Descompresión microvascular para el manejo de la neuralgia del trigemino: presentación de caso clínico y revisión de la literatura / Microvascular decompression for the handling of trigeminal neuralgia: clinical case report and literature review

La neuralgia del trigémino es un trastorno neuropático paroxístico que afecta a una o varias de las ramas sensoriales del nervio trigémino cuya etiología es variada, la más aceptada es por compresiones vasculares a nivel del ángulo ponto cerebeloso que generan conflicto de espacio. Dentro de las posibilidades de tratamiento, la descompresión microvascular permite la cura fisiopatológica de la neuralgia del trigémino, teniendo resultados satisfactorios a corto/largo plazo, y bastantes ventajas en comparación a otras técnicas de mínima invasión. Se presenta el caso de una paciente con tratamiento médico máximo no efectivo, a la cual se realizó descompresión microvascular evidenciando conflicto arterial y venoso con el nervio.

Trigeminal neuralgia is a paroxysmal neuropathic disorder that affects one or more of the sensory branches of the trigeminal nerve, the etiology of which is varied, the most accepted being due to vascular compressions at the level of the brainstem that generate conflict of space. Within the treatment possibilities, microvascular decompression allows the pathophysiological cure of trigeminal neuralgia, having satisfactory results in the short / long term, and many advantages compared to other minimally invasive techniques. We present the case of a patient with maximum ineffective medical treatment, who underwent microvascular decompression, showing arterial and venous conflict with the nerve.

Internal Neurolysis (Nerve Combing) for Trigeminal Neuralgia without Neurovascular Compression

Objective The aim of the present study was to describe and evaluate the initial and the long-term clinical outcome of internal neurolysis (IN) for trigeminal neuralgia (TN) without neurovascular compression (NVC). Methods A total of 170 patients diagnosed with TN were treated by posterior fossa exploration, during the period between April 2012 and October 2019. The patients were divided into two groups: Group A (50 patients)was treated by IN and Group B (120 patients) received microvascular decompression (MVD). Surgical outcomes and postoperative complications were compared between the two groups. Pain intensity was assessed by the Barrow Neurological Institute (BNI) pain intensity score and BNI facial numbness score. Pain recurrence was statistically evaluated with Kaplan-Meier analysis. Results Pain was completely relieved in 44 patients (88%) who underwent IN (group A); 3 (6%) experienced occasional pain but did not require medication (BNI 2). In group B, 113 (94%) experienced immediate pain relief after MVD. The median duration of follow-ups was 4 years (6 months to 7.5 years). In Group A, there was a meantime recurrence of 27 months in 3 patients (6%). The recurrence in Group B was of 5.8% during the follow-up period. There were no statistically significant differences in the surgical outcomes between the two groups. All patients with IN experienced some degree of numbness, 88% of the cases resolved in 6 months, on average. Conclusion Internal neurolysis is an effective, safe and durable treatment option for trigeminal neuralgia when NVC is absent.

Trigeminal neuralgia recurrence: a comparison of microvascular decompression and percutaneous balloon compression: a five years follow-up study / Neuralgia do trigêmeo recorrente: uma comparação entre descompressão microvascular e compressão percutânea por balão: um estudo de acompanhamento de cinco anos

ABSTRACT Background: About 50% of patients that suffer from trigeminal neuralgia do not experience sustained benefit from the use of oral medication. For their adequate management, a few surgical procedures are available. Of these, percutaneous balloon compression (PBC) and microvascular decompression (MD) are two of the most performed worldwide. In this retrospective study, we present the outcomes of these techniques through estimation of initial pain relief and subsequent recurrence rate. Methods: Thirty-seven patients with medically refractory trigeminal pain surgically treated at Hospital Cajuru, Curitiba, Brazil, with PBC, MD or both between 2013 and 2018 were enrolled into this retrospective study. The post-procedural rate for pain relief and recurrence and associations between patient demographics and outcomes were analyzed. Results: MD had an earlier recurrence time than balloon compression. Of the 37 patients, the mean age was 61.6 years, approximately one third were male and most had type I neuralgia. The most affected branch was the maxillary (V2). The time for recurrence after surgery was on average 11.8 months for PBC and 9.0 months for MD. Complications were seen only with microsurgery. Conclusions: MD presented with a more precocious recurrence of pain than PBC in this article. Moreover, it had a higher recurrence rate than described in the literature as well, which is possibly explained by the type of graft (muscle) that was used to separate the neurovascular structures.

