Neuralgies of the lower cranial nerves: Microsurgical posterior fossa exploration

Neuralgias of the lower cranial nerves are trigeminal neuralgia (TN), glossopharingeal neuralgia (GphN), and geniculate neuralgia (GN). Microsurgical posterior fossa exploration with its variations microvascular decompression (MVD), partial sensory rhisotomy (PSR), and total sensory rhisotomy (TSR) is one of the most efficient ways of treating these neuralgias. It was performed 130 operations in 125 patients with TN, 3 in GphN patients, 1 in GN patient, 1 in GN/TN patients, 1 in GphN/GN patient, and 2 in GN/hemifacial spasm patients. Of total of 125 patients with TN, MVD was performed in 63, PSR in 18, and MVD+PSR in 44 cases. In 5 patients with recidivate TN PSR was performed. Of total 3 patients with GphN MVD was performed in 2 cases, and extirpation of a small meningeoma in 1 case (it was not seen on CT). In the patients with GN TSR of intermediate nerve was performed, in GN/TN patients TSR of intermediate nerve and PSR of trigeminal nerve was performed, in the GN/GphN patients MVD of glossopharingeal and TSR of intermediate nerve were performed, and in the GN/hemifacial spasm patients TSR of intermediate and MVD of facial nerve were performed. The results of TN patients are: excellent in 82,4%, good in 12%, and poor in 5,6% of patients. There is no difference in complete pain relief, rate of recurrence, and complications between MVD, MVD+PSR and PSR operative groups (p>0,05). Among patients with other neuralgias the following results are noted: excellent in 4, good in 3, and poor in 1 patient. Microsurgical posterior fossa exploration is the method of choice in the treatment of the neuralgias of the lower cranial nerves.

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Endoscopic-Assisted Microvascular Decompression

Effective Techniques for Managing Trigeminal Neuralgia - Advances in Medical Diagnosis, Treatment, and Care ◽

10.4018/978-1-5225-5349-6.ch007 ◽

2018 ◽

pp. 139-154

Author(s):

M. Yashar S. Kalani ◽

Michael R. Levitt ◽

Celene B. Mulholland ◽

Charles Teo ◽

Peter Nakaji

Keyword(s):

Trigeminal Neuralgia ◽

Minimally Invasive ◽

Effective Treatment ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Patient Population ◽

Surgical Intervention ◽

Cranial Nerves ◽

Vascular Compression ◽

Ephaptic Transmission

Diseases of ephaptic transmission are commonly caused by vascular compression of cranial nerves. The advent of microvascular decompression has allowed for surgical intervention for this patient population. This chapter highlights the technique of endoscopic-assisted microvascular decompression for trigeminal neuralgia and hemifacial spasm. Endoscopy and keyhole techniques have resulted in a minimally invasive and effective treatment of symptoms for patients with neuralgia.

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Efficacy of primary microvascular decompression versus subsequent microvascular decompression for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/2016.5.jns151692 ◽

2017 ◽

Vol 126 (5) ◽

pp. 1691-1697 ◽

Cited By ~ 7

Author(s):

Debebe Theodros ◽

C. Rory Goodwin ◽

Matthew T. Bender ◽

Xin Zhou ◽

Tomas Garzon-Muvdi ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Pain Control ◽

Surgical Intervention ◽

Patient Records ◽

Duration Of Symptoms ◽

Facial Numbness ◽

Lancinating Pain

OBJECTIVETrigeminal neuralgia (TN) is characterized by intermittent, paroxysmal, and lancinating pain along the distribution of the trigeminal nerve. Microvascular decompression (MVD) directly addresses compression of the trigeminal nerve. The purpose of this study was to determine whether patients undergoing MVD as their first surgical intervention experience greater pain control than patients who undergo subsequent MVD.METHODSA retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis.RESULTSIn patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041). Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572).CONCLUSIONSThe results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention.

