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Blue R, Yang AI, Ajmera S, Spadola M, Howard S, Saylany A, Kvint S, Harber A, Daly M, Shekhtman E, Nair A, Deshpande R, Lee JY. Pain Outcomes Following Endoscopic Microvascular Decompression for Trigeminal Neuralgia Based on Vascular Compression Type. J Neurol Surg B Skull Base 2024; 85:287-294. [PMID: 38721365 PMCID: PMC11076079 DOI: 10.1055/a-2065-9650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background Arterial compression of the trigeminal nerve at the root entry zone has been the long-attributed cause of compressive trigeminal neuralgia despite numerous studies reporting distal and/or venous compression. The impact of compression type on patient outcomes has not been fully elucidated. Objective We categorized vascular compression (VC) based on vessel and location of compression to correlate pain outcomes based on compression type. Methods A retrospective video review of 217 patients undergoing endoscopic microvascular decompression for trigeminal neuralgia categorizing VC into five distinct types, proximal arterial compression (VC1), proximal venous compression (VC2), distal arterial compression (VC3), distal venous compression (VC4), and no VC (VC5). VC type was correlated with postoperative pain outcomes at 1 month ( n = 179) and last follow-up (mean = 42.9 mo, n = 134). Results At 1 month and longest follow-up, respectively, pain was rated as "much improved" or "very much improved" in 89 69% of patients with VC1, 86.6 and 62.5% of patients with VC2, 100 and 87.5% of patients with VC3, 83 and 62.5% of patients with VC4, and 100 and 100% of patients with VC5. Multivariate analysis demonstrated VC4 as a significant negative of predictor pain outcomes at 1 month, but not longest follow-up, and advanced age as a significant positive predictor. Conclusion The degree of clinical improvement in all types of VC was excellent, but at longest follow-up VC type was not a significant predictor out outcome. However distal venous compression was significantly associated with worse outcomes at 1 month.
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Affiliation(s)
- Rachel Blue
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Andrew I. Yang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sonia Ajmera
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Michael Spadola
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Susanna Howard
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anissa Saylany
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Alexander Harber
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Megan Daly
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Emily Shekhtman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anjana Nair
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Riddhi Deshpande
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - John Y.K. Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Cheng D, Sun H, Yang F, Guo Z, Liu W, Li X. Applying the Full Endoscopic Keyhole Technique to CPA Lesions: A Single-Center Study. J Craniofac Surg 2024:00001665-990000000-01480. [PMID: 38688021 DOI: 10.1097/scs.0000000000010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/11/2024] [Indexed: 05/02/2024] Open
Abstract
In recent years, endoscopy has become an increasingly common tool used during neurosurgical procedures. However, its application in treating cerebellopontine angle (CPA) lesions has not progressed as rapidly. In this study, the authors present their initial experience with surgically treating CPA lesions using a fully endoscopic keyhole retrosigmoid approach. They conducted a retrospective analysis of clinical data from patients who underwent endoscopic keyhole CPA surgery at their center between May 2017 and April 2022. They provide a comprehensive explanation of this method and an overview of the strategies that have been developed to achieve better clinical outcomes. The study included 107 patients, consisting of 10 cases of vestibular schwannoma, 21 cases of epidermoid cyst, 32 cases of trigeminal neuralgia, and 44 cases of hemifacial spasm. The authors analyzed the clinicodemographic details of the patients. Among the 31 tumor cases, gross total resection was achieved in 25 patients (80.6%), while near-total resection was performed in 6 patients (19.4%). In patients with trigeminal neuralgia, facial pain resolved in 31 out of 32 patients (96.9%). Similarly, facial convulsions disappeared or were relieved in all 44 patients (100%) with hemifacial spasms after the operation. Postoperative complications included facial nerve paresis (n=9, 8.4%), with improvement observed in 6 cases during follow-up, transient facial hypoesthesia (n=3, 2.8%), cerebrospinal fluid rhinorrhea (n=3, 2.8%), transient abducens paresis (n=1, 0.9%), and postoperative hemorrhage (n=1, 0.9%). Endoscopy provides improved deep illumination and, combined with close-up observation, enhances the visualization of structures within the CPA region. The fully endoscopic keyhole technique is a safe and effective method for managing CPA lesions.
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Affiliation(s)
- Dekui Cheng
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, China
| | - Hanyu Sun
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, China
| | - Fengyu Yang
- Department of Neurosurgery, Chengyang People's Hospital
| | - Zhongxiang Guo
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao City, China
| | - Wei Liu
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao City, China
| | - Xin Li
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, China
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Ong V, Schupper AJ, Bederson JB, Choudhri TF, Shrivastava RK. Bibliometric Analysis of the Top 100 Cited Articles and Author H-Indexes on the Surgical Treatment of Trigeminal Neuralgia. World Neurosurg 2024; 184:44-62. [PMID: 38216034 DOI: 10.1016/j.wneu.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Medically refractory cases of trigeminal neuralgia often require treatment escalation. Surgical options include microvascular decompression and percutaneous ablation. This paper provides a bibliometric analysis of the most influential articles on the surgical management of trigeminal neuralgia. METHODS The Web of Science database was queried to identify the top 100 cited articles concerning surgical treatment of trigeminal neuralgia. The search terms used included ALL=(("trigeminal neuralgia" OR "tic douloureux" OR "Fothergill's disease" OR "Trifacial neuralgia") AND ("surgical treatment" OR "surgical management" OR "surgery" OR "neurosurgery") NOT ("radiosurgery" OR "gamma knife")). The extracted variables included the first and senior author names, journal, publication year, institution, and surgical modality. RESULTS Our bibliometric search yielded 2104 studies, with 41,502 citations overall. Within the top 100 articles, Zakrzewska had the most first author papers (n = 5), and Burchiel had the most senior author papers (n = 6). The Massachusetts General Hospital was the most represented institution (n = 5). The United States was the most represented country (51%). Microvascular decompression was the most studied surgical strategy (51%), followed by percutaneous radiofrequency coagulation (9%), balloon/nerve compression (7%), and glycerol rhizolysis (7%). Some studies assessed multiple treatment modalities (22%). The types of studies included retrospective articles (58%), prospective articles (26%), reviews (10%), anatomic studies (2%), and basic science (1%). Neurosurgery (35%) and the Journal of Neurosurgery (33%) were the most represented journals. CONCLUSIONS The current literature consists of retrospective reviews and mostly describes microvascular decompression for trigeminal neuralgia. Future studies should include further characterization of other surgical modalities such as percutaneous radiofrequency thermocoagulation, glycerol injection, and balloon compression.
