How Percutaneous Balloon Compression Is Performed Today: Technical Adaptations for Trigeminal Neuralgia in the...

Percutaneous balloon compression is an established treatment of medically refractory trigeminal neuralgia and remains a commonly performed percutaneous procedure for patients requiring immediate pain relief. Historically, the procedure was standardized through dedicated commercial instrument kits designed for trigeminal balloon rhizotomy, facilitating technical reproducibility across centers. However, the withdrawal of the Food and Drug Administration-approved Mullan percutaneous trigeminal ganglion microcompression set from the medical supplies market in 2016 created a supply gap that required surgeons to adapt their procedural workflows to alternative instrumentation. In the absence of dedicated commercial kits, multiple technical adaptations have emerged, resulting in heterogeneity in technical execution across centers. Contemporary practice has shifted toward modular configurations assembled from widely available instruments, often combined with adjunctive imaging technologies. These adaptations aim to preserve procedural reproducibility while maintaining accessibility across different practice settings. However, considerable variability persists, with approaches ranging from proprietary bundled systems to modular and technology-assisted workflows. Despite this variability, most contemporary series describe a broadly consistent technical approach consisting of a 3 to 5 Fr Fogarty balloon catheter introduced through a 13 to 16 gauge percutaneous needle using the classical Hartel approach under fluoroscopic guidance. Within this framework, recent refinements in foramen ovale localization, including the "H-figure" fluoroscopic landmark, may further improve procedural efficiency and reduce radiation exposure. Balloon inflation is typically performed using volume-based techniques with fluoroscopic confirmation of the characteristic pear-shaped balloon configuration within Meckel's cave, whereas quantitative pressure monitoring is infrequently reported and limited to isolated cases. This narrative review aimed to characterize current percutaneous balloon compression practice in the postcommercial kit era and to determine whether a reproducible procedural framework has emerged despite the absence of dedicated, standardized kits.