)\u003c/p\u003e\n\u003cp\u003eThe dermatomal pattern of pain in our study was as follows : 31 patients (10%) in V1 region only ; 12 patients (4%) in V2 region only; 17 patients (5.3%) in V3 region only; 75 patients (24%) in V1V2 regions; 137 patients (44%) in V2V3 regions and 40 patients (12.7%) in V1V2V3 regions. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003ea)\u003c/p\u003e\n\u003cp\u003eAlso there was improvemen in secondary outcome in terms of functional and social disability, anxiety and suicidal ideation when compared between the Pre-operative and post-operative period. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003ed)\u003c/p\u003e\n\u003cp\u003eAmongst 312 patients involved in our study, almost 261 (83.7%) patients were on medical management and 51 (16.3%) cases had underwent previous open surgical or minimally invasive procedures which are available for the management of trigeminal neuralgia and such patients were categorised Failed Face Syndorme. \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrevious treatment details of the study population\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage of patients\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMEDICAL MANAGEMENT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 drug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSURGICAL PROCEDURE\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBotox injections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePercutaneous procedures \u0026ndash; RFA, PRGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eOut of 312 patients, 300 patients (96.15%) had complete pain relief immediately post procedure. Seventeen patients (5.45%) had continued occasional pain with reduced intensity on 1\u003csup\u003est\u003c/sup\u003e follow up and hence not requiring medications. On further follow ups ,out of 17 patients, 14 underwent 2\u003csup\u003end\u003c/sup\u003e injection and 3 patients required 3\u003csup\u003erd\u003c/sup\u003e injection. The mean follow-up duration was 6 years. Of the 312 patients, 12 patients (3.85%) who had no immediate pain relief (treatment failure rate) were lost to follow-up and 5 patients died due to an unrelated medical cause, hence a follow up of 295 patients was done. The mean follow-up duration was 6 years. Thus, immediate pain relief was seen in 96.15% (\u003cem\u003en\u003c/em\u003e = 300 of 312 patients), long-term pain relief in 86% (\u003cem\u003en\u003c/em\u003e = 254 of 295 patients). During the follow-up period, the efficacy of the pain relief decreased from 96.15% to 86%. All the complications encountered were mild and not life-threatening.\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTreatment success and failure rate.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTREATMENT SUCCESS RATE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1\u003csup\u003eST\u003c/sup\u003e INJECTION\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2\u003csup\u003eND\u003c/sup\u003e INJECTION\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3\u003csup\u003eRD\u003c/sup\u003e INJECTION\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTREATMENT FAILURE RATE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eWorld Trigeminal Neuralgia Foundation (WTNF) pain intensity score in the pre-operative, immediate post-operative and follow-up period.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedication Use\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-operative\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate post-operative\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up period\u003c/p\u003e\n \u003cp\u003e(Mean-6 years)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccasional mild pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild pain, not requiring daily medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccasional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate pain, controlled with regular medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate\u0026ndash;severe pain despite medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere, disabling pain uncontrolled by medication having suicidal tendency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegular (ineffective)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNumber of cases showing complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCOMPLICATION\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNUMBER\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain, at injection site Immediate upto 3 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 hours \u0026ndash; 48 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost 48 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransient Numbness over face upto 48 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent numbness over face - on 1st follow up (14th day post procedure)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorneal anaesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHerpes reactivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransient Facial palsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransient hoarseness of voice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeizure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMeningitis, life-threatening complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTrigeminal neuralgia (TN) is a neuropathic disorder characterized with sharp and sudden paroxysmal lancinating pain (electric shock pain) which lasts for few seconds. It is also known as TIC DOULOUREUX.\u003c/p\u003e\u003cp\u003eThe main characteristic of the trigeminal neuralgic pain is having multiple episodes, remissions and exacerbations.