Image-guided modified Hartel approach for percutaneous balloon compression in treating trigeminal neuralgia: a comparative cohort study.

BACKGROUND

Percutaneous balloon compression (PBC) effectively treats trigeminal neuralgia (TN), though balloon misplacement beyond the Meckel's cave (MC) may reduce long-term efficacy. To optimize the balloon placement success rate (BPSR) within the MC, we developed an image-guided modified Hartel approach and conducted a comparative study to evaluate its potential to improve BPSR and clinical outcomes.

METHODS

Patients with TN were treated using either the conventional Hartel approach (n = 39) or the image-guided modified Hartel approach (n = 38). Patients' demographic data, procedural characteristics, clinical outcomes, and complications were collected. Kaplan-Meier analysis was used to evaluate pain-free survival. The correlation between balloon shape and its position relative to the two dural layers of the MC was illustrated. The clinical outcomes were compared between patients with typical pear-shaped and pear-like balloons.

RESULTS

The modified approach was associated with higher first-attempt BPSR [34/38 (89.5 %) vs. 19/39 (48.7 %); adjusted OR, 11.7; 95 % CI, 3.1-43.7; P < 0.001] and final BPSR [36/38 (94.7 %) vs. 26/39 (66.7 %); adjusted OR, 8.8; 95 % CI, 1.8-44.2; P = 0.008]. It was also associated with shorter operative time [29.0 (20.5, 44.5) vs. 44.0 (37.0, 60.0) minutes; P = 0.008] and fluoroscopy time [34.5 (33.0, 36.0) vs. 50.0 (32.0, 95.0) seconds; P = 0.005]. Although Kaplan-Meier analysis suggested more favorable pain-free survival in the modified group, the proportions of patients achieving BNI-P grades I-II at 6, 12, and 24 months were only numerically higher, and the adjusted between-group differences at these fixed follow-up time points did not reach statistical significance. Typical pear-shaped balloons were associated with better pain outcomes than pear-like balloons (P < 0.0001), whereas pear-like balloons may indicate suboptimal positioning between the two dural layers of the MC.

CONCLUSION

The image-guided modified Hartel approach may improve the technical reliability of balloon placement during PBC. Although the modified approach was associated with improved procedural parameters, the present findings do not establish superior long-term pain control. Further studies are required to clarify whether the technical advantages translate into clinically meaningful long-term benefits.