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Aseptic meningitis caused by Teflon implantation for microvascular decompression

Journal of Neurosurgery ◽

10.3171/jns.1999.90.1.0145 ◽

1999 ◽

Vol 90 (1) ◽

pp. 145-147 ◽

Cited By ~ 12

Author(s):

Miroslav P. Bobek ◽

Oren Sagher

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Aseptic Meningitis ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Surgical Removal ◽

Content Type ◽

Initial Surgery ◽

Fine Print

✓ The authors present the case of a 47-year-old man who, after undergoing microvascular decompression for trigeminal neuralgia, experienced symptomatic pain relief but developed prolonged aseptic meningitis. This case is unusual in that the patient remained dependent on steroid medications for nearly 5 months following the initial surgery and the aseptic meningitis did not resolve until after surgical removal of the Teflon used to pad the trigeminal nerve. The pathophysiological characteristics of the body's reaction to implanted Teflon are discussed along with the rationale for removing this substance in cases of prolonged intractable aseptic meningitis.

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Open Microvascular Decompression

Effective Techniques for Managing Trigeminal Neuralgia - Advances in Medical Diagnosis, Treatment, and Care ◽

10.4018/978-1-5225-5349-6.ch004 ◽

2018 ◽

pp. 70-103

Author(s):

James Pan ◽

Lily H. Kim ◽

Allen Ho ◽

Eric S. Sussman ◽

Arjun V. Pendharkar ◽

...

Keyword(s):

Natural History ◽

Trigeminal Neuralgia ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Cranial Nerves ◽

Neurosurgical Procedure ◽

Adjuvant Therapies ◽

Alternative Techniques ◽

Nervus Intermedius Neuralgia ◽

Nervus Intermedius

Microvascular decompression (MVD) is a neurosurgical procedure used to treat various neuralgias of the cranial nerves. The clinical presentation, natural history, pathophysiology, and medical management of trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and nervus intermedius neuralgia is reviewed. A thorough discussion on the retrosigmoid approach for decompression of cranial nerves is presented, along with newer techniques and controversies on adjuvant therapies and neuromonitoring. The surgical outcomes of MVD are discussed, along with alternative techniques to open MVD.

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Use of the Arachnoid Membrane of the Cerebellopontine Angle to Transpose the Superior Cerebellar Artery in Microvascular Decompression for Trigeminal Neuralgia: Technical Note

Operative Neurosurgery ◽

10.1227/01.neu.0000367556.35258.fa ◽

2010 ◽

Vol 66 (suppl_1) ◽

pp. ons-88-ons-91 ◽

Cited By ~ 2

Author(s):

Miran Skrap ◽

Francesco Tuniz

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Cerebellopontine Angle ◽

Technical Note ◽

Superior Cerebellar Artery ◽

Arachnoid Membrane ◽

Recurrent Pain ◽

Cerebellar Artery

Abstract Background: Microvascular decompression is an accepted, safe, and useful surgical technique for the treatment of trigeminal neuralgia. Autologous muscle or implant materials such as shredded Teflon are used to separate the vessel from the nerve but may occasionally be inadequate, become displaced or create adhesions and recurrent pain. Objective: The authors evaluated the use of arachnoid membrane of the cerebellopontine angle to maintain the transposition of vessels from the trigeminal nerve. Methods: The authors conducted a retrospective review of microvascular decompression operations in which the offending vessel was transposed and then retained by the arachnoid membrane of the cerebellopontine cistern, specifically by the lateral pontomesenchepalic membrane. Results: This technique was used in 30 patients of the most recently operated series. Postoperatively, complete pain relief was achieved in 90% of the patients without any observed surgical complications. Conclusion: To the authors’ knowledge this is the first report in which the arachnoid membrane is used in the microvascular decompression of the trigeminal nerve. While this technique can be used only for selected cases, the majority of the vascular compressions on the trigeminal nerve are due to the SCA, so this sling transposition technique can be useful and effective.