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Affiliation(s)
- Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Guan H, Li S, Wang X. Fully endoscopic microvascular decompression for trigeminal neuralgia: technical note and early outcomes. Neurosurg Rev 2023; 46:292. [PMID: 37910277 DOI: 10.1007/s10143-023-02188-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/11/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
Microscopic microvascular decompression (MVD) has been considered a curative and reliable method for treating classical trigeminal neuralgia (TN) for decades. Endoscopy can provide bright illumination and a panoramic view, which enhances the visualization of the posterior fossa. In view of the above advantages of endoscopy, it gradually became an option for MVD for treating TN. This study was performed to evaluate the advantages of fully endoscopic MVD for treating TN and is presented with a description of our operative technique. From January 2020 to January 2022, 95 classical TN patients underwent fully endoscopic MVD performed by the same surgeon and assistant in our department. The assistant held the endoscope, and the surgeon operated. Brain stem auditory evoked potentials (BEMPs) were routinely monitored. For every patient, the neurovascular conflict was identified, and complete decompression was achieved. The Barrow Neurological Institute (BNI) pain intensity score was used to evaluate the degree of facial pain. The intraoperative findings, postoperative outcomes, and complications were analyzed. Immediately after the operation, 93 patients (97.9%) achieved complete pain relief (BNI score of I). Two patients (2.1%) still had some pain, but it could be adequately controlled with medicine (BNI score of III). During the 12-36 months of follow-up, recurrence was found in 3 patients (3.2%), including one patient (1.1%) with a BNI score of II and 2 patients (2.1%) with a BNI score of III. Complications were found in 5 patients (5.3%), including facial numbness in 3 patients (3.2%), vertigo in one patient (1.1%), and headache in one patient (1.1%). There were no cases of mortality, stroke, hearing impairment, facial paralysis, or other complications. Fully endoscopic MVD is a safe and effective method for treating TN. It provides bright illumination and a panoramic view for surgeons to better observe neurovascular conflicts in deep areas of the cerebellopontine angle (CPA).
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Affiliation(s)
- Hongpeng Guan
- Department of Neurosurgery, Xinhua Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Kongjiang Road & No.1665, Shanghai, 200092, China
| | - Shiting Li
- Department of Neurosurgery, Xinhua Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Kongjiang Road & No.1665, Shanghai, 200092, China
| | - Xuhui Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Kongjiang Road & No.1665, Shanghai, 200092, China.
- Department of Neurosurgery, Chongming Hospital Affiliated with Shanghai University of Medicine and Health Sciences, Nanmen Road & No. 25, Shanghai, 202150, China.
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Hirata S, Kobayashi M, Ujihara M, Takabatake K, Fujimaki T. Preoperative findings in relation to the usefulness of endoscopic assistance for microvascular decompression. Acta Neurochir (Wien) 2023; 165:3011-3017. [PMID: 37656306 DOI: 10.1007/s00701-023-05762-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Endoscopy is known to be a useful adjunct for microvascular decompression (MVD) surgery, assisting observation in blind spots such as Meckel's cave in cases of trigeminal neuralgia (TN) and the root exit zone (REZ) in hemifacial spasm (HFS). However, few reports have discussed the usefulness of endoscopy in relation to individual patient characteristics or preoperative magnetic resonance imaging (MRI). METHODS We retrospectively reviewed the medical records of 109 patients (98 with HFS and 11 with TN, 85 women, median age 55 years) who had undergone endoscopically assisted MVD at our institution between 2017 and 2021. The usefulness of endoscopy in individual cases was scored by three neurosurgeons using a grading scale: 2, essential and indispensable; 1, useful and helpful; 0, not necessary. The mean value of the assigned scores was taken as an indicator of "usefulness," and endoscopy was considered to have been "useful" in cases with a score of > 1.0. RESULTS Endoscopic assistance was judged to have been useful in 69% of the patients. The proportion of patients evaluated as useful was significantly lower for TN (18.2%) than for HFS (74.5%). Patients with superior cerebellar artery compression had significantly lower scores than patients with other vessels. Endoscopy was considered useful in a significantly higher proportion of patients with anatomically complicated offending vessels (bifurcation or strong meandering) in the REZ detected by preoperative MRI (P < 0.005). CONCLUSION Endoscopy for MVD is useful for patients with HFS, especially when preoperative MRI shows bifurcation or strongly meandering vessels in the REZ.
