Adverse Events After Microvascular Decompression: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications. OBJECTIVE: To determine the incidence and risk factors for adverse events after MVD. METHODS: Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006-2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay. RESULTS: Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III-IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P < 0.04). CONCLUSIONS: In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

Re-Exploration of Microvascular Decompression in Recurrent Trigeminal Neuralgia and Intraoperative Management Options.

BACKGROUND: Trigeminal neuralgia (TGN) is a debilitating disorder, and in patients for whom medical management is not sufficient, there are several therapeutic options. Microvascular decompression (MVD) for TGN has been shown to be highly effective; however, pain does recur after MVD in some patients. Therapeutic options for recurrent TGN are the same as those for primary TGN, including re-exploration of MVD (re-MVD). In this study we review our practice of re-MVD, comparing it with alternative options and assessing its safety and efficacy. METHODS: Retrospective analysis of prospectively collected data of patients undergoing re-MVD between 2007 and 2016. RESULTS: Thirty-two patients underwent re-MVD, all with a Barrow Neurosurgical Institute Pain Index (BNPI) of IV or V. Postoperatively, 87% of patients reported an improvement in their BNPI to III or better, with 50% being BNPI 1 or 2. Eleven patients without distortion or vascular conflict at the time of re-exploration underwent intraoperative neurolysis, and 90% reported improvement in their BNPI. Kaplan-Meier analysis showed a median pain-free period of 36 months after re-MVD. There were no significant complications. CONCLUSIONS: Re-MVD is a safe and effective method of treating recurrent TGN. Intraoperative neurolysis is an important tool in re-exploration and should be considered when there is no ongoing compression or distortion of the trigeminal nerve.

Fatal complications following microvascular decompression: could it be avoided and salvaged?

Although the microvascular decompression (MVD) surgery has become an effective remedy for cranial nerve rhizopathies, it is still challengeable and may result in a fatal sequel sometimes. Therefore, the operative skill needs to be further highlighted with emphasis on the safety and a preplan for management of postoperative fatal complications should be established. We retrospectively analyzed 6974 cases of MVD. Postoperatively, 46 patients (0.66 %) presented decline in consciousness with a positive finger-nose test (or failure to be tested) after wake up from the anesthesia, whom were focused on in this study. Their surgical findings and intraoperative manipulation as well as computer tomography (CT) delineation were reviewed in detail. These cases consisted of trigeminal neuralgia in 37 and hemifacial spasm in 9. All these patients underwent an immediate CT scan, which demonstrated cerebellar hemorrhages in 38 and epidural hematomas in 6. A later magnetic resource image delineated cerebral infarctions in basal ganglia in 2. Eventually, 15 (0.2 %) died and 31 survived. Data analysis showed that the mortality is significantly higher in trigeminal cases with cerebellar hematoma and an immediate hematoma evacuation plus ventricular drainage could give the patient more chance of survival (p < 0.05). It appeared that the cerebellar hemorrhage was the predominant cause contributable to the postoperative consciousness decline, which occurred more often in trigeminal cases. To have a safe MVD, an appropriate surgical technique is the priority. It is very important to create a satisfactory working space before decompression of the cranial nerve root, which is obtained by a patient microdissection of the arachnoids rather than blind retraction of the cerebellum and hotheaded sacrifice of the petrous vein. Once a cerebellar hematoma is confirmed, an emergency surgery should not be hesitated. A prompt evacuation of the hematomas followed by a dual ventricular drainage via both the frontal horns may save the patient.