Visual Disturbance Following Fifth Nerve Ganglion Injection R e p o r t of T w o C a s e s

BINOY CIIAKRAVORTY, M.S. (CAL.), F .R.C.S . (EDIN.), F .R.C.S. (ENG.), PH.D. (BELFAST)*

Department of Neurological Surgery, Royal Victoria Hospital, Queen's University of Belfast, Belfast, Northern Ireland

I n j e c t i o n of t he 5 th ne rve gangl ion b y H a r t e l ' s a p p r o a c h ha s been accep ted by m a n y neuro- surgeons for the relief of t ic doloreux.

A l t h o u g h th is m e t h o d is an effective t r e a t m e n t i t is no t free f rom complicat ions. Exc lud ing the usual n u m b face and an anaes the t i c cornea, mos t compl ica t ions arise f rom the difficulty of p lac ing t he needle p o i n t precisely in the ganglion, or f rom i ts en t e r ing in to the ad j acen t s t ructures .

Harr i s , in a m o n o g r a p h wr i t t en f rom his ex- per ience w i t h over ~000 cases, ~ not iced d a m a g e to n e i g h b o u r i n g s t ruc tu res due to leakage of alcohol in to t he a d j a c e n t c ran ia l nerves. Th i s d a m a g e inc luded:

(1) Fac i a l pa lsy a n d aud i to ry nerve deafness due to b a c k w a r d leakage of alcohol t owards the i n t e rna l a u d i t o r y mea tus . I n some cases t he v e s t i b u l a r po r t i on m a y be involved as well, which m a y cause ver t igo. N y s t a g m u s m a y be observed d u r i n g the procedure .

(~) P e r m a n e n t deafness due to the p o i n t of t he needle en t e r ing in to the eus tach ian tube .

(3) I ) ip lop ia f rom the i nvo lvemen t of the 3rd or 4 th or 6 th nerves in the la teral wall of the cave rnous s inus caused p robab ly b y oedema sp read ing i n to the wall of the sinus.

(4) I n v o l v e m e n t of the motor root of the 5 th ne rve w i t h weakness of the muscles of mas t ica- t ion.

I n ~ of our 60 gangl ion inject ions du r ing t he las t 14 yea r s (Tab le 1), t he pa t i en t s deve loped t e m p o r a r y b l indness a n d ocular palsy. T h e pur - pose of th i s r epor t is to describe and discuss t he p robab le m e c h a n i s m of th is visual d i s tu rbance .

C a s e R e p o r t s

Case 1. The first patient was seen in 1959. She was an elderly woman suffering from multiple sclerosis associ- ated with trigeminal neuralgia. During alcohol injection of the ganglion by Hartel 's approach she complained that she could not see anything. By that time not more than 0.i-0.8 cc. of alcohol had been injected. The needle was at once withdrawn. Blindness was com- plete: the ocular muscles were unaffected, and no other

Received for publication July i3, 1964. * Address: 50/8 Beninandan Street, Calcutta 25,

India.

abnormality was found. She was carefully observed and within ~0 minutes regained full vision.

Case 2. The second example was seen in 1964. The patient, a 84-year-old woman had had most of her teeth extracted. Three weeks later she developed a throbbing pain in the right upper jaw. The pain spread to the lower jaw and was a typical "t ic" pain, brought on by chewing or talking, with the trigger point in the right upper gum.

An alcohol block of tile right maxillary nerve was carried out. She was free from symptoms for about 10 days then the pain returned. A trigeminal ganglion injection was given on tile right side. In this case we used a mixture phenol and myodil as the ganglion blocking agent.

Hartel 's approach was used and 1 cc. of 1 in 9 phenol in myodil was injected after a preliminary test with per cent novocaine. Immediately following the injec- tion she developed a fixed dilated right pupil and diplopia. There was no light reflex in the right pupil and complete Srd, 4th, and 6th nerve palsy. Within to 8 minutes she complained that she could not see anything and both pupils were now dilated although ocular movements were present in the right eye.

Total blindness lasted for about 10 minutes after which she regained her vision. On testing it was found that there was no vision in the right eye and ocular movements on the right side were still present.

