title: Microendoscopic stereotactic-guided percutaneous radiofrequency trigeminal nucleotractotomy.
abstract: OBJECTIVE
  Over the past few decades, various authors have performed open or stereotactic trigeminal nucleotractotomy for the treatment of neuropathic facial pain resistant to medical treatment. Stereotactic procedures can be performed percutaneously under local anesthesia, allowing intraoperative neurological examination as a method for target refinement. However, blind percutaneous procedures in the region of the atlantooccipital transition carry a considerably high risk of vascular injuries that may bring prohibitive neurological deficit or even death. To avoid such complications, the authors present the first clinical use of microendoscopy to assist percutaneous radiofrequency trigeminal nucleotractotomy. The aim of this article is to demonstrate intradural microendoscopic visualization of the medulla oblongata through an atlantooccipital percutaneous approach.
  
  
  METHODS
  The authors present a case of severe postherpetic facial neuralgia in a patient who underwent the procedure and had satisfactory results. Stereotactic computational image planning for targeting the spinal trigeminal tract and nucleus in the posterolateral medulla was performed, allowing for an accurate percutaneous approach. Immediately before radiofrequency electrode insertion, a fine endoscope was introduced to visualize the structures in the cisterna magna.
  
  
  RESULTS
  Microendoscopic visualization offered clear identification of the pial surface of the medulla oblongata and its blood vessels, the arachnoid membrane, cranial nerve rootlets and their entry zone, and larger vessels such as the vertebral arteries and the branches of the posterior inferior cerebellar artery.
  
  
  CONCLUSIONS
  The initial application of this technique suggests that percutaneous microendoscopy may be useful for particular manipulation of the medulla oblongata, increasing the safety of the procedure and likely improving its effectiveness.
authors: Pain Center and Division of Functional Neurosurgery of Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.
authors: Manoel Jacobsen
authors: MJ
authors: Teixeira
authors: Fabrício Freitas
authors: FF
authors: de Almeida
authors: Ywzhe Sifuentes Almeida
authors: YS
authors: de Oliveira
authors: Erich Talamoni
authors: ET
authors: Fonoff
mesh_terms: D000328:Adult; D017115:Catheter Ablation / Q000379:methods*; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D051474:Neuralgia, Postherpetic / Q000601:surgery*; D044583:Neuroendoscopy / Q000379:methods*; D013238:Stereotaxic Techniques; D014279:Trigeminal Nucleus, Spinal / Q000601:surgery*