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Affiliation(s)
- Sachiko Hirata
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan.
| | - Masahito Kobayashi
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Masaki Ujihara
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Kazuhiko Takabatake
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
| | - Takamitsu Fujimaki
- Department of Neurosurgery, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, 350-0495, Japan
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Sekhar LN, Shenoy VS, Holdefer R, White M. Commentary: A Novel Approach to Microvascular Decompression for Hemifacial Spasm: Method Description and Associated Outcomes. Oper Neurosurg (Hagerstown) 2022; 23:e23-e25. [PMID: 35726931 DOI: 10.1227/ons.0000000000000263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | | | - Robert Holdefer
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Melodie White
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Microvascular decompression: a bibliometric analysis of the 100 most cited papers. World Neurosurg 2022; 164:e67-e81. [DOI: 10.1016/j.wneu.2022.03.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/28/2022] [Indexed: 11/20/2022]
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8
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Yano S, Hiraoka F, Morita H, Kawano H, Kuwajima T, Yoshida SI, Hama Y, Tashiro N, Hamaguchi S, Aikawa H, Go Y, Kazekawa K. Usefulness of endoscope-assisted surgery under exoscopic view in skull base surgery: A technical note. Surg Neurol Int 2022; 13:30. [PMID: 35242396 PMCID: PMC8888302 DOI: 10.25259/sni_965_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The use of the exoscope has been increasing in the field of neurosurgery, as it can set the visual axis freely, enabling the surgeon to operate in a comfortable posture. Although endoscope-assisted surgery for compensation of insufficient surgical field is useful under the microscope, we report that using an endoscope in exoscopic surgery is safer and more useful. Methods: The exoscope used was ORBEYE. All surgical procedures were performed exoscopically from the beginning of the surgery. When endoscopic observation was required during the operation, the endoscope was inserted under observation by an exoscope. The exoscopic screen was 4K-3D and endoscopic screen was 4K-2D, the operation was performed while observing both screens at the same time. The endoscope was held manually or by a mechanical holder. Results: Twenty-two cases, including 14 requiring microvascular decompression (MVD) and eight requiring tumor removal, were performed by endoscopic-assisted exoscopic surgery. The endoscope could be inserted safely because its relationship with the surrounding structure could be observed under the exoscope, and the operator could observe both screens without moving the head. Fourteen of 22 patients required additional endoscopic treatment. Satisfactory two-handed operation was performed in 13 cases. Symptomatology disappeared in all cases of MVD, and sufficient tumor resection was achieved. Conclusion: Exoscopic surgery provides excellent surgical view that is not inferior to conventional microsurgery. As a large space can be secured between the scope and the surgical field, it is safer and easier to manipulate the endoscope under the exoscope.
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McGahan BG, Albonette-Felicio T, Kreatsoulas DC, Magill ST, Hardesty DA, Prevedello DM. Simultaneous Endoscopic and Microscopic Visualization in Microvascular Decompression for Hemifacial Spasm. Oper Neurosurg (Hagerstown) 2021; 21:540-548. [PMID: 34662911 DOI: 10.1093/ons/opab348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/31/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hemifacial spasm (HFS) is a socially limiting condition leading to decreased quality of life that can be treated with microvascular decompression (MVD). Endoscopy has been described as an adjunct to traditional microscopy for MVD, although the best visualization technique is debated. OBJECTIVE To review the current literature on use of endoscopy in MVD for HFS and to describe the simultaneous microscopic and endoscopic visualization technique along with a video illustration. METHODS Patients who underwent MVD for HFS were retrospectively reviewed from January 2011 to December 2019. The first set of patients in the series were done using traditional endoscopic assisted visualization, followed by a change in technique in the subsequent patients using the simultaneous endoscopic technique. The surgical technique is described as well as illustrated with a video. RESULTS In total, 21 patients underwent 24 MVDs to treat HFS. The simultaneous endoscopic/microscopic technique was used in 48% of cases for visualization. All but one patient had resolution of their symptoms immediately after the procedure. In total, 7 patients had recurrence of HFS, with 4 (17%) resolving spontaneously and 3 (13%) ultimately undergoing redo MVD. Postoperatively 7 patients (29%) had transient complications that all resolved completely. There was no significant difference between the traditional alternating microscopic and endoscopic technique with the simultaneous endoscopic microscopic technique. CONCLUSION Endoscopic assistance during MVD for HFS is beneficial and may be streamlined by using the simultaneous microscope and endoscope visualization technique.
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Affiliation(s)
- Ben G McGahan
- Department of Neurosurgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | | | - Daniel C Kreatsoulas
- Department of Neurosurgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Stephen T Magill
- Department of Neurosurgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA.,Northwestern University, Feinberg School of Medicine, Neurological Surgery, Chicago, IL, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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10
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Fully endoscopic versus microscopic vascular decompression for hemifacial spasm: a retrospective cohort study. Acta Neurochir (Wien) 2021; 163:2417-2423. [PMID: 33765219 DOI: 10.1007/s00701-021-04824-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Microvascular decompression (MVD) is the preferred surgical method for hemifacial spasm (HFS). The purpose of this study was to analyze the effectiveness and safety of fully endoscopic MVD for HFS relative to microscopic MVD. MATERIAL AND METHODS The retrospective study was conducted on HFS patients who underwent microscopic or fully endoscopic MVD from January 2018 to March 2019. All patients were treated at a single institution and by a single surgeon. Patients were divided into two groups based on the surgical method, and clinical data were then compared between groups. RESULTS A total of 116 patients, including 54 cases who received fully endoscopic MVD (E group) and 62 cases who received microscopic MVD (M group), were included in this study. Follow-up efficacy did not differ significantly between groups, with total effective rates of 88.9% in the E group and 90.3% in the M group. When postoperative complications were compared individually, there were no statistically significant differences between the two groups; however, the E group had a higher total incidence of complications than the M group (48.1% vs. 29.0%, P = 0.034). CONCLUSION Although both fully endoscopic and microscopic MVD for HFS achieved good efficacy, the former method had a higher total incidence of complications. Based on the results of this study, there is no evidence that a microscope can be replaced by a full endoscope in MVD for HFS.