RESUMO Introdução: Cerca de 50% dos pacientes com neuralgia do trigêmeo não apresenta benefícios a longo prazo com o uso de medicação oral. Para a manutenção do tratamento, algumas opções cirúrgicas estão disponíveis, sendo a compressão percutânea por balão (CPB) e a descompressão microvascular (DM) algumas das modalidades mais realizadas em todo o mundo. Neste estudo retrospectivo, apresentamos os desfechos dessas técnicas por meio de estimativa da melhora inicial da dor e da taxa de recorrência subsequente. Métodos: Trinta e sete pacientes com dor trigeminal refratária ao tratamento medicamentoso tratados cirurgicamente no Hospital Cajuru, Curitiba, Brasil, com CPB, DM ou ambos entre 2013 e 2018 foram incluídos neste estudo retrospectivo. A taxa pós-procedimento para alívio e recorrência da dor e suas associações com a demografia e desfechos dos pacientes foram analisadas. Resultados: A DM foi associada a menor recorrência que a compressão por balão. Entre os 37 pacientes, a idade média foi de 61,6 anos, aproximadamente um terço eram do sexo masculino e a maioria apresentava neuralgia do tipo I. O ramo mais afetado foi o maxilar (V2). O tempo de recorrência após a cirurgia foi em média de 11,8 meses para CPB e 9,0 meses para DM. Foram vistas complicações apenas na microcirurgia. Conclusões: A DM apresentou recidiva mais precoce da dor em comparação à CPB. Além disso, apresentou uma taxa de recorrência mais alta do que a descrita na literatura, o que é possivelmente explicado pelo tipo de enxerto (músculo) usado para separar as estruturas neurovasculares.

Application of Methylprednisolone Sodium Succinate Combined with Tropisetron in Prevention of Nausea and Vomiting under Microvascular Decompression of Hemifacial Spasm / 中国医学科学院学报

Objective To evaluate the effect of methylprednisolone sodium succinate combined with tropisetron on postoperative nausea and vomiting(PONV)under microvascular decompression of hemifacial spasm.Methods From January to June 2019,485 patients undergoing microvascular decompression for facial spasm at Department of Neurosurgery,Peking University People's Hospital were randomly assigned into two groups with random number table method.For group A(n=242),2 ml saline was administrated by intravenous drip before induction and 5 mg tropisetron after operation.For group B(n=243),40 mg methylprednisolone sodium succinate was administrated by intravenous drip before induction and 5 mg tropisetron after operation.The anesthesia time,operation time,and incidence of PONV in 0-24 h and 24-48 h were recorded for the comparison of the remedial treatment rate of nausea and vomiting between the two groups.Results There was no significant difference in age,gender,smoking history,body mass index value,American Society of Anesthesiologists score,medical history,surgical side,PONV history,operation time or anesthesia time between the two groups(all P > 0.05).The incidence of PONV in group A was 35.5% and 18.2% during 0-24 h and 24-48 h,respectively,which was significantly higher than that(18.5%,χ

Hemifacial Spasm Associated with Chiari Type I Malformation: Surgical Considerations and Case Report

