Percutaneous Approach to the Skull Base: Complication Avoidance and Management

Introduction: Percutaneous approaches to the skull base are routinely performed in the treatment of trigeminal neuralgia. Despite their quasi absence from the scientific literature, immediate postoperative complications of these approaches have been reviewed several times by the senior author in the context of legal actions against the surgeon who performed the procedure. The most common complication involved immediate postoperative blindness.

Materials and Methods: In the laboratory we studied the possible trajectories that can cause injury to the globe or the optic nerve during attempts at penetration of the foramen ovale. We also analyzed a personal case who presented with transient postoperative blindness.

Results: Direct injury to the optic nerve at its entrance into the optic canal can be caused by an excessively steep needle angulation. Reversible visual loss in our patient was due to transient obstruction of the orbital venous outflow during inflation of the rhizotomy balloon.

Conclusions: Repeated fluoroscopic confirmation of the needle trajectory can easily prevent accidental penetration of the optic canal during percutaneous approaches to the gasserian ganglion. In the legal cases reviewed by the senior author, this was the most likely cause of immediate postoperative blindness. This complication should be thoroughly discussed with patients and included in the informed consent.