A new modified method of percutaneous puncture targeting of foramen ovale

Technical note
Abstract:
Purpose: In some cases, percutaneous interventions targeting the semilunar
ganglion via foramen ovale under fluoroscopical guidance may be difficult because
of anatomic variability, and difficulty in identification of the foramen ovale. We
report a new radiologic technique for trigeminal puncture via the foramen ovale,
in which coronoid needle is used for locating the foramen ovale, and a canal
intruducing technique are used for rhizotomy needle insertion .
Technical features: 20 patients with trigeminal neuralgia underwent radiofrequency
trigeminal rhizotomy, whose foramen ovale is not visualized under the fluoroscopy.
First, the coronoid needle using for locating the foramen ovale was advanced to
the mandibular nerve just caudal to the foramen ovale. Second, a radiopaque marker
is placed 2.5cm lateral to the labial commissure. Then, turned the fluoroscopic
device until the marker is projected vertically, over the coronoid needle tip,
Third, taken a canal aimed to the entry point and paralleling the fluoroscopic
beam and pointing toward the coronoid needle tip to serve as an introducer. The
rhizotomy needle be advanced along the safe line determined by the coronoid needle
tip and the lateral labial puncture site and the canal axis.
Conclusion: when the foramen ovale was difficult to identify, The use of this
technique turns foramen ovale's puncture easier, fast and precise, the foramen
ovale was successfully localized and cannulated on the first attempt, Obviates
multiple needle passes, and takes less than 5 min. decreased fluoroscopy time as
experience. This technique is learned easily, allowing practice for residents and
young neurosurgeons.
Key Words: modified technique. Percutaneous puncture. Foramen ovale. Fluoroscopy
Introduction
Contemporary interventional treatment of trigeminal neuralgia (TN) relies on,
alternatively, percutaneous interventions targeting the semilunar ganglion. One of
the most important step of these procedures is the penetration of the foramen
ovale(FO). The anterior approach to the foramen ovale has been used since its
description by Hartel in 1914. The free-hand technique of Hartel in introducing
a needle through the foramen ovale may cause serous complication. Therefore, the
method has been improved by a combination of new technology and modification by
several authors using radiographic and free hand techniques 1, 7. In some cases,
even with an ideal positioning of the patients head and fluoroscopy device, it can
be difficult to clearly visualize the foramen ovale. Hunting for foramen with the
needle can cause the patient annoyance, facial hematoma, and postoperative pain.
Inadvertent puncture of the foramen lacerum, inferior orbital fissure, carotid
artery, and jugular foramen has been reported.2 technical difficulties in finding
the foramen ovale and with the risk of damage to surrounding tissue have
encouraged surgeons to design special percutaneous technique and instruments for
that purpose1, 2,3. Most author describe new method for foramen ovale puncture in
which, e.g., CT fluoroscopy guidance was used4, but this method has some
limitations, including higher exposure to radiation and not easily performed and
the first puncture attempt is free-hand. Michael7developed the Dual Radiation
Targeting System (DRTS) for performing the cannulation of the foramen ovale, but
this instrument is unavailable in most hospital.
My own experience in performing percutaneous procedures for trigeminal
neuralgia made me aware of limitation inherent in all of these approaches.
20 patients whose foramen ovale was difficult to identify in the oblique
submental fluoroscopy, underwent radiofrequency trigeminal rhizotomy
in the DSA room at the affiliated hospital of Guiyang medical college (GuiYang,
China). There were 12 women and 8 men. Whose mean age were 63±11 years (±
standard deviation).
we describe a new method for foramen ovale puncture, in which coronoid needle for
locating the foramen ovale and a canal (5mm in diameter, 5cm in length)
intruducing technique are used for rhizotomy needle insertion. The results of this
method in 20 patients with trigeminal neuralgia and a description of the procedure
are presented.
Technique:
Mandibular nerve puncture: the first needle for locating the foramen ovale
The patient is in supine position with the cervical spine in the neutral
position. The coronoid notch is identified by asking the patient to open and close
the mouth several times and palpating the area just anterior and slightly inferior
to the acoustic auditory meatus. A 20-gauge, 15cm needle assembly with a 2-mm
active tip is inserted just below the zygomatic arch directly in the middle of the
coronoid notch, the needle is advanced in a plane perpendicular to the skull until
the lateral pterygoid plate is encountered, the needle is withdrawn after it comes
in contact with the lateral pterygoid plate and is redirected posterior and
slightly cephaticly, so it will slip pass the superior posterior margin (the upper
aspect) of the lateral pterygoid plate. As soon as the needle impinges on the
mandibular nerve just as it exits the foramen ovale, a paresthesia in the
distribution of mandibular nerve is elicited. Trial sensory stimulation is then
carried out with 0.5V at 50Hz. if the needle is in the proper position, the
patient should experience a paresthesia in the distribution of mandibular nerve.
The position of the needle tip is directly below the exit hole of the foramen
ovale (fig 1)
Cannulation of the foramen ovale
Oblique submental fluoroscopy
The neck is extended slightly; the fluoroscopy is aligned 30 to 45 degrees
caudal to rostral and 15 degrees from the opposite side, the first needle tip is
directly visualized (overlapping the foramen ovale in some cases of which the
foramen ovale is visualized . Fig 1) just medial to the mandible , lateral to the
maxillary sinus, and just above the petrous ridge. If the foramen ovale was
difficult to identify, this needle tip is the target of the foramen ovale (Fig2,
3).
Placed a radiopaque marker on the site at 2.5 cm lateral to the oral commisure
(entry point), whether the foramen ovale is visualized or not, the C-Arm was
rotated until the radiopaque marker is projected vertically over the image of the
first needle tip.
Placed the introducing canal
A canal is placed paralleling the fluoroscopic beam to serve as an introducer,
with one end of the canal aimed to the entry point at 2.5cm lateral to the oral