Hemifacial spasm (HS) is a movement disorder characterized by paroxysmal and irregular contractions of the muscles innervated by the facial nerve. Chiari malformation type I (CM I) is a congenital disease characterized by caudal migration of the cerebellar tonsils, and surgical decompression of foramen magnum structures has been used for treatment. The association of HS with CM I is rare, and its pathophysiology and therapeutics are speculative. There are only a few cases reported in the literature concerning this association. The decompression of the posterior fossa for the treatment of CM I has been reported to relieve the symptoms of HS, suggesting a relation between these diseases. However, the possible complications of posterior fossa surgery cannot be underrated. We report the case of a 66-year-old patient, in ambulatory follow-up due to right HS, no longer responding to botulinum toxin treatment. Magnetic resonance imaging (MRI) of the skull revealed compression of the facial nerve and CM I. The patient underwent surgery for HS by neurovascular microdecompression of the facial nerve via right lateral suboccipital craniectomy, but presented significant clinical worsening in the postoperative period even though the cerebellum edema related to surgical manipulation was mild. Due to the clinical worsening, the patient underwent a median suboccipital craniectomy with decompression of the foramenmagnum structures. After this second surgery, the patient had progressive improvement and was discharged from the hospital for ambulatory care.

Asistencia Endoscópica en la Descompresión Microquirúrgica del Hemiespasmo Facial / Endoscopic Assistance in Microsurgical Decompression of Facial Hemiespasm

Introducción: El hemiespasmo facial primario (HFP) se produce por la hiperexcitabilidad del nervio facial y sus núcleos de origen como consecuencia de la compresión vascular. La cirugía de descompresión neurovascular se plantea como alternativa al tratamiento médico refractario. Objetivos: Presentar nuestra experiencia respecto a esta patología. Material y métodos: Se realizó una revisión retrospectiva de pacientes operados por HPF refractarios a tratamiento médico en nuestra institución en los últimos 5 años (periodo 2014-2019). Todos fueron intervenidos vía retrosigmoidea. Se evaluaron datos demográficos, evaluación prequirúrgica y evolución postoperatoria. Resultados: Se operaron 4 pacientes bajo técnica microquirúrgica asistido por endoscopía. Edad promedio 52 años (rango 41-61) con una relación femenino masculino 3:1. El 25% (n=1) presentaba paresia facial grado 2 (HB) en el prequirúrgico. No hubo cambios en cuanto al grado de paresia facial en el postoperatorio en ningún caso. Sólo un paciente registró caída leve en la audiometría postquirúrgica. El 75% (n=3) resolvieron el HFP. Conclusión: Si bien nuestra serie es acotada a un número reducido de pacientes, la cirugía descompresiva microvascular es efectiva como alternativa al tratamiento médico refractario del HFP.

Introduction: Primary hemifacial spasm (PHS) is defined as the hyper excitability of the nerve due to the compression of the facial nerve or its nuclei, most commonly by a vascular structure. The surgical indication for microvascular decompression is resistance to pharmacological treatment or severe adverse effects. Objectives: To present our experience in the surgical treatment of this pathology with this novel technique. Materials and methods: We retrospectively reviewed all patients (n=4) with a diagnosis of PHS, who underwent endoscope-assisted microvascular decompression surgery in our institution during the last 5 years. In all the cases, we choose the retrosigmoid approach. We evaluated demographic data, preoperative evaluation, and post-operative evolution. Results: Endoscope-assisted microvascular decompression was the surgical technique in all the patients. The median age was 52 years, the female-male ratio of 3:1. Only one patient presented a grade 2 facial palsy (House-Brackmann scale) in the preoperative evaluation; there were no significant changes in the post-operative evaluation in any patient. Only one patient experienced worsening in the post-operative audiometric follow-up. The 75% (n=3) of the patients solved the HFP after the surgical treatment. Conclusion: By taking into account our experience in this small case series, we can support the concept that endoscope-assisted microvascular decompression is as effective as the open surgical treatment of the PHS.

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience / Abordagem retrosigmóidea assistida por endoscopia em espasmo hemifacial: nossa experiência

Abstract Introduction: The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. Objective: To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. Methods: We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49-71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. Results: Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24 h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p < 0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. Conclusions: The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.

