Case Report: Direct Visualization of the Nervus Intermedius During the Microvascular Decompression Procedure: Should We Take It Seriously?

Background: Nervus intermedius neuralgia (NIN), known as geniculate neuralgia (GN), is an uncommon cranial nerve disease caused by an offending vessel compressing the nervus intermedius (NI). Microvascular decompression (MVD) has now become a valued treatment approach for NIN because it can resolve neurovascular conflict (NVC) at the root entry zone of the NI. In the era of continuously optimizing and improving the surgical technique of MVD, further minimization of all possible postoperative complications is not only welcome but also necessary.Objective: The aim of this work is to assess the postoperative outcome of direct visualization of the NI during the MVD procedure.Methods: This study retrospectively reviewed the clinical records of a group of seven consecutive patients with NIN who underwent MVD in the period of 2013–2020 in our clinic and 16 studies reported NIN patients who underwent MVD in the period of 2007–2020.Results: In total, 91.3% of all patients experienced immediate and complete relief of cranial neuralgia after MVD. Six of 23 patients have experienced direct visualization of the NI intraoperatively, and 66.7% of those patients had complications such as facial paralysis, dysacousia, or a combination of these conditions postoperatively. Slight surgical approach-related complications such as complaints associated with excessive drainage of cerebrospinal fluid (CSF), nausea and vertigo, and delayed wound union were observed in 80% of the remaining 15 patients, and these symptoms are totally relieved in the telephone and outpatient follow-up after 6 months.Conclusion: Our case series shows that MVD produced immediate pain relief in the majority of NIN patients. MVD carries surgical risk, especially in patients who experience direct visualization of the NI after mechanical stretch and blunt dissection in surgical procedures. Attempts to avoid mechanical stretch and blunt dissection of the compressed nerve were important for intraoperative neuroprotection, especially facial nerve protection

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Microvascular Decompression of the VII/VIII Cranial Nerve Complex for the Treatment of Intermediate Nerve Neuralgia: A Retrospective Case Series

Operative Neurosurgery ◽

10.1093/ons/opx271 ◽

2017 ◽

Vol 15 (4) ◽

pp. 378-385 ◽

Cited By ~ 1

Author(s):

Eric Goulin Lippi Fernandes ◽

Tristan van Doormaal ◽

Sander de Ru ◽

Kai Miller ◽

Kuo Sen Han

Keyword(s):

Microvascular Decompression ◽

Cranial Nerve ◽

Treatment Options ◽

Case Series ◽

Csf Leak ◽

Complete Relief ◽

Pathophysiological Mechanism ◽

Contributing Factors ◽

Retrospective Case ◽

Root Entry Zone

Abstract BACKGROUND Intermediate nerve neuralgia (INN) is a rare and often overlooked form of primary otalgia. The pathophysiological mechanism is unknown, although one of the possible contributing factors is a neurovascular conflict at the root entry zone of the intermediate nerve. The pain can be severely debilitating, and the palette of treatment options is small. OBJECTIVE To assess the outcome of microvascular decompression (MVD) of the VII/VIII cranial nerve complex for treating INN. METHODS We retrospectively reviewed the records of a group of 8 consecutive patients with INN who underwent MVD of the VII/VIII cranial nerve complex in the period 1994 to 2015. RESULTS In total, 7 of the 8 patients experienced almost immediate and complete relief of pain, which remained at long-term follow-up (mean 35 mo ± 24 mo, range 8-84 mo). Postoperatively, 1 patient had a cerebrospinal fluid (CSF) leak, 3 patients experienced permanent ipsilateral hearing loss, and 3 patients had temporary complaints associated with excessive drainage of CSF. CONCLUSION This study suggests MVD as a valid treatment for medically refractory INN. MVD carries surgical risk, but given the severity of complaints of these patients, we believe the treatment benefits outweigh the associated complications.

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FRI0419 LOW DOSE OF GLUCOCORTICOIDS FOR PAIN CONTROL IN THE ESTROGEN-DEPENDENT PRIMARY POLYARTICULAR OSTEOARTHRITIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.4033 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 807.2-808

Author(s):

G. Puerta ◽

M. Bautista ◽

M. Urbano ◽

F. Bonilla ◽

C. Cañas

Keyword(s):

