Calculating a guaranteed zone of foramen ovale cannulation: a technical note with implications for trigeminal neuralgia

Chad A Kuhns, Matthew J Zdilla


Cannulation of the foramen ovale is often performed for treatment of trigeminal neuralgia. Despite advances in resolution and visualization, fluoroscopy and computed tomography paired with navigation technology have proven unsuccessful in cannulating the foramen. Therefore, approaches to foramen ovale cannulation warrant improvement. This study applies a geometric model to analyze the region of a foramen occupied by a cylindrical surgical tool (e.g., a cannula, stylet, catheter, or needle) inserted at an angle (ϕ) to the plane of the foramen. As the tool passes through the plane of the foramen, its cross-section is an ellipse with a major axis depending on ϕ. Accordingly, the area of the region depends on ϕ, as well as on the radius of the surgical tool. Knowing the area of the region provides a means of comparing a candidate surgical instrument to the foramen it will cannulate when the area of the foramen is known (e.g., as determined from imaging). After accounting for irregularities in the boundary of the foramen, the angle of approach ϕ, and relative orientations of the foramen and the elliptical region occupied by the tool, the geometric model proceeds to describe two new regions: one which guarantees successful cannulation and one which guarantees the tool will not cannulate. The technique predicts when cannulation of a foramen will likely be impossible. Therefore, this method may prevent adverse surgical events and improve the surgical approach and outcomes in the treatment of trigeminal neuralgia.


cranial base; neuronavigation; neurosurgery; stereotaxic techniques; trigeminal neuralgia

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Abdennebi, B. and L.Guenane. 2014. Technical considerations and outcome assessment in retrogasserian balloon compression for treatment of trigeminal neuralgia. Series of 901 patients. Surg. Neurol. Int. 5:118.

Alvernia, J.E., M.P. Sindou, N.D. Dang, J.H. Maley, and P. Mertens. 2010. Percutaneous approach to the foramen ovale: An anatomical study of the extracranial trajectory with the incorrect trajectories to be avoided. Acta. Neurochir. 152:1043–1053.

Arishima, H., and M. Sindou. 2010. Benefits and pitfalls of percutaneous biopsy for cavernous sinus tumors through the foramen ovale: two case reports. Minim. Invasive Neurosurg. 53:194-197.

Bale, R.J., I. Laimer, A. Martin, A. Schlager, C. Mayr, M. Rieger, B.V. Czermak, P. Kovacs, and G. Widmann. 2006. Frameless stereotactic cannulation of the foramen ovale for ablative treatment of trigeminal neuralgia. Neurosurgery. 59:ONS394-401.

Berlis, A., R. Putz, and M. Schumacher. 1992. Direct and CT measurements of canals and foramina of the skull base. Br. J. Radiol. 65:653-661.

Bohnstedt, B.N., R.S. Tubbs, and A.A. Cohen-Gadol. 2012. The use of intraoperative navigation for percutaneous procedures at the skull base including a difficult-to-access foramen ovale. Neurosurgery. 70:177-180.

Cheng, J.S., D.A. Lim, E.F. Chang, and N.M Barbaro. 2014. A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery. 1:25-33.

Daimi, S.R., A.U. Siddiqui, and S.S. Gill. 2011. Analysis of foramen ovale with special emphasis on pterygoalar bar and pterygoalar foramen. Folia Morphol. 70:149-153.

Dutta, A.K. 2005. Essentials of Human Anatomy, Head and Neck. 4th ed. Current Books International. Kolkata.

Esposito, S., and A. Delitala. 1991. Transoval administration of opiates into trigeminal cistern for cancer pain. Preliminary report. Neurochirurgia. 34:116-118.

Fransen, P. 2013. Fluoroscopic exposure during percutaneous balloon compression of the Gasserian ganglion. J. Neurointerv. Surg. 5:494-495.

Furman, M.B., T.S. Lee, A. Mehta, J.I. Simon, and W.G. Cano. 2008. Contrast flow selectivity during transforaminal lumbosacral epidural steroid injections. Pain Physician. 11:855-861.