commisure and pointing toward the coronoid needle tip (the radiopaque marker has
been removed), the other end is up toward the fluoroscopy device and adjusted
until the fluoroscopic beam is directly through the introducing canal, which will
appear as a small ring overlapping the first needle tip( or the foramen ovale if
the foramen ovale is visualized )on the fluoroscopy screen . The path of the canal
is the puncture trajectory. Hold the canal firmly and turn off the X-ray
radiation.
cannulation of the foramen ovale
With the canal navigation, A 20 cm, 20-gauge needle assembly with a 5-mm active
tip is inserted through the introducing canal toward the first needle tip (the
location of foramen ovale)(Fig2, 3) or the FO(if the foramen ovale is visualized).
Entrance of the needle into the foramen ovale is achieved at a depth of about 6 to
8 cm and is signaled by a brief contraction of the masseter muscle as the needle
touches the mandibular nerve. Fluoroscopy is aligned laterally such that the sella
turcica and the clival edge are clearly visualized. The shadows of the left and
right auditory meatus, tuberculum sella, and sphenoid ridge should overlap. The
needle is advanced under intermittent lateral fluoroscopy toward the angle formed
by the shadows of the petrous bone and the clivus, the needle engages the foramen
ovale proximal to the clival line.(fig4)
RF rhizotomy
After removed the first coronoid needle, the rhizotomy electrode was inserted
through the needle cannula, the desired branch of the nerve was located and
rhizotomy after using standard neurophysiological procedure (stimulation for
sensory and motor responses).
Results
Using our method, the foramen ovale was successfully localized and cannulated on
the first attempt in all 20 patients whose foramen ovale was difficult to
identify. In all cases, less than 5 min were required to pass the needle through
the foramen ovale. There were no complications. Obviates multiple needle passes,
and decreased fluoroscopy time as experience.
Discussion
The anterior approach to foramen ovale has been used for over 90 years since its
description by Hartel in 1914. This method is still used today. At the present
time, percutaneous trigeminal nerve lesions can be made by using radiofreqency
heating, chemical injection or balloon compression.4 one of the most important
step of these procedures is the penetration of the foramen ovale. But foramen
ovale may be mistakenly penetrated during the free-hand technique, include the
superior orbital fissure (anterior superior), the jugular foramen (posterior
inferior), foramen vesalii (anterior medial) and innominant canal of Arnold
(posterior), foramen magnum, foramen lacerum.2
Under the fluoroscopic guidance, there were limitations inherent in these
approaches. Even with ideal positioning of the patients head and the radiographic
device, it can be difficult to clearly visualize the foramen ovale. This may be
because of osteoporosis involving a target structure or increased calcification of
the skull or dura5. Technical difference in imaging equipment could also influence
clarity. Missing the foramen ovale and going further poster medially could result
in puncture laceration of the internal carotid artery5.
The foramen ovale is located on the greater wing of the sphenoid bone and
approximately measures 8×4 mm6 and serves as the cranial opening through which the
mandibular nerve exits; it lies approximately in the same horizontal plane as the
zygoma at the level of the mandibular notch, immediately dorsolateral to the
pterygoid process, The mandibular nerve exits the cranium through the foramen
ovale, traveling parallel to the posterior margin of the lateral pterygoid plate.
In the penetrating procedure of the foramen ovale, it is important to seek the
location of the foramen ovale precisely using markers and image intensifier, the
precise location of the foramen ovale cannot be localized using uniplanar
fluoroscopy, also visualization of the foramen in the anteroposterior (submental)
view can be difficult. When several punctures are needed to reach the foramen
ovale, patient can experience postoperative facial pain and hematomas,
occasionally the foramen ovale cannot be found or other structure are encountered,
and failure rate as high as 4%have been reported.3
Use of our technique protects against inadvertent cannulation of other skull
base foramen or injury to cranial nerves or vascular structures.
The mandibular nerve exits the cranium through the foramen ovale, traveling
parallel to the posterior margin of the lateral pterygoid plate, we describe a
new, simple method for locating foramen ovale, in which zygomatic point puncture
is used , the needle tip is walked off the supperior and posterior margin of the
lateral pterygoid plate. As soon as the needle impinge on the mandibular nerve
just as it exits the foramen ovale, the patient should be warned that a
paresthesia will occur and asked to say ''there'', the coronoid needle tip is
close enough proximity to and overlap the foramen ovale in the oblique submental
fluoroscopy.
Guided puncture was performed as previously described. A marker was placed at
2.5cm lateral to the labial commissure, using oblique submental fluoroscopy,
rotated the fluoroscopy device until the image of the coronoid needle tip and the
maker being overlap. The fluoroscopy beam path is the puncture trajectory. We use
a radiopaque canal (a cut short 1ml syringe) to parallel the fluoroscopy beam and
point at the entry point, serve as an introducer, adjusting the up end of the
canal, as soon as the fluoroscopy beam is aimed directly through the canal which
will appear as a small single ring on the fluoroscopy screen, overlapping the
coronoid needle tip. Subsequently, the path of the canal axis line is toward the
foramen ovale. Holding the canal, the entry needle is advanced along the axis into
the foramen ovale.
The present study demonstrate that using this method for transforaminal puncture
significantly reduced the number of puncture attempts, this may not only improve
patient safety by reducing the likelihood of injury to adjacent structures, but
also patient satisfaction by reducing the number of attempts at puncturing the
foramen ovale.
Conclusion: The employment of this guiding method facilitated percutaneous
transforaminal puncture and resulted in a significantly decreased number of
puncture attempts, enhancing patient safety and comfort. Our experience with this
method demonstrated that the target (foramen ovale) could be easily punctured.
This technique is learned easily, allowing practice for residents and young
neurosurgeons.

