Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Abstract

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure-with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed. Video LinkThe video component of this article can be found at https://www.jove.com/video/2590/ Protocol 1. Positioning 1. Positioning is an integral component of microvascular decompression. Following induction of anesthesia, the patient is placed in pins while on the operating room table and moved to the lateral park bench position with side of the desired MVD placed up. Of note, JSN prefers to insert a lumbar drain prior to the procedure to allow greater control of intra-op drainage of CSF and cerebellar relaxation (the drain is then removed when the patient is discharged, often on POD2). 2. All pressure points are padded and an axillary roll is placed. The patient's chest and hips are taped securely to the table to allow rotation of the table, if necessary, later in the case. The patient's shoulder is taped down for purposes of visualization. The head is rotated approximately 10-15 degrees away from the affected side and the neck is flexed slightly so that the planned surgical trajectory is now almost orthogonal to the floor. The vertex is tilted slightly down. Special attention is made to ensure that there no pathologic compression of venous drainage from the head. Specifically, there should be room for at least two finger breadths between the mandible and upper thorax. Head rotation should not exceed 30 degrees. 3. c. The body is secured prior to three-point head fixation. Electrophysi...

Effectiveness and Safety of Microvascular Decompression Surgery for Treatment of Trigeminal Neuralgia

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Bone Cement Cranioplasty Reduces Cerebrospinal Fluid Leak Rate after Microvascular Decompression: A Single-Institutional Experience

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Minimally invasive asterional approach for microvascular decompression in trigeminal neuralgia

“…To improve postoperative results, some authors have chosen to refine the MVD surgical technique [9][10][11][12][13][14][15] . In this work, we present our experience in the surgical treatment of TN through a minimally-invasive asterional approach for trigeminal vascular decompression.…”