Bone Scintigraphy ◽

Pain Control ◽

Controlled Trial ◽

Case Series ◽

Tender Joint Count ◽

Hand Osteoarthritis ◽

Average Dose ◽

Tender Joint ◽

Double Blind ◽

Clinical Records

Background:Low doses of glucocorticoids (GCs) can be useful in the management of osteoarthritis when it is related to hypoestrogenic states (estrogen-dependent primary polyarticular osteoarthritis [EDPOA]), that usually can appear after the menopause. Deflazacort is a GC that has similar anti-inflammatory effects than other steroids, but with fewer side effects.Objectives:To describe the average dose of GCs that best controlled articular pain, based on tender joint count in patients with EDPOA.Methods:The diagnosis of EDPOA was made in postmenopausal patients with polyarticular compromised (six or more joints affected), morning stiffness less than 30 minutes, erythrocyte sedimentation rate less than 45mm/hour and imaging studies with changes related to osteoarthritis (radiography, magnetic resonance imaging or bone scintigraphy). Patients with autoimmune diseases such as rheumatoid arthritis, lupus or Sjögren syndrome were excluded.The clinical records of patients diagnosed with EDPOA and treated between January 2015 and June 2019 at the Valle del Lili foundation Hospital were reviewed. The patients treated with deflazacort GC were included. Pain was assessed by the treating rheumatologist using the visual analog scale (VAS, possible score 0-10). Tender joints were those with VAS> 5. The count of compromised joints was compared with inflammatory findings on bone scintigraphy (Figure 1).Figure 1.Comparison between number of joints with inflammatory findings on bone scintigraphy and number of swollen joints in physical evaluationThe number of tender joints was recorded at the start of treatment, which was a dose of 6 mg/day of deflazacort for two months. Subsequently, the dose was reduced depending on the improvement of pain (items: intensity of pain and number of tender joints) until achieving a stabilization along the time with an improvement of 75% of the items evaluated. The number of painful joints was recorded again two months after the stabilization on pain control was achieved.Quantitative variables were described with medians and interquartile ranges because the absence of normal distribution of the sample size. To assess the presence of a significant decrease on the number of tender joints the Wilcoxon range test was used, a value of p<0.001 was considered statistically significant. The data were analyzed with Stata v.15.Results:Twenty-eight patients with EDPOA were included, with a median of age of 50 years (IQR 44-51), 56 years (IQR 52-66) and 61 years (IQR 54-69) at the time of menopause, onset of symptoms and the diagnosis of EDPOA respectively. A median of 18 tender joints (IQR 10-27) was obtained from the physical examination of the records reviewed. The dose of deflazacort that achieved stabilization on the improvement of the pain along the time was 21mg/week (IQR 12-21); after 8 weeks of treatment the number of tender joints was 2 (IQR 1-4), which implies a reduction of 14 (IQR 8-20; p<0.0001) on the tender joint count (Figure 2).Figure 2.Number of tender joints before and after eight weeks of treatment achieving with a stable pain control in patients with EDPOA treated with deflazacort with a media dose of 3mgr/day.Conclusion:In this case series a media dose of deflazacort of 21mg per week (3mg/day) was useful to significantly reduce the number of tender joints in patients with EDPOA.References:[1]Roman-Blas JA, Castañeda S, Largo R,et al. Osteoarthritis associated with estrogen deficiency. Arthritis Research & Therapy 2009;11:241.[2]Cvoro A, Yuan C, Paruthiyil S,et al. Crosstalk between glucocorticoid and estrogen receptors occurs at a subset of proinflammatory genes. The Journal of Immunology 2011;186:4354-4360.[3]Féline K, Marion K, Annelies B,et al. Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): a double-blind, randomised, placebo-controlled trial. Lancet 2019;394:1993-2001.Disclosure of Interests:None declared

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Acute abdomen in children due to different presentations of complicated Meckel’s diverticulum: a case series

Annals of Pediatric Surgery ◽

10.1186/s43159-020-00055-7 ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Hisham A. Almetaher ◽

Mohammed Awad Mansour

Keyword(s):

Congenital Abnormality ◽

Wedge Resection ◽

Meckel’S Diverticulum ◽

Case Series ◽

Postoperative Outcome ◽

Meckel's Diverticulum ◽

Gastrointestinal Disorders ◽

Clinical Presentations ◽

Life Threatening ◽

Small Base

Abstract Background Meckel’s diverticulum (MD) is the commonest congenital abnormality of the gastrointestinal tract that occurs in 2% of general population. It remains asymptomatic, but it may lead to life-threatening complications. These complications may be misdiagnosed with other gastrointestinal disorders like acute appendicitis, making its diagnosis challenging among pediatricians and pediatric surgeons. In this study, we reported five cases with different presentations of complicated MD in children. Results Five patients with different presentations of MD were reported during the period from January 2016 to January 2020. Patients’ demographics, clinical presentations, investigations, operative data, and postoperative outcome were recorded and analyzed. Conclusions The present study highlights different presentations of MD. Surgical interference is the main key of treatment of symptomatic MD either by wedge resection of a small base diverticulum or by resection anastomosis of the small intestine in wide base and inflamed diverticulum.