Resumo Introdução: O uso de descompressão cirúrgica do espasmo hemifacial devido ao loop no canal auditivo interno nem sempre é aceito devido ao risco relacionado ao procedimento cirúrgico. Atualmente, uma nova técnica cirúrgica permite trabalhar em condições seguras. Objetivo: Relatar os resultados que obtivemos com a abordagem retrosigmóidea assistida por endoscopia para a descompressão microvascular do nervo facial em casos de espasmo hemifacial devido a conflito neurovascular. A técnica cirúrgica é descrita. Método: Realizamos um estudo prospectivo em um centro de referência terciária observando 12 pacientes (5M, 7F), com média de idade de 57,5 (intervalo 49-71) anos com espasmo hemifacial submetidos a uma abordagem retrosigmóide assistida por endoscopia para descompressão microvascular. Foram avaliados os achados intraoperatórios, a resolução pós-operatória do espasmo hemifacial e as taxas de complicações. Resultados: A resolução do espasmo hemifacial foi observada em 9/12 (75%) dos casos nas 24 horas após a cirurgia e em 12/12 (100%) dos indivíduos até 45 dias. Uma correlação significativa (p < 0,001) entre a duração do histórico pré-operatório de espasmo hemifacial e o tempo de recuperação pós-operatório foi registrado. Apenas um paciente apresentou uma complicação (meningite), que foi resolvida após administração de antibióticos por via intravenosa sem sequelas. Nenhum caso fístula liquórica, paralisia facial ou deficiência auditiva foi registrado. A recorrência do espasmo hemifacial foi observada em único indivíduo em quem o conflito neurovascular foi causado por um vaso no interior do canal auditivo interno. Conclusões: A técnica da abordagem retrosigmóidea assistida por endoscopia oferece uma ótima visualização do conflito neurovascular através de uma abordagem minimamente invasiva, permite assim uma descompressão precisa do nervo facial com baixas taxas de complicações. Por ser menos invasivo, o procedimento deve ser considerado na cirurgia funcional do ângulo pontocerebelar como tratamento de espasmo hemifacial, especialmente quando o procedimento é feito por um otorrinolaringologista.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Gamma Knife Radiosurgery in Recurrent Trigeminal Neuralgia after Other Procedures / 고신대학교의과대학학술지

OBJECTIVES: Trigeminal neuralgia (TN) is undurable paroxysmal pain in the distribution of the fifth cranial nerve. Invasive treatment modalities for TN include microvascular decompression (MVD) and percutaneous procedures, such as, radiofrequency rhizotomy (RFR). Gamma Knife radiosurgery (GKRS) is a considerable option for patients with pain recurrence after an initial procedure. This study was undertaken to analyze the effects of gamma knife radiosurgery in recurrent TN after other procedures. METHODS: Eleven recurrent TN patients after other procedures underwent GKRS in our hospital from September 2004 to August 2016. Seven patients had previously undergone MVD alone, two underwent MVD with partial sensory rhizotomy (PSR), and two underwent RFR. Mean patient age was 60.5 years. We retrospectively analyzed patient's characteristics, clinical results, sites, and divisions of pain. Outcomes were evaluated using the Visual Analog Scales (VAS) score. RESULTS: Right sides were more prevalent than left sides (7:4). The most common distribution of pain was V1 + V2 division (n = 5) following V2 + V3 (n = 3), V2 (n = 2), and V1 + V2 + V3 (n = 1) division. Median GKRS dose was 80 Gy and the mean interval between the prior treatment and GKRS was 74.45 months. The final outcomes of subsequent GKRS were satisfactory in most cases, and at 12 months postoperatively ten patients (90.0%) had a VAS score of ≤ 3. CONCLUSIONS: In this study, the clinical result of GKRS was satisfactory. Invasive procedures, such as, MVD, RFR are initially effective in TN patients, but GKRS provides a safe and satisfactory treatment modality for those who recurred after prior invasive treatments.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Abordaje asterional mínimamente invasivo para descompresión microvascular en neuralgia del trigémino / Minimally invasive asterional approach for microvascular decompression in trigeminal neuralgia