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11
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El Refaee E, Fleck S, Matthes M, Marx S, Baldauf J, Schroeder HWS. Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery. Oper Neurosurg (Hagerstown) 2021; 20:E399-E405. [PMID: 33693935 DOI: 10.1093/ons/opab008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microvascular decompression (MVD) is the most effective treatment option for hemifacial spasm (HFS). However, deeply located forms of compression would require proper identification to allow for adequate decompression. OBJECTIVE To describe the usefulness of endoscopic visualization in one of the most challenging compression patterns in HFS, where the posterior inferior cerebellar artery (PICA) loop is severely indenting the brain stem at the proximal root exit zone of facial nerve along the pontomedullary sulcus. METHODS Radiological and operative data were checked for all patients in whom severe indentation of the brainstem by PICA at pontomedullary sulcus was recorded and endoscope-assisted MVD was performed. Clinical correlation and outcome were analyzed. RESULTS A total of 58 patients with HFS were identified with radiological and surgical evidence proving brainstem indentation at the VII transitional zone. In 31 patients, PICA was the offending vessel to the facial nerve. In 3 patients, the PICA loop was mobilized under visualization of a 45° endoscope. A total of 31 patients had a mean follow-up duration of 52.1 mo. The mean duration between start of complaints and surgery was 7.2 yr. In the last follow-up, all patients had remarkable spasm improvement. A total of 5 patients had more than 90% disappearance of spasms and 26 patients experienced spasm-free outcome. CONCLUSION Although severe indentation of brain stem implies morphological damage, outcome after MVD is excellent. A 45° endoscope is extremely helpful to identify compression down at the pontomedullary sulcus. Deeply located compression site can easily be missed with microscopic inspection alone.
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Affiliation(s)
- Ehab El Refaee
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany.,Department of Neurosurgery, Cairo University, Giza, Egypt
| | - Steffen Fleck
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Sascha Marx
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Joerg Baldauf
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
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12
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Khan NR, Morcos JJ. Commentary: Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery. Oper Neurosurg (Hagerstown) 2021; 20:E406-E407. [PMID: 33693928 DOI: 10.1093/ons/opab027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/14/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nickalus R Khan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jacques J Morcos
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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13
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Feng BH, Zhong WX, Li ST, Wang XH. Fully endoscopic microvascular decompression of the hemifacial spasm: our experience. Acta Neurochir (Wien) 2020; 162:1081-1087. [PMID: 32133573 DOI: 10.1007/s00701-020-04245-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/23/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Microvascular decompression (MVD) surgery has been accepted as a potentially curative method for hemifacial spasm (HFS). The primary cause of failure of MVD is incomplete decompression of the offending vessel due to inadequate visualization. This study is aimed at evaluating the benefit of endoscopic visualization and the value of fully endoscopic MVD. METHODS From March 2016 to March 2018, 45 HFS patients underwent fully endoscopic MVD in our department. From opening the dura to preparing to close, the assistant held the endoscope and the surgeon operated. Abnormal muscle response (AMR) and brainstem auditory evoked potentials (BAEP) were monitored. For every patient, the offending vessel was transposed or interposed and achieved complete decompression. AMR was used to evaluate the adequacy of decompression at the end of the surgery. The intra-operative findings and postoperative outcomes and complications were analyzed. RESULTS Immediately after surgeries, 39 patients (86.7%) achieved excellent result; 2 cases (4.4%) had good result. So the postoperative effective rate was 91.1% (41/45). During 12-36 month follow-up, the outcomes were excellent in 42 cases (93.3%) and good in 2 cases (4.4%), and the effective rate reached to 97.8% (44/45). No recurrence was noted. The postoperative complications were found in 2 patients (4.4%). One patient (2.2%) showed delayed facial palsy on the tenth day but was fully recovered 1 month later. Intracranial infection was noticed in 1 patient (2.2%) and was cured by using intravenous antibiotics for 2 weeks. There was no hearing impairment, hoarseness, or other complications. CONCLUSIONS Fully endoscopic MVD is both safe and effective in the treatment of HFS. Electrophysiological monitoring is helpful to gain a good result and reduce hearing impairment.
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Affiliation(s)
- Bao-Hui Feng
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, the Cranial Nerve Disease Center of Shanghai JiaoTong University, Shanghai, 200092, China
| | - Wen-Xiang Zhong
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, the Cranial Nerve Disease Center of Shanghai JiaoTong University, Shanghai, 200092, China
| | - Shi-Ting Li
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, the Cranial Nerve Disease Center of Shanghai JiaoTong University, Shanghai, 200092, China
| | - Xu-Hui Wang
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, the Cranial Nerve Disease Center of Shanghai JiaoTong University, Shanghai, 200092, China.
- Department of Neurosurgery, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Chongming Branch, Shanghai, 202150, China.
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Blue R, Li C, Spadola M, Saylany A, McShane B, Lee JYK. Complication Rates During Endoscopic Microvascular Decompression Surgery Are Low With or Without Petrosal Vein Sacrifice. World Neurosurg 2020; 138:e420-e425. [PMID: 32145425 DOI: 10.1016/j.wneu.2020.02.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Endoscopic-microvascular decompression (E-MVD) is a well-described treatment for trigeminal neuralgia (TGN), but there has been debate on the safety of intraoperative sacrifice of the petrosal vein (PV) due to concern for subsequent venous insufficiency. Our objective was to investigate the risk of PV sacrifice during E-MVD in TGN and subsequent postoperative complications and pain outcomes. METHODS 5 five-year review yielded 201 patients who underwent MVD for TGN. PV sacrifice, vascular compressive anatomy, and postoperative complications attributable to venous insufficiency were analyzed. Preoperative and postoperative pain outcomes were analyzed. RESULTS PV was sacrificed in 118 of 201 (59%) of patients, with 43 of 201 (21%) patients undergoing partial sacrifice versus 75 of 201 (37%) with complete sacrifice. No cases of venous infarction, cerebellar swelling, or fatal complications were noted in either cohort. Non-neurologic complications occurred in 1.69% (2 of 118) of patients with PV sacrifice and 0% (0 of 83) of patients with PV preservation. Neurologic deficits (facial palsy, conductive hearing loss, gait instability, memory deficit) occurred in equal proportions in PV preservation and sacrifice groups (2.41% vs. 1.69%) Overall, 87.3% (145 of 166) patients reported their pain as "very much improved" or "much improved" at 1 month, and no difference between groups was identified. CONCLUSIONS This study did not find higher complication rates in patients undergoing petrosal vein sacrifice during E-MVD for trigeminal neuralgia. In this series where petrosal vein was sacrificed only 59% of the time, it appears to be a safe technique, but larger studies will be needed to determine true incidence of complications after PV sacrifice.