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A Case Report of Pediatric Geniculate Neuralgia Treated with Sectioning of the Nervus Intermedius and Microvascular Decompression of Cranial Nerves IX and X

Pediatric Neurosurgery ◽

10.1159/000509760 ◽

2020 ◽

Vol 55 (6) ◽

pp. 439-443

Author(s):

Georgios Zenonos ◽

Michael M. McDowell ◽

Hussam Abou-Al-Shaar ◽

Kenan Alkhalili ◽

Paul A. Gardner

Keyword(s):

Microvascular Decompression ◽

Pediatric Population ◽

English Literature ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Rare Condition ◽

Extensive Evaluation ◽

Patient Reported ◽

Nervus Intermedius

Background: Classic geniculate neuralgia (GN) is a rare condition characterized by lancinating pain centered in the ear and not involving the throat. To the best of our knowledge, no case of pediatric GN has been reported in the English literature. Case Presentation: We present the first reported case of successfully treated GN in a child via an endoscopic approach. The patient was a 9-year-old boy who presented with a 1-year history of lancinating right ear pain. Neuroleptics resulted in a short-lived improvement in symptoms, but with significant side effects. Extensive evaluation by multiple specialties did not reveal a cause for his pain. Imaging disclosed a tortuous loop of the right posterior inferior cerebellar artery abutting cranial nerves IX and X but no other abnormalities. The patient underwent an endoscopic microvascular decompression of cranial nerves IX and X, and sectioning of the nervus intermedius through a right retromastoid craniotomy. Postoperatively, the patient reported complete resolution of his symptoms that persisted at 3 months of follow-up. At the 5-year follow-up, the patient maintained pain relief and was developing normally. Conclusion: GN can affect the pediatric population. In carefully selected patients with consistent clinical and radiographic presentation, sectioning of the nervus intermedius and microvascular decompression of the lower cranial nerves can be an effective treatment.

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Bilateral Nervus Intermedius Sectioning for Geniculate Neuralgia: Case Report and Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab354 ◽

2021 ◽

Author(s):

Keaton Piper ◽

Qizhi Victoria Zheng ◽

Robert S Heller ◽

Siviero Agazzi

Keyword(s):

Side Effects ◽

Microvascular Decompression ◽

Treatment Options ◽

Rare Condition ◽

Contralateral Side ◽

Wide Range ◽

Successful Resolution ◽

Surgical Options ◽

Vascular Loop ◽

Nervus Intermedius

Abstract BACKGROUND AND IMPORTANCE Geniculate neuralgia is a rare condition characterized by excruciating ear pain. Surgical options for geniculate neuralgia include microvascular decompression and sectioning of the nervus intermedius. We report herein a case of bilateral geniculate neuralgia treated by nervus intermedius sectioning without prior microvascular decompression. To our knowledge, this is the first report of this treatment strategy with a subsequent description of the side effects of bilateral nervus intermedius disruption. CLINICAL PRESENTATION A 54-yr-old woman presented with bilateral geniculate neuralgia, worse on the left, refractory to medical therapy. Surgical treatment options were reviewed, including microvascular decompression and sectioning of the nervus intermedius. She opted for left nervus intermedius sectioning. The procedure was uncomplicated and no compressive vascular loop was identified during surgery. Postoperatively, she had complete symptom resolution with no discernable side effects. Three years later, the patient developed worsening geniculate neuralgia on the contralateral side. After the discussion of treatment options, she opted again for sectioning of the contralateral nervus intermedius with successful resolution of all symptoms after surgery. Following surgery, the patient identified partial impairment of lacrimation and gustation. She continued to have functional taste of the anterior two-thirds of the tongue, lacrimation, and hearing bilaterally. CONCLUSION Bilateral sectioning of nervus intermedius may provide benefit in patients with bilateral geniculate neuralgia without egregious side effects. However, lacrimatory and gustatory alterations are a potentially significant side effect with a wide range of symptomatology.