Georgiopoulos, M., J. Ellul, E. Chroni, and C. Constantoyannis. 2014. Minimizing technical failure of percutaneous balloon compression for trigeminal neuralgia using neuronavigation. I.S.R.N. Neurol. 2014:630418.

Gitkind, A.I., T.R. Olson, and S.A. Downie. 2014. Vertebral artery anatomical variations as they relate to cervical transforaminal epidural steroid injections. Pain Med. 15:1109-1114.

Göçer, A.I., E. Cetinalp, M. Tuna, Y. Gezercan, and F. Ildan. 1997. Fatal complication of the percutaneous radiofrequency trigeminal rhizotomy. Acta. Neurochir. 139:373–374.

Ghom, A.G. 2014. Basic oral radiology. Jaypee Brothers Medical Publishers. New Dheli. p. 139.

Gökalp, H., Y. Kanpolat, and B. Tumer. 1980. Carotid-cavernous fistula following percutaneous trigeminal ganglion approach. Clin. Neurol. Neurosurg. 82:269–272.

Gupta, N., and A.L. Rai. 2013. Foramen ovale – morphometry and its surgical importance. I.J.M.H.S. 3:4-6.

Harrigan, M.R., and W.F. Chandler. 1998. Abducens nerve palsy after radiofrequency rhizolysis for trigeminal neuralgia: Case report. Neurosurgery. 43:623–625.

Hilbert, D., and S. Cohn-Vossen. 1999. Geometry and the Imagination. Chelsea Publishing. New York. pp. 7-11.

Huntoon, M.A. 2005. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 117:104-111.

Huo, X., X. Sun, J. Luo, N. Guan, W. Guo, and Z. Zhang. 2013. Percutaneous microballoon compression for trigeminal neuralgia using Dyna-CT. Interv. Neuroradiol. 19:359-364.

Huo, X., X. Sun, Z. Zhang, W. Guo, N. Guan, and J. Luo. 2014. Dyna-CT-assisted percutaneous microballoon compression for trigeminal neuralgia. J. Neurointerv. Surg. 6:521-526.

James, E.A., C.C. Kibbler, and S.H. Gillespie. 1995. Meningitis due to oral streptococci following percutaneous glycerol rhizotomy of the trigeminal ganglion. J. Infect. 31:55–57.

Janknegt, R.A., M.M. Hassouna, S.W. Siegel, R.A. Schmidt, J.B. Gajewski, D.A. Rivas, M.M. Elhilali, D.C. Milam, P.E. van Kerrebroeck, H.E. Dijkema, A.A. Lycklama à Nÿeholt, M. Fall, U. Jonas, F. Catanzaro, C.J. Fowler, and K.A. Oleson. 2001. Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence. Eur. Urol. 39:101-106.

Kanpolat, Y., A. Savas, A. Bekar, and C. Berk. 2001. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery. 48:524-532.

Khairnar, K.B., and P.A. Bhusari. 2013. An anatomical study on the foramen ovale and the foramen spinosum. J. Clin. Diagn. Res. 7:427-429.

Kim, S.H., W.J. Choi, J.H. Suh, S.R. Jeon, C.J. Hwang, W.U. Koh, C. Lee, J.G. Leem, S.C. Lee, and J.W. Shin. 2013. Effects of transforaminal balloon treatment in patients with lumbar foraminal stenosis: a randomized, controlled, double-blind trial. Pain Physician. 16:213-224.

Lazorthes, Y., and J.C. Verdie. 1979. Radiofrequency coagulation of the petrous ganglion in glossopharyngeal neuralgia. Neurosurgery. 4:512-516.

Lin, M.H., M.H. Lee, T.C. Wang, Y.K. Cheng, C.H. Su, C.M. Chang, and J.T. Yang. 2011. Foramen ovale cannulation guided by intra-operative computed tomography with integrated neuronavigation for the treatment of trigeminal neuralgia. Acta. Neurochir. 153:1593-1599.