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Affiliation(s)
- Rachel Blue
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Carrie Li
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Spadola
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anissa Saylany
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brendan McShane
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Farid AM, ElKheshin SE. Endoscope Assisted Microvascular Decompression: Are the Advantages Still Worthy Towards More? EGYPTIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1186/s41984-019-0072-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Microvascular decompression is the definitive treatment of various neuralgias affecting cranial nerves. The compression on a cranial nerve could be at the root entry zone, especially the trigeminal nerve. Endoscope-assisted microsurgery may help avoid missing a hidden vascular structure.
Study design
Retrospective clinical case series.
Patient and methods
Twenty-five patients with facial pain and five patients with hemifacial spasm constituted this study. FIESTA MRI was the pre-operative neuroimaging modality. Retrosegmoid craniectomy was done for all patients. Microscope was initially used for exploration and arachnoid dissection around the nerve. The endoscope was applied thereafter for exploration and confirmation of the proper insertion of the Teflon.
Results
Using the endoscope, cerebellar retraction was reduced by 0.5 to 0.8 cm in 90% of patients. Root entry zone and entry of the nerve through the corresponding skull base foramen was clearly visualized by the endoscope. Endoscope enabled a wider area of exploration and panoramic view, which could not be obtained by the microscope. Patients with trigeminal neuralgia had a median pre-operative VAS of 9, while it was only 1 in early post-operative and 0 in 6-month post-operatively. Patients with HFS were completely recovered.
Conclusion
The advantages of microvascular decompression are still worthy. Complications are minimal, and the view is much more panoramic. The different viewing angles and ability to directly reach corners is an absolute endoscopic advantage. Therefore, avoidance of missing vascular structures and incomplete recovery can be assured.
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Flanders TM, Blue R, Roberts S, McShane BJ, Wilent B, Tambi V, Petrov D, Lee JYK. Fully endoscopic microvascular decompression for hemifacial spasm. J Neurosurg 2019; 131:813-819. [PMID: 30497190 DOI: 10.3171/2018.4.jns172631] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 04/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hemifacial spasm (HFS) is characterized by involuntary tonic and/or clonic contractions of facial nerve muscles. Fully endoscopic microvascular decompression (E-MVD) for HFS has not been widely adopted. This paper aims to illustrate the safety and efficacy of the fully endoscopic technique for HFS treatment. METHODS The authors conducted a single-center retrospective study of 27 patients (28 separate E-MVD cases; 1 patient had bilateral E-MVD) diagnosed with HFS who underwent fully E-MVD from January 2013 to October 2016. Intraoperative brainstem auditory evoked potentials and lateral spread resolution were reviewed. Outcome was based on the clinical status of the patient at the last contact point with the senior author. Complications were categorized as facial weakness, hearing loss, ataxia, dysphagia, or any adverse event able to be attributed to the surgical procedure. RESULTS HFS was relieved either completely or partially in the majority of cases (24 of 28, 85.7%). Of the 28 separate procedures, 17 (60.7%) resulted in complete resolution of symptoms, 4 (14.3%) resulted in near-complete resolution, 2 (7.1%) resulted in 50% reduction of symptoms, 1 (3.6%) resulted in minimal reduction, and 4 (14.3%) resulted in no relief. Of the 27 patients, 26 (96%) had no permanent postoperative complications. In multivariate logistic regression, the best predictor of greater than 50% resolution of spasm was resolution of intraoperative lateral spread response. CONCLUSIONS A fully E-MVD for HFS provides a safe and comprehensive view of the neurovascular conflict. Exclusive use of the endoscope in MVD is both safe and feasible in the treatment of HFS. Attention to lateral spread response monitoring remains an integral part of comprehensive neurosurgical management.
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Affiliation(s)
- Tracy M Flanders
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Rachel Blue
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Sanford Roberts
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Brendan J McShane
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | | | - Dmitriy Petrov
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - John Y K Lee
- 1Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Pure Endoscopic Surgery via Subtemporal Extradural Keyhole Approach for Middle Cranial Fossa Tumors. World Neurosurg 2019; 130:e487-e497. [DOI: 10.1016/j.wneu.2019.06.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/27/2022]
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A minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal: a step by step description. Braz J Otorhinolaryngol 2019; 87:47-52. [PMID: 31494085 PMCID: PMC9422673 DOI: 10.1016/j.bjorl.2019.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/01/2019] [Accepted: 06/22/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction Arachnoid cyst in the internal auditory canal is a quite rare pathology but due to its compressive action on the nerves in this district should be surgically removed. Several surgical techniques have been proposed but no surgeons have used the minimally assisted endoscope retrosigmoid approach for its removal. Objective To investigate the feasibility of using a minimally invasive endoscope assisted retro-sigmoid approach for surgical removal of arachnoid cysts in the internal auditory canal. Methods Minimally invasive endoscope assisted retrosigmoid approach allows to access to the internal auditory canal through a minimally invasive retrosigmoid approach that combines the use of a microscope and an endoscope. It is performed in six steps: soft tissue step, bone step, dura step, cerebellopontine angle step (performed using an endoscope and a microscope), microscope-endoscope assisted arachnoid cysts removal and closure. We tested minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal on two human cadaveric heads (specimens) of subjects affected from audio-vestibular disorders and with arachnoid cysts in the internal auditory canal confirmed by magnetic resonance imaging. Results The mass was completely and successfully removed from the two specimens with no damage to the nerves and/or vessels in the surgical area. Conclusion The results of our study are encouraging and support the feasibility of using minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal. While further clinical in-vivo studies are needed to confirm the accuracy and safety of using the minimally invasive endoscope assisted retrosigmoid approach for this specific surgery, our group has successfully used the minimally invasive endoscope assisted retrosigmoid approach in the treatment of microvascular compressive syndrome, schwannoma removal and vestibular nerve resection.