Resumen Objetivo: La neuralgia del trigémino (NT) es un trastorno neuropático susceptible de tratamiento quirúrgico. El objetivo es presentar los hallazgos quirúrgicos y resultados obtenidos en 26 pacientes con NT, tratados mediante un abordaje asterional mínimamente invasivo para descompresión vascular trigeminal. Métodos: Estudio longitudinal descriptivo. Se intervino mediante abordaje asterional a 26 pacientes. Se registró el historial médico, hallazgos quirúrgicos, respuesta al tratamiento y complicaciones. Se les dio seguimiento durante 36 meses. Resultados: Diecinueve casos se asociaron a compresión vascular, cinco casos a aracnoiditis y los dos restantes se relacionaron con esclerosis múltiple y neuralgia postherpética. El dolor se controló significativamente en todos los pacientes durante el postoperatorio inmediato. A 36 meses de seguimiento, en 25 pacientes se alcanzó un control total o aceptable del dolor. A largo plazo 22 pacientes evolucionaron sin complicaciones permanentes. Conclusiones: La cirugía de descompresión microvascular a través de un abordaje asterional mínimamente invasivo para el tratamiento de la NT es una alternativa con resultados similares al abordaje retrosigmoideo clásico, pero que suma las bondades de una técnica quirúrgica que se rige con los principios de la mínima invasión. Se requieren esfuerzos constantes para optimizar las técnicas quirúrgicas en el tratamiento de la NT.

Abstract Objective: Trigeminal neuralgia (TN) is a neuropathic disorder that can be treated surgically. This study aimed to present the surgical findings and the clinical outcomes of 26 patients with TN treated by minimally invasive asterional surgery. Methods: Longitudinal descriptive study. Twenty-six patients with TN underwent minimally invasive asterional surgery. The medical history, surgical findings, therapeutic response, and complications were registered. They were followed for 36 months. Results: Nineteen cases were associated with vascular compression; five were associated with arachnoiditis. The two remaining cases were associated with multiple sclerosis and post-herpetic neuralgia. The pain was substantially reduced in all patients in the immediate postoperative period. At 36 months, in 25 patients, total or acceptable pain control was achieved. In the long term, 22 patients evolved with no permanent complications. Conclusion: The microvascular decompression surgery by an asterional approach is an alternative with similar results to the classic retrosigmoid approach to treat TN, but that adds the benefits of the principles of minimally invasive surgery. Constant efforts need to be made to optimize minimally invasive surgical techniques for TN.

Microvascular Compressicaude by Slinging a Tortuous Vertebrobasilar Artery to the Petrous Dura in Hemifacial Spasm: Technical Note

Objective In cases of hemifacial spasm caused by a tortuous vertebrobasilar artery (TVBA), the traditional treatment technique involves Teflon (polytetrafluoroethylene), which can be ineffective and fraught with recurrence and neurological complications. In such cases, there are various techniques of arteriopexy using adhesive compositions, 'suspending loops' made of synthetic materials, dural or fascial flaps, surgical sutures passed around or through the vascular adventitia, as well as fenestrated aneurysmal clips. In the present paper, we describe a new technique of slinging the vertebral artery (VA) to the petrous dura for microvascular decompression (MVD) in a patient with hemifacial spasm caused by a TVBA. Method A 50-year-old taxi driver presented with a left-sided severe hemifacial spasm. A magnetic resonance imaging (MRI) scan of the brain showed a large tortuous left-sided vertebral artery impinging and compressing the exit/entry zone of the 7th and 8th nerve complex. After a craniotomy, a TVBAwas found impinging and compressing the entry zone of the 7th and 8th nerve complex. Arachnoid bands attaching the artery to the nerve complex and the pons were released by sharp microdissection. Through the upper part of the incision, a 2.5 1 cmtemporal fascia free flap was harvested. After the fixation of the free flap, a 6­0 prolene suture was passed through its length several times using the traditional Bengali sewing and stitching techniques to make embroidered quilts called Nakshi katha. The'prolenated' fascia was passed around the compressing portion of the VA. Both ends of the fascia were brought together and stitched to the posterior petrous dura to keep the TVBA away from the 7th and 8th nerves and the pons. Result The patient had no hemifacial spasm immediately after the recovery from the anesthesia. A postoperative MRI of the brain showed that the VA was away from the entry zone of the 7th and 8th nerves.