Linderoth, B., and G. Lind. 2012. Retrogasserian rhizolysis in trigeminal neuralgia in Quinones-Hinojosa A., (ed.), Schmidek and Sweet: Operative Neurosurgical Techniques, Indications, Methods, and Results. Elsevier Health Sciences. Philadelphia.

Mandat, T., B. Brozyna, G. Krzymanski, and J.K. Podgorski. 2009. An image-guided, noninvasive method of cannulation of the foramen ovale for awake, percutaneous radiofrequency rhizotomy. J. Neurosurg. 111:1223-1225.

Messerer, M., J. Dubourg, G. Saint-Pierre, E. Jouanneau, and M. Sindou. 2012. Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients. J. Neurosurg. 116:390-398.

Missios, S., A.M. Mohammadi, and G.H. Barnett. 2014. Percutaneous treatments for trigeminal neuralgia. Neurosurg. Clin. N. Am. 25:751-762.

Natarajan, M. 2000. Percutaneous trigeminal balloon compression experience in 40 patients. Neurol. India. 99:785-786.

Nordenstam, J., A.M. Boller, and A. Mellgren. 2015. Sacral Nerve Stimulation in the Treatment of Bowel Disorders. Prog. Neurol. Surg. 29:200-212.

Ong, K.S., and S.B. Keng. 2003. Evaluation of surgical procedures for trigeminal neuralgia. Anesth. Prog. 50:181-188.

Pang, J., S. Hou, M. Liu, H. Feng, L. Zu, Y. Guo, Y. Ma, J. Qin, X. Wang, Y. Feng Jr, and K. Cheng. 2012. Puncture of foramen ovale cranium in computed tomography three-dimensional reconstruction. J. Craniofac. Surg. 23:1457-1459.

Park, S.S., M.K. Lee, J.W. Kim, J.Y. Jung, I.S. Kim, C.G. Ghang. 2008. Percutaneous balloon compression of trigeminal ganglion for the treatment of idiopathic trigeminal neuralgia: experience in 50 patients. J. Korean Neurosurg. Soc. 43:186-189.

Patil, G.V., Shishirkumar, D. Apoorva, Thejeswari, J. Sharif, C. Sheshgiri, and N.K. Sushanth. 2014. Morphometry of the foramen ovale of sphenoid bone in human dry skulls in Kerala. I.J.H.S.R. 4:90-93.

Peris-Celda, M., F. Graziano, V. Russo, R.A. Mericle, and A.J. Ulm. 2013. Foramen ovale puncture, lesioning accuracy, and avoiding complications: microsurgical anatomy study with clinical implications. J. Neurosurg. 119:1176-1193.

Ratto, C., U. Morelli, S. Paparo, A. Parello, and G.B. Doglietto. 2003. Minimally invasive sacral neuromodulation implant technique: modifications to the conventional procedure. Dis. Colon Rectum. 46:414-417.

Reymond, J., A. Charuta, and J. Wysocki. 2005. The morphology and morphometry of the foramina of the greater wing of the human sphenoid bone. Folia Morphol. 64:188-193.

Ray, B., N. Gupta, and S. Ghose. 2005. Anatomic variations of foramen ovale. Kathmandu Univ. Med. J. 3:64-68.

Sekimoto, K., S. Koizuka, S. Saito, and F. Goto. 2005. Thermogangliolysis of the Gasserian ganglion under computed tomography fluoroscopy. J. Anesth. 19:177-179.

Sindou, M., J.M. Chavez, G. Saint Pierre, and A. Jouvet. 1997. Percutaneous biopsy of cavernous sinus tumors through the foramen ovale. Neurosurgery. 40:106-110.

Sindou, M., Y. Keravel, B. Abdennebi, and J. Szapiro. 1987. [Neurosurgical treatment of trigeminal neuralgia. Direct approach of percutaneous method?]. Neurochirurgie. 33:89-111.

Somesh, M.S., H.B. Sridevi, L.V. Prabhu, M.S. Swamy, A. Krishnamurthy, B.V. Murlimanju, and G.K. Chettiar. 2011. A morphometric study of foramen ovale. Turk. Neurosurg. 21:378-383.