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Li Ching Ng A, Di Ieva A. How I do it: 3D exoscopic endoscope-assisted microvascular decompression. Acta Neurochir (Wien) 2019; 161:1443-1447. [PMID: 31144166 DOI: 10.1007/s00701-019-03954-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Microvascular decompression (MVD) is an effective treatment for drug-resistant trigeminal neuralgia and hemifacial spasm. However, failure of symptomatic improvement can arise from difficulties in identifying and/or decompressing the offending vessel. Microscopic and endoscopic techniques have been used to improve visualisation and safety of the procedure but there are limitations to each technique. METHOD A 3D exoscopic endoscope-assisted MVD technique is described, including advice on potential pitfalls. CONCLUSION Compared with the standard microscope-assisted techniques, the 3D exoscopic endoscope-assisted MVD offers an improved visualisation without compromising the field of view within and outside the surgical field.
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Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience. Braz J Otorhinolaryngol 2019; 85:465-472. [PMID: 29784621 PMCID: PMC9443034 DOI: 10.1016/j.bjorl.2018.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/27/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. Objective To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. Methods We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49–71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. Results Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24 h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p < 0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. Conclusions The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.
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Kurucz P, Ganslandt O, Buchfelder M, Barany L. Arachnoid Membranes Around the Cisternal Segment of the Trigeminal Nerve: A Cadaveric Anatomic Study and Intraoperative Observations During Minimally Invasive Microvascular Decompression Surgery. World Neurosurg 2019; 125:e262-e272. [DOI: 10.1016/j.wneu.2019.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
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Wang L, Cai L, Qian H, Oh JS, Tanikawa R, Shi X. Repositioning Technique for the Decompression of Symptomatic Dolichoectatic Vertebrobasilar Pathology: A Comprehensive Review of Sling Characteristics and Surgical Experience. World Neurosurg 2019; 122:620-631. [DOI: 10.1016/j.wneu.2018.11.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
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Luzzi S, Del Maestro M, Trovarelli D, De Paulis D, Dechordi SR, Di Vitantonio H, Di Norcia V, Millimaggi DF, Ricci A, Galzio RJ. Endoscope-Assisted Microneurosurgery for Neurovascular Compression Syndromes: Basic Principles, Methodology, and Technical Notes. Asian J Neurosurg 2019; 14:193-200. [PMID: 30937034 PMCID: PMC6417326 DOI: 10.4103/ajns.ajns_279_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Microscopic microvascular decompression (MVD) has a low but not negligible failure rate due to some missed conflicts, especially in case of multiple offending vessels. The reported study is aimed to assess the principles, methodology, technical notes, and effectiveness of the endoscope-assisted (EA) MVD for neurovascular compression syndromes (NVCS) in the posterior fossa. Materials and Methods: A series of 43 patients suffering from an NVCS and undergone to an EA MVD were retrospectively reviewed. Syndromes were trigeminal neuralgia in 25 cases, hemifacial spasm in nine cases, positional vertigo in six cases, glossopharyngeal neuralgia in two cases, and spasmodic torticollis in one case. In all cases, a 0°–30° specially designed endoscope was inserted into the surgical field to find/treat those conflicts missed by the microscopic exploration. Each procedure was judged in terms of the effectiveness of the adjunct of the endoscope according to a three types classification system: Type I – improvement in the visualization of the nerve's root entry/exit zone; Type II – endoscopic detection of one or more conflicts involving the ventral aspects of the nerve and missed by the microscope; Type III – endoscope-controlled release of the neurovascular conflict otherwise difficult to treat under the only microscopic view. Results: A total of 55 conflicts were found and treated. Twenty-eight procedures were classified as Type I, nine as Type II, and six as Type III. All the patients had a full recovery from their symptoms. Conclusions: In selected cases, EA MVD offers some advantages in the detection and treatment of neurovascular conflicts in the posterior fossa.