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Microvascular transposition using Teflon sling technique

Neurosurgical Focus: Video ◽

10.3171/2020.6.focvid2040 ◽

2020 ◽

Vol 3 (2) ◽

pp. V2

Author(s):

Mitchell W. Couldwell ◽

Vance Mortimer, AS ◽

William T. Couldwell

Keyword(s):

Trigeminal Neuralgia ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Cranial Nerve ◽

Cranial Nerves ◽

Vascular Compression ◽

Link Type ◽

Pain Syndromes ◽

Established Technique

Microvascular decompression is a well-established technique used to relieve abnormal vascular compression of cranial nerves and associated pain. Here the authors describe three cases in which a sling technique was used in the treatment of cranial nerve pain syndromes: trigeminal neuralgia with predominant V2 distribution, hemifacial spasm, and geniculate neuralgia and right-sided ear pain. In each case, the artery was mobilized from the nerve and tethered with a sling. All three patients had reduction of symptoms within 6 weeks.The video can be found here: https://youtu.be/iM7gukvPz6E

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Microvascular decompression of cranial nerves: lessons learned after 4400 operations

Neurosurgical FOCUS ◽

10.3171/foc.1998.5.5.1 ◽

1998 ◽

Vol 5 (5) ◽

pp. E1 ◽

Cited By ~ 2

Author(s):

Mark R. McLaughlin ◽

Peter J. Jannetta ◽

Brent L. Clyde ◽

Brian R. Subach ◽

Christopher H. Comey ◽

...

Keyword(s):

Hearing Loss ◽

Trigeminal Neuralgia ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Cranial Nerve ◽

Cranial Nerves ◽

Lessons Learned ◽

Glossopharyngeal Neuralgia ◽

Complication Rates ◽

Csf Leakage

Object Microvascular decompression has become an accepted surgical technique for the treatment of trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and other cranial nerve rhizopathies. The senior author (P.J.J.) began performing this procedure in 1969 and has performed more than 4400 operations. The purpose of this article is to review some of the nuances of the technical aspects of this procedure. Methods A review of 4415 operations shows that numerous modifications to the technique of microvascular decompression have occurred during the last 29 years. Of the 2420 operations performed for trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia before 1990, cerebellar injury occurred in 21 cases (0.87%), hearing loss in 48 (1.98%), and cerebrospinal fluid (CSF) leakage in 59 cases (2.44%). Of the 1995 operations performed since 1990, cerebellar injuries declined to nine cases (0.45%), hearing loss to 16 (0.8%), and CSF leakage to 37 (1.85%) (p < 0.01, test for equality of distributions). The authors describe slight variations made to maximize surgical exposure and minimize potential complications in each of the six principal steps of this operation. These modifications have led to decreasing complication rates in recent years. Conclusions Using the techniques described in this report, microvascular decompression is an extremely safe and effective treatment for many cranial nerve rhizopathies.

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Demonstration of neurovascular compression in trigeminal neuralgia with magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/jns.1995.83.5.0799 ◽

1995 ◽

Vol 83 (5) ◽

pp. 799-805 ◽

Cited By ~ 120

Author(s):

James F. M. Meaney ◽

Paul R. Eldridge ◽

Lawrence T. Dunn ◽

Thomas E. Nixon ◽

Graham H. Whitehouse ◽

...

Keyword(s):

Magnetic Resonance ◽

Trigeminal Neuralgia ◽

Posterior Fossa ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Vascular Compression ◽