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The main pathophysiology over years was considered to be due to EHAPTIC TRANSMISSION in trigeminal nerve from the A fibres (partially de-myelinated larger diameter) to the A-Delta (thinly myelinated) and C (nociceptive) fibres. Peter Jannetta explained the concept of vascular compression at the root entry zone of trigeminal nerve either by arterial loops or veins. \u003csup\u003e3,4\u003c/sup\u003e Most common involvement was by the Superior Cerebellar Artery (80%). \u003csup\u003e5\u003c/sup\u003e Although studies by Ramesh and Premkumar suggested that vascular compression at the trigeminal root entry zone is also seen in normal individuals, questioning its causative role in trigeminal neuralgia (TN).\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Alternative theories, including axonal or myelin alterations by Loeser et al\u003csup\u003e7\u003c/sup\u003e and the ignition hypothesis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, attempt to explain TN. However, its unclear etiopathogenesis creates ambiguity in selecting optimal treatment for refractory cases.\u003c/p\u003e\u003cp\u003eThe main goal of the procedures available for the management of trigeminal neuralgia, is always and will be alleviation of pain with an acceptable level of side effects of the procedure.\u003c/p\u003e\u003cp\u003eAmongst the percutaneous procedures available, PRGR is preferred by many neuro-surgeons for primary as well as refractory TN. Anhydrous glycerol used in our study, works by chemically ablating the pathological areas on the axons. While the exact mechanism behind its ability to relieve neuralgic attacks without causing the intense anesthesia typically remains unclear.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAmongst the treatment modalities available for trigeminal neuralgia management, each one have their share of recurrence of pain and complications. In 1994, Walchenbach et al conducted a study which reported recurrence of trigeminal neuralgia after MVD in 58 patients, to be 29% on a 5 year long term follow-up period.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In the year 2000, Lee et al performed MVD in\u003c/p\u003e\u003cp\u003eTN patients and found a recurrence rate of 31% and the etiology behind the recurrence as venous compression. \u003csup\u003e11\u003c/sup\u003e A study done by Kanpolat et al in the year 2001, in which 1,600 patients with idiopathic trigeminal neuralgia after RF-TR were analyzed after a follow-up period of 1 to 25 years and reported a recurrence rate of 17.4%. \u003csup\u003e12\u003c/sup\u003e Karam et al in the year 2014, showed results of gamma-knife radiosurgery to be about 32% free from any pain and 63% free from severe pain and hence a recurrence rate of around 37% on a 5 year follow up period. \u003csup\u003e13\u003c/sup\u003e Kondziolka and Lunsford (2005) reviewed their experience of Percutaneous Retrogasserian Glycerol rhizotomy (PRGR) in 1174 cases and reported a recurrence rate of about 23%. \u003csup\u003e14\u003c/sup\u003e Another study conducted by Kodeeswaran et al (2015), in which PRGR was performed in 93 patients and the recurrence rate was found to be 11% on an average period of 18.8 months follow-up. \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn comparison with other procedures and their study in the published literatures, our study shows that PRGR is better in terms of immediate and long term pain relief and also recurrence of pain is minimal. [Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of various studies of treatment modalities available for management of trigeminal neuralgia with our current study in terms of immediate pian relief, long-term pain relief, recurrence and follow-up period\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTUDY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIMMEDIATE RELIEF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLONG-TERM RELIEF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRECURRENCE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFOLLOW-UP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRFA, Singh et al, 2014 \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.5 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePRGR, Tew and Taha, 1995 \u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRetrospective\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMVD, Campero et al, 2014\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36 months\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBalloon compression, Mullan and Lichtor, 1983 \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.6 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGamma Knife radiosurgery, Kondziolka et al, 1988 \u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs per the technique of the PRGR with our modified KRGR protocol and technique, we are able to attain good results due to few modifications done. One such modification is that the procedure is performed in supine position. We also use 100% anhydrous glycerol and no contrast is being used. Also there is significant variation in the size, shape and orientation of the foramen ovale. Hence we have made it compulsory as a protocol to do CT skull base with 3D reconstruction in order to delineate the shape, size and orientation of the foramen ovale for tailoring our entry into the retro-gasserian space and reduces the incidence of failures. Most importantly, once the glycerol is injected, the patient is immediately made to sit upright with neck flexion for approximately 2 hours after the procedure and this facilitates contact of glycerol in the retro-gasserian space without seepage into the posterior fossa cisterns. Also with the technique elaborated in detail above, we have achieved perfection of needle entry into the foramen ovale by confirming step by step on lateral x ray revealing the needle entry to first enter below the lower border of maxillary sinus and above the upper part of third molar, next at the skull base into the foramen ovale and lastly the needle tip at the mid-clival point. These are the modifications and pearls of our modified KRGR protocol and technique.