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Affiliation(s)
- Sabino Luzzi
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | - Mattia Del Maestro
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | | | - Danilo De Paulis
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | | | | | - Valerio Di Norcia
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | | | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy
| | - Renato Juan Galzio
- Department of Neurosurgery, San Salvatore City Hospital, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
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Endoscope-Assisted Microvascular Decompression for the Management of Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia. World Neurosurg 2019; 121:e566-e575. [DOI: 10.1016/j.wneu.2018.09.166] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/21/2022]
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Belykh E, Onaka NR, Zhao X, Cavallo C, Yağmurlu K, Lei T, Byvaltsev VA, Preul MC, Nakaji P. Endoscopically Assisted Targeted Keyhole Retrosigmoid Approaches for Microvascular Decompression: Quantitative Anatomic Study. World Neurosurg 2018; 119:e1-e15. [PMID: 29960095 DOI: 10.1016/j.wneu.2018.04.218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We describe and quantitatively assess minimally invasive keyhole retrosigmoid approaches targeted to the upper, middle, and lower cranial nerve (CN) complexes of the cerebellopontine angle (CPA). METHODS Anatomic dissections were performed on 10 sides of 5 fixed, silicone-injected cadaver heads. Surgical views through various trajectories were assessed in endoscopic videos and 3-dimensional (3D) interactive virtual reality microscope views. Surgical freedom and angles of attack to the proximal and distal areas of CN complexes of the CPA were compared among upper and lower keyholes and conventional retrosigmoid craniotomy using neuronavigation. RESULTS Compared with keyholes, the conventional approach had superior surgical freedom to most areas except for the distal CN V, the root of CN VII, and the root of CN IX, where differences were not significant. The conventional retrosigmoid approach provided a larger horizontal angle of attack than either the upper or lower keyholes for all selected areas; however, the vertical angles of attack were not different. Splitting the petrosal fissure resulted in a significant increase in the vertical angle of attack to the root zones of CNs V and VII but not to the distal areas of these nerves or CN IX. Illustrative cases of endoscope-assisted keyhole retrosigmoid approaches for the treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia are presented. CONCLUSIONS Targeted keyhole retrosigmoid approaches require detailed understanding of the 3D anatomy of the CPA to create appropriate locations of corridors, including skin incisions and keyholes. Endoscope assistance complements the standard microsurgical technique by maximizing the visualization and identification of the delicate neurovascular structures.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Naomi R Onaka
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ting Lei
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vadim A Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Microsurgical Decompression of the Cochlear Nerve to Treat Disabling Tinnitus via an Endoscope-Assisted Retrosigmoid Approach: The Padua Experience. World Neurosurg 2018; 113:232-237. [DOI: 10.1016/j.wneu.2018.02.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 11/20/2022]
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Full Endoscopic Vascular Decompression in Trigeminal Neuralgia: Experience of 230 Patients. World Neurosurg 2018; 113:e612-e617. [DOI: 10.1016/j.wneu.2018.02.108] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 12/22/2022]
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Xiang H, Wu G, Ouyang J, Liu R. Prospective Study of Neuroendoscopy versus Microscopy: 213 Cases of Microvascular Decompression for Trigeminal Neuralgia Performed by One Neurosurgeon. World Neurosurg 2018; 111:e335-e339. [DOI: 10.1016/j.wneu.2017.12.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 12/07/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
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Akiyama O, Matsushima K, Gungor A, Matsuo S, Goodrich DJ, Shane Tubbs R, Klimo P, Cohen-Gadol AA, Arai H, Rhoton AL. Microsurgical and endoscopic approaches to the pulvinar. J Neurosurg 2017; 127:630-645. [DOI: 10.3171/2016.8.jns16676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEApproaches to the pulvinar remain challenging because of the depth of the target, surrounding critical neural structures, and complicated arterial and venous relationships. The purpose of this study was to compare the surgical approaches to different parts of the pulvinar and to examine the efficacy of the endoscope as an adjunct to the operating microscope in this area.METHODSThe pulvinar was examined in 6 formalin-fixed human cadaveric heads through 5 approaches: 4 above and 1 below the tentorium. Each approach was performed using both the surgical microscope and 0° or 45° rigid endoscopes.RESULTSThe pulvinar has a lateral ventricular and a medial cisternal surface that are separated by the fornix and the choroidal fissure, which wrap around the posterior surface of the pulvinar. The medial cisternal part of the pulvinar can be further divided into upper and lower parts. The superior parietal lobule approach is suitable for lesions in the upper ventricular and cisternal parts. Interhemispheric precuneus and posterior transcallosal approaches are suitable for lesions in the part of the pulvinar forming the anterior wall of the atrium and adjacent cisternal part. The posterior interhemispheric transtentorial approach is suitable for lesions in the lower cisternal part and the supracerebellar infratentorial approach is suitable for lesions in the inferior and medial cisternal parts.The microscope provided satisfactory views of the ventricular and cisternal surfaces of the pulvinar and adjacent neural and vascular structures. The endoscope provided multi-angled and wider views of the pulvinar and adjacent structures.CONCLUSIONSA combination of endoscopic and microsurgical techniques allows optimal exposure of the pulvinar.
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Affiliation(s)
- Osamu Akiyama
- 1Department of Neurological Surgery, University of Florida, Gainesville, Florida
- 2Department of Neurosurgery, Juntendo University, Tokyo
| | - Ken Matsushima
- 1Department of Neurological Surgery, University of Florida, Gainesville, Florida
- 3Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Abuzer Gungor
- 1Department of Neurological Surgery, University of Florida, Gainesville, Florida
- 4Department of Neurosurgery, Bakirkoy Research and Training Hospital for Neurology, Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Satoshi Matsuo
- 1Department of Neurological Surgery, University of Florida, Gainesville, Florida
- 5Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dylan J. Goodrich
- 6Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - R. Shane Tubbs
- 6Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- 7Seattle Science Foundation, Seattle, Washington
| | - Paul Klimo
- 8Semmes-Murphey Neurologic & Spine Institute and Le Bonheur Children's Hospital, Memphis, Tennessee; and
| | - Aaron A. Cohen-Gadol
- 9Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hajime Arai
- 2Department of Neurosurgery, Juntendo University, Tokyo
| | - Albert L. Rhoton
- 1Department of Neurological Surgery, University of Florida, Gainesville, Florida