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Microvascular Decompression and Nervus Intermedius Sectioning for the Treatment of Geniculate Neuralgia

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1675151 ◽

2018 ◽

Vol 80 (S 03) ◽

pp. S316-S317 ◽

Cited By ~ 1

Author(s):

Tyler J. Kenning ◽

Christine S. Kim ◽

Alexander G. Bien

Keyword(s):

Vertebral Artery ◽

Microvascular Decompression ◽

Single Case ◽

Anterior Inferior Cerebellar Artery ◽

Root Entry Zone ◽

Vertebrobasilar System ◽

Tertiary Center ◽

History Of ◽

Magnetic Resonance Imaging Mri ◽

Nervus Intermedius

Objectives Demonstrate the surgical treatment of geniculate neuralgia via microvascular decompression and nervus intermedius sectioning. Designs Single case-based operative video. Setting Tertiary center with dedicated skull base team. Participants The patient is a 62-year-old female with a history of deep right-sided otalgia consistent with geniculate neuralgia. She failed appropriate medical treatment. Her magnetic resonance imaging (MRI) showed an ectatic vertebrobasilar system as well as an anterior inferior cerebellar artery (AICA) loop causing compression of the VII/VIII nerve complex in the cerebellopontine angle. Main Outcome Measures Resolution of right-sided otalgia. Results The patient underwent retrosigmoid craniotomy with microvascular decompression of the VII/VIII nerve complex and nervus intermedius sectioning. Intraoperatively, the patient was noted to have an ectatic vertebral artery and AICA that were compressing the root entry zone of the VII/VIII nerve complex. Microvascular decompression was performed of both the vertebral artery and AICA with Teflon. The nervus intermedius was sharply sectioned. The patient's postoperative course was uneventful with no complications. She continues to have resolution of her right sided otalgia at 6 months postoperatively.The link to the video can be found at: https://youtu.be/uRb_QfrINSk.

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Microvascular Decompression for Geniculate Neuralgia through a Retrosigmoid Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1676837 ◽

2018 ◽

Vol 80 (S 03) ◽

pp. S322-S322

Author(s):

Vincent N. Nguyen ◽

Jaafar Basma ◽

Jeffrey Sorenson ◽

L. Madison Michael

Keyword(s):

Microvascular Decompression ◽

Cerebellopontine Angle ◽

Cranial Nerves ◽

Senior Author ◽

Retrosigmoid Approach ◽

Microsurgical Anatomy ◽

Pain Syndromes ◽

Large Vein ◽

Microsurgical Techniques ◽

Nervus Intermedius

Objectives To describe a retrosigmoid approach for the microvascular sectioning of the nervus intermedius and decompression of the 5th and 9th cranial nerves, with emphasis on microsurgical anatomy and technique. Design A retrosigmoid craniectomy is performed in the lateral decubitus position. The dura is opened and cerebrospinal fluid (CSF) is released from the cisterna magna and cerebellopontine cistern. Dynamic retraction without rigid retractors is performed. Subarachnoid dissection of the cerebellopontine angle exposes the 7th to 8th nerve complex. A neuromonitoring probe is used with careful inspection of the microsurgical anatomy to identify the facial nerve and the nervus intermedius as they enter the internal auditory meatus. The nervus intermedius is severed. A large vein coursing superiorly across cranial 9th nerve was coagulated and cut. A Teflon pledget is inserted between a small vessel and the 5th nerve. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Drs. V.N. and J.B. Outcome Measures Outcome was assessed by postoperative neurological function. Results The nervus intermedius was successfully cut and the 5th and 9th nerves were decompressed. The patient's pain resolved after surgery and at later follow-up. Conclusions Understanding the microsurgical anatomy of the cerebellopontine angle is necessary to identify the cranial nerves involved in facial pain syndromes. Subarachnoid dissection and meticulous microsurgical techniques are key elements for a successful microvascular decompression.The link to the video can be found at: https://youtu.be/pV5Wip7WusE.

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Diagnosis of lung cancer: a necropsy-based study of 128 cases (1997–2016)

Tumori Journal ◽

10.1177/0300891620949665 ◽

2020 ◽

pp. 030089162094966

Author(s):

Pietro Gino Barbieri ◽

Dario Mirabelli

Keyword(s):