Severe Hemifacial Spasm is a Predictor of Severe Indentation and Facial Palsy after Microdecompression Surgery

BACKGROUND AND PURPOSE: Hemifacial spasm (HFS) is mostly caused by the compression of the facial nerve by cerebral vessels, but the significance of spasm severity remains unclear. We investigated the clinical significance of spasm severity in patients with HFS who underwent microvascular decompression (MVD). METHODS: We enrolled 636 patients with HFS who underwent MVD between May 2010 and December 2013 at Samsung Medical Center (SMC), Seoul, Korea. Subjects were divided into two groups based on spasm severity: severe (SMC grade 3 or 4) and mild (SMC grade 1 or 2). We compared demographic, clinical, and surgical data between these two groups. RESULTS: The severe-spasm group was older and had a longer disease duration at the time of MVD compared to the mild-spasm group. Additionally, hypertension and diabetes mellitus were more common in the severe-spasm group than in the mild-spasm group. Regarding surgical findings, there were more patients with multiple offending vessels and more-severe indentations in the severe-spasm group than in the mild-spasm group. Even though the surgical outcomes did not differ, the incidence of delayed facial palsy after MVD was higher in the severe-spasm group than in the mild-spasm group. Logistic regression analysis showed that severe-spasm was correlated with longer disease duration, hypertension, severe indentation, multiple offending vessels, and delayed facial palsy after MVD. CONCLUSIONS: Spasm severity does not predict surgical outcomes, but it can be used as a marker of pathologic compression in MVD for HFS, and be considered as a predictor of delayed facial palsy after MVD.

Prospective Comparison of Redo Microvascular Decompression and Percutaneous Balloon Compression as Primary Surgery for Recurrent Trigeminal Neuralgia

OBJECTIVE: To prospectively compare facial pain outcomes for patients having either a repeat microvascular decompression (MVD) or percutaneous balloon compression (PBC) as their surgery for trigeminal neuralgia (TN) recurrence.METHODS: Prospective cohort study of 110 patients with TN recurrence who had either redo MVD (n=68) or PBC (n=42) from July 2010 until September 2016. The mean follow-up was 45.6 months.RESULTS: After redo MVD, 65 patients (95.6%) experienced immediate relief of pain. After PBC, 34 patients (81%) were immediately relieved of their neuralgia. After 1 month, the clinical effect of redo MVD was better than PBC (p < 0.01). Patients who had redo MVD more commonly were pain free off medications (93.4% at 1 year, 78.2% at 4 years) compared with the PBC patients (85.1% at 1 year, 59.3% at 4 years). However, mean length of stay was longer (p>0.05). Patients after PBC who occurred developed herpes simplex (35.7%), facial numbness (76.2%), and annoying dysesthesia (21.4%) more frequently compared with patients after redo MVD who occurred developed herpes simplex (14.7%), facial numbness (8.8%), and hypoesthesia (5.9%) (p < 0.05). The symptoms recurred respectively in 15 patients (22.1%) and 19 patients (45.2%) after redo MVD and PBC within the entire 6-year follow-up period.CONCLUSION: For the patients with TN recurrence, redo MVD was a more effective procedure than PBC. The cure rate and immediate relief of pain were better, and the incidence of complications was lower.