Since the patient had been injected with myodil, we were able to study the course of the injection by x-ray. Thus it was seen tha t the needle had passed through the foramen ovale. The medium had been deposited intracranially and had passed forwards and backwards along the base of the skull (Figs. 1 and ~). Anteriorly it

T A B L E 1

Results of 60 eases having ganglion injections

Alcohol Phenol Result Injection Injection

(~8 patients) (3~ patients)

Complete relief No relief Severe paraesthesia Corneal ulcer Facial herpes Diplopia (long lasting) Recurrence Meningitic symptoms

~S 1

l 4 1 6 1

81 1

1 1

1

354

Visual Disturbance Following Trigeminal Injections 355

FIG. ~. Lateral x-ray showing the opaque media flowing forwards and backwards along the base of the skull from the chiasmatic region posteriorly along the anterior surface of the pons.

Fro. 1. Submento-vertical radiograph. The "X" indi- cates iutracranial deposition of phenol and myodil in the neighbourhood of the trigeminal ganglion.

was seen to have flowed to the optic chiasma and posteriorly along the anterior surface of the pons.

Bilateral recovery of vision and eye movements were all complete within ~ hours. The pain was relieved and the patient was discharged.

Discussion

In cadaver injections with methylene blue Harris has shown that dye sometimes stains the cavernous sinus and the anterior surface of the pons. 1 Jefferson (1963) 2 in an elaborate injection study with dye and myodil in cadavers and clin- ical eases reported 3 common patterns of dis- tribution of the agent. He observed that in some eases the injection may follow the posterior root fibres or adhere to them. In others it may enter ganglion substance or 1Vfeckel's cave and from this site escape into the posterior cranial fossa. In some it may escape from Meckel's cave in the subarachnoid space and pass out of the skull into the spinal canal. Jefferson did not observe an- terior migration of the material towards the chiasma.

In the second ease, the submento-vertieal radio- graph (Fig. 1) shows the deposition of the agent but it does not indicate the actual extent of its dispersion. The lateral picture (Fig. ~) convinc- ingly shows the extent of the flow of the medium

along the base of the skull, anteriorly to the chiasma and posteriorly along the clivus to the posterior cranial fossa.

Reports seem to agree regarding the possible escape of the dye into the posterior cranial fossa but observation of forward migration of the dye and involvement of the optic nerve or tract is rare. I t is difficult to define the exact course of the dye, whether it passes in the extra-arachnoid plane (Jefferson, Group II) or subarachnoid plane (Jefferson, Group III) . I n this particular ease, it is assumed that the dye had probably escaped into the subarachnoid space of the inter-peduncu- lar cistern. Being hyperbaric compared to the cerebrospinal fluid, it had travelled backwards along the base of the skull into the pontine cistern and forwards into the cistern of the ehiasma bathing the nerves on the anterior surface of the pons and the optic chiasma respectively. The 8rd, 4th, and 6th cranial nerves on the right side were involved probably because of the right- sided injection.

I t is known that phenol particularly affects the nonmyelinated "c" group of fibres and the chance of a permanent effect on the medullated optic nerve fibres is remote. This may not be guaran- teed with absolute alcohol. This formidable com- plication, although very rare, suggests that phenol may be preferable to absolute alcohol.

Summary

Two cases in which temporary blindness and

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loss of ocular m o v e m e n t followed t r igemina l gangl ion in jec t ion are described. T h e p robab le m e c h a n i s m of this compl ica t ion is briefly dis- cussed.

My sincere thanks are due to Mr. C. A. Gleadhill, M.D., F.R.C.S. (Edin.), Neurological Surgeon, Royal Victoria Hospital, Belfast, for his kind permission to report the first case. Thanks are also extended to

Binoy Chakravorty Dr. J. Chakravorty for her kind cooperation in prepara- tion of this paper.

References

1. HARMS, W. The facial neuralgias. London: Oxford Univ. Press, 1937, x, 109 pp.

2. JEFFEnSOY, A. Trigeminal root and ganglion in- jections using phenol in glycerine for the relief of trigeminal neuralgia. J. Neurol. Neurosurg. Psyehiat., 1963, 26:$45-35~