Patients experience significant benefit from optic nerve decompression irrespective of pre-operative visual status. Although early decompression is desirable, good results can still be obtained in patients with severe visual failure. Detailed data on visual outcome can help counsel patients pre-operatively to aid decision-making and set expectations.
Petrous endostosis is an uncommon finding in posterior fossa procedures for TN (3.4%). However, it can obscure the region of neurovascular conflict, which is venous compression in these cases. We have found that drilling away endostosis or using endoscopic-assisted microsurgery increases the chances of good outcome and avoids unnecessary rhizotomy. All magnetic resonance imaging scans should be inspected for evidence of petrous endostosis and, when present, a bone window computed tomographic scan should be performed to clarify the image and check for the presence of petrous air cells. If the endostosis is drilled, failure to detect and to seal these air cells thoroughly can result in postoperative cerebrospinal fluid rhinorrhea. Attention to these details will optimize the surgical results. However, the use of an angled endoscope avoids this problem and is now our preferred method.
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