\u003c/p\u003e\u003cp\u003eThe most common complications of PRGR are minor like development of a local hematoma, reactivation of labial herpetic lesions, transient injection site pain and anesthesia dolorosa (transient numbness over face). Rarest complications include transient facial palsy, transient hoarseness of voice, seizure and severe complications like chemical meningitis and infectious meningitis were nil.\u003c/p\u003e\u003cp\u003ePRGR showed no life-threatening complications, in our study as well as in the available published literature, in comparison to a study done by Yong Yue et al.\u003csup\u003e21\u003c/sup\u003e The study showed 7 cases with life-threatening complications. One was cerebellar infarction with acute hydrocephalus, one was cerebellum and the brain stem infarction with acute hydrocephalus, 2 cases had cerebellar hematoma, one was multiple hemorrhage with acute hydrocephalus, one was supratentorial subdural hematoma, and one was cerebellar swelling with acute hydrocephalus. After therapy, one patient died, one was in a persistent vegetative state, and five were discharged from the hospital upon recovery. In brief, life-threatening complications accompanying MVD are present but rare, hence requires attention.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe would like to conclude through our case series of 312 patients ,that the percutaneous retro-gasserian glycerol rhizotomy (PRGR) is relatively safe as the major complication found in our series was injection site pain and numbness over face which over period of time improved and there was no life-threatening complications. The 51 (16.3%) cases diagnosed as recurrent post-interventional patients or Failed face syndrome patients were treated with PRGR and showed ablation of the neuralgic pain with single injection without any recurrence so far. PRGR can be done just under local anaesthesia with sedation, as an outpatient procedure and the patient gets back to his/her normal routine within few days hence acts as a day care procedure. In comparison to other procedures in the management of trigeminal neuralgia, PRGR is better in terms of immediate (96.15%) and long term (86%) pain relief and also recurrence of pain (14%) is minimal. The efficacy of PRGR in management of trigeminal neuralgia through our case series was found to be 86% with treatment failure rate of just 3.85%. Hence PRGR is to be considered as preferred treatment of choice in the management of trigeminal neuralgia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments: The authors wish to thank Mr.Loganathan for the illustrations included in this article\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding :\u0026nbsp;The authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003c/p\u003e\n\u003cp\u003eConflict of interest :\u0026nbsp;The authors have no relevant financial or non-financial interests to disclose\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAuthor Contributions : All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr.Kodeeswaran.M, Dr.Chiraag Hiran.S and Dr.Ashwin Retnam. The first draft of the manuscript was written by Dr.Chiraag Hiran.S and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003eEthics approval :\u0026nbsp;Approval from the Institutional Ethics Committee was not required for this study, as it did not involve experimental interventions or procedures beyond standard clinical practice\u003c/p\u003e\n\u003cp\u003eConsent to participate : Informed consent was obtained from all individual participants included in the study\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKodeeswaran M, Gaurav R, Dhoka KP, Priyadharshan SS, Padmanaban V, Sathyabal R, Fathima K, Dhinesh Kumar (2024) Om Saran Kodeeswaran, Vishal Chadva, Bipin Chaurasia, Failed Face Syndrome: Understanding and Addressing the Challenges of Persistent Facial. Pain After Trigeminal Neuralgia Procedures,World Neurosurgery\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaini SS (1987) Retrogasserian anhydrous glycerol injection therapy in trigeminal neuralgia: Observations in 552 patients. J Neurol Neurosurg Psychiatry 50:1536\u0026ndash;1538\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCalvin WH, Loeser JD, Howe JF (1977) A neurophysiological theory for the pain mechanism of tic douloureux Pain. 3:147\u0026ndash;154\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJannetta PJ (1967) Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia. J Neurosurg 26(Suppl):159\u0026ndash;162\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHardy DG, Rhoton AL (1978) Microsurgical Relationships of the Superior Cerebellar Artery and the Trigeminal Nerve. J Neurosurg 49:669\u0026ndash;678\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRamesh VG, Premkumar G (2009) An anatomical study of the neurovascular relationships at the trigeminal root entry zone. J Clin Neurosci 16:934\u0026ndash;936\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLoeser JD, Calvin WH, Howe JF (1977) Pathophysiology trigeminal neuralgia Clin Neurosurg 24:527\u0026ndash;537\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDevor M, Amir R, Rappaport ZH (2002) Pathophysiology of trigeminal neuralgia: The ignition hypothesis. Clin J Pain 18:4\u0026ndash;13\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKodeeswaran M1, Ramesh VG1,2;, Saravanan N1 Udesh, Reshmi1. Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: A simple, safe, cost-effective procedure. Neurology India 63(6):p 889\u0026ndash;894, November\u0026ndash;December 2015\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalchenbach R, Voormolen JH, Hermans J Microvascular decompression for trigeminal neuralgia: a criticalreappraisal.ClinNeurolNeurosurg.1994;96(4):290\u0026ndash;295\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee SH, Levy EI, Scarrow AM, Kassam A, Jannetta PJ Recurrent trigeminal neuralgia attributable to veins after microvascular decompression.Neurosurgery.2000;46 (2):356\u0026ndash;361\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanpolat Y, Savas A, Bekar A, Berk C (2001) Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients.Neurosurgery.;48(3):524\u0026thinsp;\u0026ndash;\u0026thinsp;32\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaram SD, Tai A, Wooster M, Rashid A, Chen R, Baig N, Jay A, Harter KW, Randolph-Jackson P, Omogbehin A, Aulisi EF (2014) Jacobson J.Trigeminal neuralgia treatment outcomes following Gamma Knife radiosurgery with a minimum 3-year follow-up. J Radiat Oncol 3:125\u0026ndash;130 Epub 2013 Nov 20\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKondziolka D, Lunsford LD (2005) Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: technique and expectations.Neurosurg Focus. 18(5):E7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKodeeswaran M, Ramesh VG, Saravanan N, Udesh R (2015) Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: A simple, safe, cost-effective procedure. Neurol India 63(6):889\u0026ndash;894\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh S, Verma R, Kumar M, Rastogi V, Bogra J (2014) Experience with conventional radiofrequency thermorhizotomy in patients with failed medical management for trigeminal neuralgia Korean. J Pain 27:260\u0026ndash;265\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTew JM Jr, JMSchmidek T, Sweet HH WH. Percutaneous rhizotomy in the treatment of intractable facial pain (trigeminal, glossopharyngeal, and vagal nerves) Operative Neurosurgical Techniques: Indications, Methods and Results. 19963rd Philadelphia WB Saunders\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMullan S, Lichtor T (1983) Percutaneous microcompression of the trigeminal ganglion for trigeminal neuralgia. J Neurosurg 59:1007\u0026ndash;1012\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKondziolka D, Perez B, Flickinger JC, Habeck M, Lunsford LD (1998) Gamma knife radiosurgery for trigeminal neuralgia: Results and expectations. Arch Neurol 55:1524\u0026ndash;1529\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCampero A, Ajler P, Campero AA (2014) Microvascular decompression for trigeminal neuralgia, report of 36 cases and literature review. Surg Neurol Int 5(Suppl 11):S441\u0026ndash;S445\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYue Y, Zhao ZR, Liu DC, Liu HJ, Lu DL, Zhang H, Jin P (2021) Life-threatening complications after microvascular decompression procedure: Lessons from a consecutive series of 596 patients. J Clin Neurosci 86:64\u0026ndash;70 Epub 2021 Jan 29\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8057873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8057873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective:\u003c/h2\u003e\u003cp\u003eTo evaluate the Modified Kodeeswaran\u0026rsquo;s Retro-gasserian Glycerol Rhizotomy (KRGR) protocol and technique of Glycerol Rhizotomy as a preferred treatment option for trigeminal neuralgia, by assessing its efficacy, impact on functional and social disability, psychiatric improvements, hospital stay, complications, and recurrence of pain. While various procedures exist for managing trigeminal neuralgia, evidence on PRGR is limited, particularly regarding its efficacy, safety, and suitability as a minimally invasive day-care procedure.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA prospective study was conducted on 312 patients with trigeminal neuralgia involving the V1/V2/V3 branches. Pain duration ranged from 3 months to 20 years and assessed using World Trigeminal Neuralgia Foundation (WTNF) pain score. All patients underwent radiological evaluation for neurovascular conflict,anatomy and variations of foramen ovale. After informed consent, the modified KRGR was performed. Post-procedure assessments included pain relief, comparison of pre- and post-procedure scores, complications, and improvements in functional, social, and psychiatric status during the immediate and follow-up post-operative periods were noted.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eMost patients were aged 51\u0026ndash;60 years; 56% were female. Left-sided pain (54%) and V2V3 involvement (44%) were most common. 83.7% were medically refractory and 16.3% had recurrent pain (Failed Face Syndrome). Neurovascular conflict was seen in 73.7%. Immediate pain relief seen in 96.15%, and 86% had long-term relief over a 6-year mean follow-up. 17 patients required repeat injections. Minor complications occurred in 11.24% (facial numbness, injection site pain, transient hoarseness, herpes reactivation, facial palsy, and seizures); none were life-threatening.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003ePRGR is a safe, cost-effective, and minimally invasive outpatient procedure with excellent immediate (96.15%) and long-term (86%) pain relief, low recurrence (14%) and a low treatment failure rate (3.85%). Only 11.24% experienced minor complications, along with improved social, functional and psychiatric outcomes post-operatively. Therefore KRGR should be considered a preferred and first-line therapy for trigeminal neuralgia relief.\u003c/p\u003e","manuscriptTitle":"Revolutionising Trigeminal Neuralgia Pain Relief using the Modified Kodeeswaran's Retro-gasserian Glycerol Rhizotomy (KRGR) Protocol and Technique in the management of Trigeminal Neuralgia ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-25 07:13:36","doi":"10.21203/rs.3.rs-8057873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d61bbed-e1ae-4e83-84b1-22babbeaf41f","owner":[],"postedDate":"November 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T21:38:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-25 07:13:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8057873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8057873","identity":"rs-8057873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}