Standring, S. (ed.). 2008. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. Churchill-Livingstone/Elsevier. New York. p. 529.

Trojnik, T., and T. Ŝmigoc. 2012. Percutaneous trigeminal ganglion balloon compression rhizotomy: experience in 27 patients. ScientificWorldJournal. 2012:328936.

Tubbs, R.S., W.R. May Jr., N. Apaydin, M.M. Shoja, G. Shokouhi, M. Loukas, and A.A. Cohen-Gadol. 2009. Ossification of ligaments near the foramen ovale: an anatomic study with potential clinical significance regarding transcutaneous approaches to the skull base. Neurosurgery. 65(6 Suppl):60-64.

Tubbs, R.S., E. Rizk, M.M. Shoja, M. Loukas, N. Barbaro, and R.J. Spinner (eds.). 2015. Nerves and Nerve Injuries: Vol 2: Pain, Treatement, Injury, Disease and Future Directions. Academic Press. London.

Ugur, H.C., A. Savas, A. Elhan, and Y. Kanpolat. 2004. Unanticipated complication of percutaneous radiofrequency trigeminal rhizotomy: Rhinorrhea: Report of three cases and a cadaver study. Neurosurgery. 54:1522–1524.

Urdaneta-Moncada, A., L. Feng, and J. Chen. 2013. Occlusion of a clival dural arteriovenous fistula using a novel approach through the foramen ovale. J. Neurointerv. Surg. 5:e46.

Van Buyten, J.P., I. Smet, and E. Van de Kelft. 2009. Electromagnetic navigation technology for more precise electrode placement in the foramen ovale: a technical report. Neuromodulation. 12:244-249.

Wadhwa, A., M. Sharma, and P. Kaur. 2012. Anatomic variations of foramen ovale – clinical implications. Int. J. Basic and Applied Med. Sci. 2:21-24.

Wieser, H.G., and A.M. Siegel. 1991. Analysis of foramen ovale electrode-recorded seizures and correlation with outcome following amygdalohippocampectomy. Epilepsia. 32:838-850.

Xiaochuan, H., S. Xiaoyun, L. Junsheng, G. Ning, G. Wenshi, and Z. Zhenxing. 2013. Percutaneous microballoon compression for trigeminal neuralgia using Dyna-CT. Interv. Neuroradiol. 19:359-364.

Yao, J.H., D. Yao, L. Chen, M. Liu, Y.Q. Zhang, and Y.Q. Li. 2013. Anatomical study of the relatively safe needling angle of minimally invasive treatment for trigeminal neuralgia. J. Craniofac. Surg. 24:e429-432.

Zdilla, M.J., and K.M. Fijalkowski. 2017. The Shape of the Foramen Ovale: A Visualization Aid for Cannulation Procedures. J Craniofac Surg. 28:548-551.

Zdilla, M.J., S.A. Hatfield, K.A. McLean, L.M. Cyrus, J.M. Laslo, and H.W. Lambert. 2016a. Circularity, Solidity, Axes of a Best Fit Ellipse, Aspect Ratio, and Roundness of the Foramen Ovale: A Morphometric Analysis with Neurosurgical Considerations. J. Craniofac. Surg. 27:222-228.

Zdilla, M.J., S.A. Hatfield, K.A. McLean, J.M. Laslo, L.M. Cyrus, and H.W. Lambert. 2016b. Orientation of the Foramen Ovale: An Anatomic Study with Neurosurgical Considerations. J Craniofac Surg. 27:234-237.

Zdilla, M.J., S.A. Hatfield, and K.R. Mangus. 2016c. Angular Relationship between the Foramen Ovale and the Trigeminal Impression: Percutaneous Cannulation Trajectories for Trigeminal Neuralgia. J. Craniofac. Surg. 27:2177-2180.

Zhu, H.Y., J.M. Zhao, M. Yang, C.L. Xia, Y.Q. Li, H. Sun, Y.Q. Zhang, and Y. Tian. 2014. Relative location of foramen ovale, foramen lacerum, and foramen spinosum in Hartel pathway. J. Craniofac. Surg. 25:1038-1040.

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