Neurovascular Compression ◽

Posterior Fossa Surgery ◽

Content Type ◽

Fine Print

✓ Until recently, the inability to demonstrate neurovascular compression of the trigeminal nerve preoperatively resulted in surgery being offered only in cases of severe trigeminal neuralgia (TGN), frequently after a prolonged trial of medical treatment and following less invasive procedures, despite the fact that posterior fossa microvascular decompression gives long-term pain relief in 80% to 90% of cases. To assess whether vascular compression of the nerve could be demonstrated preoperatively, high definition magnetic resonance tomographic angiography (MRTA) was performed in 50 consecutive patients, five of whom had bilateral TGN, prior to posterior fossa surgery. The imaging results were compared with the operative findings in all patients, including two patients who underwent bilateral exploration. Vascular compression of the trigeminal nerve was identified in 42 of 45 patients with unilateral symptoms and on both sides in four patients with bilateral TGN. In the last patient with bilateral TGN, neurovascular compression was identified on one side, and on the other side the compressing superior cerebellar artery was separated from the nerve by a sponge placed during previous surgery. There was full agreement regarding the presence or absence of neurovascular compression demonstrated by MRTA in 50 of 52 explorations, but MRTA misclassified four vessels compressing the trigeminal nerve as arteries rather than veins. In two cases, there was disagreement between the surgical and MRTA findings. In the first of these cases, surgery revealed distortion of the nerve at the pons by a vein that MRTA had predicted to lie 6 mm remote from this point. In the second patient, venous compression was missed; however, this patient was investigated early in the series and did not have gadolinium-enhanced imaging. In nine cases, MRTA correctly identified neurovascular compression of the trigeminal nerve by two arteries. Moreover, MRTA successfully guided surgical reexploration in one patient in whom a compressing vessel was missed during earlier surgery and also prompted exploration of the posterior fossa in two patients with multiple sclerosis and one patient with Charcot-Marie-Tooth syndrome, in whom neurovascular compression was identified preoperatively. It is concluded that MRTA is an extremely sensitive and specific method for demonstrating vascular compression in TGN. As a result, open surgical procedures can be recommended with confidence, and microvascular decompression is now the treatment of choice for TGN at the authors' unit. They propose MRTA as the definitive investigation in such patients in whom surgery is contemplated.

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Interactive virtual simulation using a 3D computer graphics model for microvascular decompression surgery

Journal of Neurosurgery ◽

10.3171/2012.5.jns112334 ◽

2012 ◽

Vol 117 (3) ◽

pp. 555-565 ◽

Cited By ~ 19

Author(s):

Makoto Oishi ◽

Masafumi Fukuda ◽

Tetsuya Hiraishi ◽

Naoki Yajima ◽

Yosuke Sato ◽

...

Keyword(s):

Computer Graphics ◽

Trigeminal Neuralgia ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Multidetector Ct ◽

Cranial Nerves ◽

Virtual Simulation ◽

Decompression Surgery ◽

Neurovascular Compression ◽

Microsurgical Anatomy

Object The purpose of this paper is to report on the authors' advanced presurgical interactive virtual simulation technique using a 3D computer graphics model for microvascular decompression (MVD) surgery. Methods The authors performed interactive virtual simulation prior to surgery in 26 patients with trigeminal neuralgia or hemifacial spasm. The 3D computer graphics models for interactive virtual simulation were composed of the brainstem, cerebellum, cranial nerves, vessels, and skull individually created by the image analysis, including segmentation, surface rendering, and data fusion for data collected by 3-T MRI and 64-row multidetector CT systems. Interactive virtual simulation was performed by employing novel computer-aided design software with manipulation of a haptic device to imitate the surgical procedures of bone drilling and retraction of the cerebellum. The findings were compared with intraoperative findings. Results In all patients, interactive virtual simulation provided detailed and realistic surgical perspectives, of sufficient quality, representing the lateral suboccipital route. The causes of trigeminal neuralgia or hemifacial spasm determined by observing 3D computer graphics models were concordant with those identified intraoperatively in 25 (96%) of 26 patients, which was a significantly higher rate than the 73% concordance rate (concordance in 19 of 26 patients) obtained by review of 2D images only (p < 0.05). Surgeons evaluated interactive virtual simulation as having “prominent” utility for carrying out the entire surgical procedure in 50% of cases. It was evaluated as moderately useful or “supportive” in the other 50% of cases. There were no cases in which it was evaluated as having no utility. The utilities of interactive virtual simulation were associated with atypical or complex forms of neurovascular compression and structural restrictions in the surgical window. Finally, MVD procedures were performed as simulated in 23 (88%) of the 26 patients . Conclusions Our interactive virtual simulation using a 3D computer graphics model provided a realistic environment for performing virtual simulations prior to MVD surgery and enabled us to ascertain complex microsurgical anatomy.

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