Computed Tomography ◽

Lung Cancer ◽

Case Series ◽

The Elderly ◽

Positive Finding ◽

Chest Computed Tomography ◽

Pleural Plaques ◽

High Prevalence ◽

Diagnosis Of Lung Cancer ◽

Clinical Records

Background: The diagnosis of lung cancer (LC) may be difficult to make in the elderly. We report on the diagnostic elements available in life in an LC necropsy case series of asbestos-exposed workers and describe the frequency of non-neoplastic asbestos-related diseases as biological exposure indices. Methods: We reviewed pathologic and clinical records of an unselected series of autopsies (1997–2016) in patients with LC employed in the Monfalcone shipyards. We assessed the consistency with autopsy results of diagnoses based on, respectively, radiologic, cytologic, and histologic findings. Results: Data on 128 autopsy-confirmed LC cases were available; in life, 119 had been diagnosed as LC. Among these, 49 had histologic confirmation of diagnosis (17 with immunophenotyping); histology had been negative in 4. Cytology had been the main positive finding and the basis for diagnosis in 24 cases, but had been negative in 13. Chest computed tomography had been the basis for diagnosis in 45; in 18 cases, it had been negative. Nine patients had received a diagnosis different from LC, among whom 4 had been suspected to have malignant pleural mesothelioma by chest computed tomography. Pleural plaques were found in 124 and histologic asbestosis in 46 cases. Conclusions: Autopsies confirmed all LC diagnoses received in life, including 46 that would have been considered only possible LC based on clinical workup. The overall survival in this case series was poor. The high prevalence of pleural plaques and asbestosis suggest severity of asbestos exposures.

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Pyrocardan Trapeziometacarpal Joint Arthroplasty—Medium-Term Outcomes

Journal of Wrist Surgery ◽

10.1055/s-0040-1714685 ◽

2020 ◽

Vol 9 (06) ◽

pp. 509-517

Author(s):

James Logan ◽

Susan E. Peters ◽

Ruby Strauss ◽

Silvia Manzanero ◽

Gregory B. Couzens ◽

...

Keyword(s):

Case Series ◽

Postoperative Outcome ◽

Preoperative Assessment ◽

Pinch Strength ◽

Level Of Evidence ◽

Original Series ◽

Surgery Outcome ◽

Trapeziometacarpal Osteoarthritis ◽

Patient Reported

Abstract Objective Pyrocardan trapeziometacarpal interposition implant is a free intra-articular spacer composed of pyrocarbon. This biconcave resurfacing implant, both ligament and bone-stock sparing, is indicated for use in early-to-moderate stage trapeziometacarpal osteoarthritis. It was hypothesized that the postoperative outcome measures of the Pyrocardan implant would be comparable to those seen with ligament reconstruction and tendon interposition (LRTI) surgeries and those reported by the designer of the implant, Phillipe Bellemère, but that strength would be greater than for LRTI. Methods In this prospective case series, 40 Pyrocardan implants were performed in 37 patients. Average age was 58 years (range: 46–71). Patients were assessed preoperatively, 3 months, 6 months, 1 year, 2 years, and beyond (long term) wherever possible. Results There have been no major complications or revision surgeries for the series. Average follow-up was 29 months (range: 12 months–7 years). Twenty-eight joints were assessed at over 2 years post index surgery. Outcome measure scores improved from preoperative assessment to the most recent follow-up equal or greater than 2 years. Average grip strength at 2 years was 30 kg, as compared with 19.6 kg in an age-matched cohort who underwent trapeziectomy and 25 kg in Bellemère's original series of Pyrocardan implants. Conclusions Pyrocardan interposition arthroplasty appears to be a safe, effective treatment for trapeziometacarpal arthritis. Patient-reported clinical outcomes were at least equivalent to LRTI and are comparable to Bellemère's original series. Grip and pinch strength appear to be better than LRTI. Level of Evidence This is a Level III, prospective observational cohort study.

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Trigeminal Neuralgia Caused by Venous Compression

Neurosurgery ◽

10.1227/01.neu.0000129552.87291.87 ◽

2004 ◽

Vol 55 (2) ◽

pp. 334-339 ◽

Cited By ~ 72

Author(s):

Toshio Matsushima ◽

Phuong Huynh-Le ◽

Masayuki Miyazono

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Complete Relief ◽

Surgical Results ◽

Meckel’S Cave ◽

Trigeminal Pain ◽

Venous Compression ◽

Facial Numbness ◽

Meckel's Cave

Abstract OBJECTIVE: The purpose of this study is to clarify whether venous compression on the trigeminal nerve really causes trigeminal neuralgia or not, and to identify which veins are the offending veins. METHODS: We used microvascular decompression in operations on 121 patients with typical trigeminal neuralgia. We analyzed the intraoperative findings and surgical results in these 121 cases. RESULTS: In 7 of the 121 cases, only the vein was identified as a compressive factor on the trigeminal nerve. In 6 of these 7 cases, single venous compression was found, whereas the remaining case had two offending veins. The transverse pontine vein was most frequently found as the offending vein near Meckel's cave. All patients showed complete relief of trigeminal pain after decompression of the veins, but four of them developed facial numbness after surgery, which tended to be slight and did not require any treatment. CONCLUSION: Our surgical experiences showed that venous compression could cause trigeminal neuralgia by itself and that the transverse pontine vein should be carefully observed because it is most frequently the offending vein.

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