Fully Endoscopic Vascular Decompression of the Glossopharyngeal Nerve

Abstract

Microvascular decompression of the glossopharyngeal nerve is an effective treatment of patients with glossopharyngeal neuralgia in whom compression of the nerve by a blood vessel is implicated in the pathogenesis of the disease. The standard surgical technique uses a binocular operating microscope for intra-operative visualization. Growing experience with posterior fossa endoscopy, however, has suggested that endoscopes may provide more comprehensive anatomical views of cerebellopontine angle. This report describes the case of a patient suffering from glossopharyngeal neuralgia who underwent fully endoscopic vascular decompression of the glossopharyngeal nerve. During this procedure the endoscope was used to survey the posterior fossa, guide the placement of insulating sponges, and conduct a final assessment of the intervention. We found the endoscope ideally suited to the constricted operating space of the posterior fossa, allowing for accurate localization and careful separation of the pathological vascular conflict with minimal brain retraction and no damage to surrounding structures. The versatility of endoscopy allows for superior visual appreciation of neurovascular conflicts in the posterior fossa. To date, endoscopy has primarily been used to supplement microscopy in cranial nerve decompression surgery. This report demonstrates how the endoscope can be used as the sole imaging modality in glossopharyngeal nerve decompression, with excellent results.

Fully endoscopic microvascular decompression for hemifacial spasm

“…5,14 In recent years, endoscopy has entered the neurosurgical arena as an attractive alternative or adjunct for conventional microsurgery. 1,7,[15][16][17]20,27,28,33 The endoscope provides the advantage over the microscope of enhanced and safe visualization of the neurovascular anatomy. 23 The panoramic view afforded by the endoscope enlarges the surgical field of vision while eliminating cerebellar or brainstem retraction and the need for extensive dissection, which is necessary when using the microscope, to allow for an unobstructed view of the relevant neurovascular structures.…”

Endoscopic Minimally Invasive Neurosurgery: Emerging Techniques and Expanding Role through an Extensive Review of the Literature and Our Own Experience – Part II: Extraendoscopic Neurosurgery

“…Recently, the Shahinian group in Los Angeles [48,49,50] published a series of case reports of endoscopic vascular decompressions (EVD) for the treatment of trigeminal neuralgia, glossopharyngeal neuralgia, and excision of vestibular schwannomas. Their initial results highlight the many advantages of purely endoscopic approaches, namely the superior visualization of the anatomy and panoramic views, thus facilitating the decompression through the available operating window with otherwise narrow views.…”

Minimally Invasive Endoscopic and Endoscopy-Assisted Microsurgery of Vestibular Schwannoma

“…Although its use has been described as an adjunctive imaging modality in many surgical procedures the use of endoscopy as the sole means of intra-operative imaging in this setting has not been reported at that time. Microvascular decompressions were the first fully endoscopic procedures reported (Eby et al 2001, Jarrahy et al 2002a, Jarrahy et al 2002b, Kabil et al 2005, Cheng et al 2008). The first report of fully endoscopic resection of vestibular schwannoma was by Shainian and coworkers in 2004 (Shahinian et al 2004).…”

“…However this potential problem was solved with introduction of either rigid pneumatic holding arms for the endoscope or freehand endoscopic technique with the endoscope being moved and held by a second surgeon. Both techniques were shown to be safe at allowing bimanual surgical dissection (Eby et al 2001, Jarrahy et al 2002a, Jarrahy et al 2002b, Schroeder et al 2004, Kabil & Shahinian, 2006, de Vitiis et al 2007). Another important step forward was the introduction of an irrigation system, eliminating the time consuming and unsafe practice of removing and reinserting the endoscope.…”

“…Among the main drawbacks of endoscopic surgery of vestibular schwannoma is the risk of injury of very sensitive and critical structures of the cerebellopontine angle as the endoscope does not see the instrument used before it passes in front of the lens. Thus it is mandatory to achieve synchronized, in-and-out movements of the endoscope together with the instruments (Jarrahy et al 2002a, Jarrahy et al 2002b, Kabil & Shahinian, 2006, de Vitiis et al 2007). Using the video-endoscopy assisted microsurgical technique the handling of instruments is controlled by the microscope befor e comin g in fr on t of t h e len s of t h e endoscope , Miyazaki et al 2005, Betka et al 2010, Gerganov et al 2010.…”