References
1. Laitinen LL: Trigeminus stereoguide : an instrument for stereotatic approach

through the foramen ovale and foramen jugulare. Surg Neurol 22: 519-523, 1984
2. Berk C, Honey CR : percutaneous biopsy through the foramen ovale : a case
report.
Stereotact Funct Neurosurg 78: 49-52 , 2002
3. Gusmao S, Oliveira M, Tazinaffo U, et al: percutaneous trigeminal nerve
radiofrequency rhizotomy guided by computerized tomography fluoroscopy .J
Neurosurg 99: 785-786 , 2003
4. Jamal Taha . M.D. : Trigeminal Neuralgia : percutaneous procedures . Seminars
in
Neurosurgery, Volume 15, numbers 2/3 2004[Medline]
5.Arthur M. Gerber, M.D. : Improved visulization of the foramen ovale for
percutaneous approaches to the gasserian ganglion . Technical note .J
Neurosurg.80" 156-159, 1994
6. Sung Hyuk Hwang , M.D. ,Myung KiLee. M.D., et al : A Morphometric Analysis
of the Foramen Ovale and the Zygomatic points Determined by a computed
Tomography in patients with Idiopathic Trigeminal Neuralgia . J Korean
Neurosurg Soc 38: 202-205, 2005
7. Michael K. Landi, M.D. , Walter Grand , M.D.: Trigeminal neuralgia :
fluoroscopically-assisted laser targeting of the foramen ovale : Technical
Note.
Congress of Neurological Surgeons 1998 Annual Meeting , October 3-8, 1998,
Seattle , Washington.[Medline]

Fig 1: The coronoid needle tip is close enough proximity to and overlap the
foramen ovale in the oblique submental fluoroscopy.

Fig 2: A 15 cm, 20-gauge needle assembly with a 5-mm active tip is inserted
through the introducing canal toward the first needle tip (the location of foramen
ovale) when the foramen ovale is not visualized.
Fig 3 : A 15 cm, 20-gauge needle assembly with a 5-mm active tip is inserted
through the introducing canal toward the first needle tip (the location of foramen
ovale) under lateral fluoroscopy.

Fig 4: The needle is advanced under intermittent lateral fluoroscopy toward the
angle formed by the shadows of the petrous bone and the clivus,