Fully Endoscopic Vascular Decompression of the Trigeminal Nerve

Abstract

Microvascular decompression of the trigeminal nerve is an accepted and effective means of treating patients with trigeminal neuralgia in whom compression of the nerve by a vascular structure is implicated in the pathogenesis of the disease. The current standard technique uses the binocular operating microscope for all intra-operative visualization. Posterior fossa endoscopy has demonstrated that the endoscope provides more comprehensive views of the anatomy of the cerebellopontine angle than does the operating microscope. To date, endoscopy has only been used to supplement microscopy in cranial nerve decompression surgery. In this report, we describe our completely endoscopic surgical technique as we present the case of a patient with trigeminal neuralgia who underwent successful vascular decompression by this approach. Using this technique the offending vessel was separated from the nerve with minimal brain retraction or dissection of surrounding structures. This report represents the first documented case where the endoscope was used as the exclusive imaging modality for decompression of the trigeminal nerve. From our experience we conclude that the endoscope's superior visualization more accurately identifies neurovascular conflicts, and provides a comprehensive evaluation of the completeness of the decompression. Additionally, this new method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. From this study we conclude that completely endoscopic vascular decompression represents the next step forward in the safe and effective surgical treatment of trigeminal neuralgia.

Apport de l’endoscopie pour la décompression microvasculaire dans l’angle ponto-cérébelleux : à propos de 27 cas

“…Outre le caractère moins invasif de l'endoscopie, son intérêt réside également dans les possibilités d'exploration offertes par les optiques et, notamment, celles angulées qui permettent de contourner les obstacles anatomiques autorisant des explorations plus complètes. L'intérêt de l'endoscope lors des procédures totalement endoscopiques pourrait être encore plus évident car il pourrait permettre de supprimer toute rétraction d'éléments neurologiques par l'utilisation d'une optique et d'une instrumentation angulées (Jarrahy et al, 2002).…”

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.…”