Prospective Comparison of Redo Microvascular Decompression and Percutaneous Balloon Compression as Primary Surgery for Recurrent Trigeminal Neuralgia

OBJECTIVE: To prospectively compare facial pain outcomes for patients having either a repeat microvascular decompression (MVD) or percutaneous balloon compression (PBC) as their surgery for trigeminal neuralgia (TN) recurrence. METHODS: Prospective cohort study of 110 patients with TN recurrence who had either redo MVD (n=68) or PBC (n=42) from July 2010 until September 2016. The mean follow-up was 45.6 months. RESULTS: After redo MVD, 65 patients (95.6%) experienced immediate relief of pain. After PBC, 34 patients (81%) were immediately relieved of their neuralgia. After 1 month, the clinical effect of redo MVD was better than PBC (p 0.05). Patients after PBC who occurred developed herpes simplex (35.7%), facial numbness (76.2%), and annoying dysesthesia (21.4%) more frequently compared with patients after redo MVD who occurred developed herpes simplex (14.7%), facial numbness (8.8%), and hypoesthesia (5.9%) (p < 0.05). The symptoms recurred respectively in 15 patients (22.1%) and 19 patients (45.2%) after redo MVD and PBC within the entire 6-year follow-up period. CONCLUSION: For the patients with TN recurrence, redo MVD was a more effective procedure than PBC. The cure rate and immediate relief of pain were better, and the incidence of complications was lower.

Microvascular Decompression for Glossopharyngeal Neuralgia: Clinical Analyses of 30 Cases

OBJECTIVE: We present our experience of microvascular decompression (MVD) for glossopharyngeal neuralgia (GPN) and evaluate the postoperative outcomes in accordance with four different operative techniques during MVD. METHODS: In total, 30 patients with intractable primary typical GPN who underwent MVD without rhizotomy and were followed for more than 2 years were included in the analysis. Each MVD was performed using one of four different surgical techniques: interposition of Teflon pieces, transposition of offending vessels using Teflon pieces, transposition of offending vessels using a fibrin-glue-coated Teflon sling, and removal of offending veins. RESULTS: The posterior inferior cerebellar artery was responsible for neurovascular compression in 27 of 30 (90%) patients, either by itself or in combination with other vessels. The location of compression on the glossopharyngeal nerve varied; the root entry zone (REZ) only (63.3%) was most common, followed by both the REZ and distal portion (26.7%) and the distal portion alone (10.0%). In terms of detailed surgical techniques during MVD, the offending vessels were transposed in 24 (80%) patients, either using additional insulation, offered by Teflon pieces (15 patients), or using a fibrin glue-coated Teflon sling (9 patients). Simple insertion of Teflon pieces and removal of a small vein were also performed in five and one patient, respectively. During the 2 years following MVD, 29 of 30 (96.7%) patients were asymptomatic or experienced only occasional pain that did not require medication. Temporary hemodynamic instability occurred in two patients during MVD, and seven patients experienced transient postoperative complications. Neither persistent morbidity nor mortality was reported. CONCLUSION: This study demonstrates that MVD without rhizotomy is a safe and effective treatment option for GPN.

Microvascular decompression for hemifacial spasm induced by vertebral artery dissecting aneurysm: one case report / 浙江大学学报·医学版

A 61-year-old female presented with 4 years history of left-sided hemifacial spasm. Head MRI and angiography indicated left vertebral artery dissecting aneurysm which compressed ipsilateral cranial nerves Ⅶ and Ⅷ. Microvascular decompression was performed. The dissecting aneurysm was pushed apart and the distal part of the parent artery was adhered to the dura on the petrosum. The compressed nerves were totally decompressed. The symptom of facial spasm was completely resolved immediately after surgery and did not recur during 6 months of follow up.

