Facial motor responses evoked by direct electrical stimulation of the trigeminal root. Localizing value for radiofrequency thermorhizotomy.

In Sweet's description of RF-thermocoagulation for trigeminal neuralgia, the trigeminal nerve was stimulated at 50 c/s to evoke paraesthesias, in order to check the electrode location before the thermolesion is made. In 1979, we changed the frequency to 5 c/s, so as to produce in addition twitches in the masticatory muscles (in stead of the less detectable tetanization produced by 50 c/s stimulation). Since then, we started to observe, also, twitches in the muscles innervated by the facial nerve. These twitches were not always in the Orbicularis oculi (which corresponds to the classical blink reflex), but also in the lower facial muscles. Such clinically observable evoked motor responses (EMR)-which had not been reported before--were noticed in 44% of the 459 procedures performed from 1979 to 1988. When EMR were present, the threshold to evoke paraesthesias before thermolesion, and the duration of the thermolesion for obtaining a marked hypoaesthesia covering the entire painful territory, were significantly lower, respectively p < 0.01 and p < 0.001, than when EMR were absent. This indicates that the electrode was closer to the nerve when EMR were present. As a probable consequence, recurrence of pain was significantly lower in the EMR (+) group: 1.4%, than in the EMR (-) group: 5.8% (p < 0.05). The twitches corresponded to the territory of the evoked paraesthesias in 95%, and to the hypoaesthetic area created by the thermolesion in 96%. So, getting EMR in the territory of the pain can be a helpful indicator for an accurate location of the electrode in the trigeminal root, according to its somatotopic organization. These EMR are hypothesized to be due to a trigemino-facial reflex. A preliminary intra-operative EMG study clearly shows that for EMR in the upper part of the face we are dealing with blink-like reflexes, whilst for EMR in the lower face, mechanisms still remain unclear and need further study to be understood.