Bioglue-Coated Teflon Sling Technique in Microvascular Decompression for Hemifacial Spasm Involving the Vertebral Artery

OBJECTIVE: Microvascular decompression (MVD) for hemifacial spasm (HFS) involving the vertebral artery (VA) can be technically challenging. We investigated the therapeutic effects of a bioglue-coated Teflon sling technique on the VA during MVD in 42 cases. METHODS: A bioglue-coated Teflon sling was crafted by the surgeon and applied to patients in whom neurovascular compression was caused by the VA. The radiologic data, intra-operative findings with detailed introduction of the procedure, and the clinical outcomes of each patient were reviewed and analyzed. RESULTS: The 42 patients included in the analysis consisted of 22 females and 20 males, with an average follow-up duration of 76 months (range 24–132 months). Intraoperative investigation revealed that an artery other than the VA was responsible for the neurovascular compression in all cases : posterior inferior cerebellar artery (PICA) in 23 patients (54.7%) and anterior inferior cerebellar artery (AICA) in 11 patients (26.2%). All patients became symptom-free after MVD. Neither recurrence nor postoperative neurological deficit was noted during the 2-year follow-up, except in one patient who developed permanent deafness. Cerebrospinal fluid (CSF) leak occurred in three patients, and one required dural repair. CONCLUSION: Transposition of the VA using a bioglue-coated Teflon sling is a safe and effective surgical technique for HFS involving the VA. A future prospective study to compare clinical outcomes between groups with and without use of this novel technique is required.

A Clinical Analysis of Secondary Surgery in Trigeminal Neuralgia Patients Who Failed Prior Treatment

OBJECTIVE: Although many treatment modalities have been introduced for trigeminal neuralgia (TN), the long-term clinical results remain unsatisfactory. It has been particularly challenging to determine an appropriate treatment strategy for patients who have responded poorly to initial therapies. We analyzed the surgical outcomes in TN patients who failed prior treatments. METHODS: We performed a retrospective analysis of 37 patients with recurrent or persistent TN symptoms who underwent surgery at our hospital between January 2010 and December 2014. Patients with follow-up data of at least one year were included. The prior treatment modalities of the 37 patients included microvascular decompression (MVD), gamma knife radiosurgery (GKRS), and percutaneous procedures such as radiofrequency rhizotomy (RFR), balloon compression, and glycerol rhizotomy (GR). The mean follow-up period was 69.9 months (range : 16–173). The mean interval between the prior treatment and second surgery was 26 months (range : 7–123). We evaluated the surgical outcomes using the Barrow Neurological Institute (BNI) pain intensity scale. RESULTS: Among the 37 recurrent or persistent TN patients, 22 underwent MVD with partial sensory rhizotomy (PSR), 8 received MVD alone, and 7 had PSR alone. Monitoring of the surgical treatment outcomes via the BNI pain intensity scale revealed 8 (21.6%) patients with a score of I, 13 (35.1%) scoring II, 13 (35.1%) scoring III, and 3 (8.2%) scoring IV at the end of the follow-up period. Overall, 91.8% of patients had good surgical outcomes. With regard to postoperative complications, 1 patient had transient cerebrospinal fluid rhinorrhea (2.7%), another had a subdural hematoma (2.7%), and facial sensory changes were noted in 8 (21.1%) patients after surgery. CONCLUSION: Surgical interventions, such as MVD and PSR, are safe and very effective treatment modalities in TN patients who failed initial or prior treatments. We presume that the combination of MVD with PSR enabled us to obtain good short- and long-term surgical outcomes. Therefore, aggressive surgical treatment should be considered in patients with recurrent TN despite failure of various treatment modalities.

Microvascular Decompression for Tinnitus / 한양의대학술지

Tinnitus had been considered a surgically incurable disease, given the failure of several treatment methods. Jannetta reported that tinnitus is one of the hyperactive diseases of the cranial nerve along with hemifacial spasm and trigeminal neuralgia (TGN). Microvascular decompression (MVD) of the eighth cranial nerve was introduced to treat medically intractable tinnitus. Intraoperative monitoring of brainstem auditory evoked potential (BAEP) was able to reduce postoperative complication rates. Less than 1 ms of latency delay and a 40% decrease in amplitude of wave V of the brainstem evoked potential is a landmark of monitoring during surgery. Less than 6 years of duration of tinnitus, normal BAEP before surgery, no accompanying dizziness before surgery and a loop-type offending artery are effective factors for good surgical results of MVD.