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Lee JYK, Pierce JT, Sandhu SK, Petrov D, Yang AI. Endoscopic versus microscopic microvascular decompression for trigeminal neuralgia: equivalent pain outcomes with possibly decreased postoperative headache after endoscopic surgery. J Neurosurg 2017; 126:1676-1684. [DOI: 10.3171/2016.5.jns1621] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndoscopic surgery has revolutionized surgery of the ventral skull base but has not yet been widely adopted for use in the cerebellopontine angle. Given the relatively normal anatomy of the cerebellopontine angle in patients with trigeminal neuralgia (TN), the authors hypothesized that a fully endoscopic microvascular decompression (E-MVD) might provide pain outcomes equivalent to those of microscopic MVD (M-MVD) but with fewer complications.METHODSThe authors conducted a single-institution, single-surgeon retrospective study with patients treated in the period of 2006–2013. Before surgery, all patients completed a questionnaire that included a validated multidimensional pain-outcome tool, the Penn Facial Pain Scale (PFPS, formerly known as Brief Pain Inventory–Facial), an 11-point scale that measures pain intensity, interference with general activities of daily living (ADLs), and facial-specific ADLs. Using a standardized script, independent research assistants conducted follow-up telephone interviews.RESULTSIn total, 167 patients were available for follow-ups (66.5% female; 93 patients underwent M-MVD and 74 underwent E-MVD). Preoperative characteristics (i.e., TN classification, PFPS components, and medication use) were similar for the 2 surgical groups except for 2 variables. Patients in the M-MVD group had slightly higher incidence of V3 pain, and the 2 groups differed in the date of surgery and hence in the length of follow-up (2.4 years for the M-MVD group and 1.3 years for the E-MVD group, p < 0.05). There was a trend toward not finding neurovascular conflict at the time of surgery more frequently in the M-MVD than in the E-MVD group (11% vs 7%, p = 0.052). Internal neurolysis was more often performed in the E-MVD group (26% vs 7%, p = 0.001). The 2 groups did not significantly differ in the length of the MVD procedure (approximately 2 hours). Self-reported headaches at 1 month postoperatively were present in 21% of the patients in the M-MVD group versus 7% in the E-MVD group (p = 0.01). Pain outcomes at the most recent followup were equivalent, with patients reporting a 5- to 6-point (70%–80%) improvement in pain intensity, a 5-point (85%) improvement in pain interference with ADLs, and a 6-point (85%) improvement in interference with facial-specific ADLs. Actuarial freedom from pain recurrence was equivalent in the 2 groups, with 80% pain control at 3 years.CONCLUSIONSBoth the fully endoscopic MVD and the conventional M-MVD appear to provide patients with equivalent pain outcomes. Complication rates were also similar between the groups, with the exception of the rate of headaches, which was significantly lower in the E-MVD group 1 month postoperatively.
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Correlation Between Cerebellar Retraction and Hearing Loss After Microvascular Decompression for Hemifacial Spasm: A Prospective Study. World Neurosurg 2017; 102:97-101. [PMID: 28286281 DOI: 10.1016/j.wneu.2017.02.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study prospectively investigated the relationship between cerebellar retraction factors measured on preoperative magnetic resonance and the development of postoperative hearing loss and evaluated their potential role in predicting the possibility of hearing loss after microvascular decompression (MVD) for hemifacial spasm (HFS). METHODS The study included 110 patients clinically diagnosed with primary HFS who underwent MVD in our department. The cerebellar retraction factors were quantitatively measured on preoperative magnetic resonance. Associations of cerebellar retraction and other risk factors with postoperative hearing loss were analyzed. RESULTS Eleven patients (10%) developed nonserviceable hearing loss after MVD. Compared with the group without hearing loss, the cerebellar retraction distance and depth of the group with hearing loss were significantly greater (P < 0.05). Multivariate logistic regression analysis showed that greater cerebellar retraction depth was significantly associated with the higher incidence of postoperative hearing loss (P < 0.05). CONCLUSIONS The results in this study strongly suggested the correlation between the cerebellar retraction depth and the possibility of hearing loss after MVD for HFS. In addition, cerebellar retraction depth could be considered as a useful tool to predict the risk of post-MVD hearing loss.
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Abstract
Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadav Nishtha
- Department of Radio Diagnosis and Imaging, All India Institute of Medical Science, New Delhi, India
| | - Pande Sonjjay
- Department of Radio Diagnosis and Imaging, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Parihar Vijay
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ratre Shailendra
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Khare Yatin
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Kurucz P, Baksa G, Patonay L, Thaher F, Buchfelder M, Ganslandt O. Endoscopic approach-routes in the posterior fossa cisterns through the retrosigmoid keyhole craniotomy: an anatomical study. Neurosurg Rev 2016; 40:427-448. [DOI: 10.1007/s10143-016-0800-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/03/2016] [Indexed: 11/30/2022]
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Bartek J, Gulati S, Unsgård G, Weber C, Förander P, Solheim O, Jakola AS. Standardized reporting of adverse events after microvascular decompression of cranial nerves; a population-based single-institution consecutive series. Acta Neurochir (Wien) 2016; 158:1775-81. [PMID: 27260489 DOI: 10.1007/s00701-016-2856-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/19/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate frequencies of adverse events occurring within 30 days after microvascular decompression (MVD) surgery using a standardized report form of adverse events. METHODS We conducted a retrospective review of 98 adult patients (≥16 years) treated with MVD between 1 January 1994 and 1 June 2013. Adverse events occurring within 30 days were classified according to the Landriel Ibanez classification for neurosurgical complications: grade I represents any non-life threatening complication treated without invasive procedures; grade II is complications requiring invasive management; grade III is life-threatening adverse events requiring treatment in an intensive care unit (ICU); grade IV is death as a result of complications. We sought to compare our results with reports from the literature. RESULTS Patients' median age was 61 years (range 26-83), and 64 (65 %) were females. Indications for MVD were trigeminal neuralgia (n = 77, 79 %), glossopharyngeal neuralgia (n = 4, 4 %), hemifacial spasm (n = 16, 16 %) and combined trigeminal neuralgia and hemifacial spasm (n = 1, 1 %). The overall 30-day complication rate was 20 %, with 14 % grade I complications, 5 % grade II complications and 1 % grade III complications. The comparison with the literature was hampered by the diverse and unsystematic way of reporting complications. CONCLUSION We provide a standardized report of postoperative complications in a consecutive patient series undergoing MVD. Due to the heterogeneous and non-standardized reporting of complications in the literature, it is difficult to know if our 20 % complication rate is low or high. Standardized reporting is a necessity for meaningful and more valid comparisons across studies. The safety of MVD, a fairly standardized neurosurgical procedure, is well suited for comparisons across centers provided that complications are reported in a standardized manner.
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Affiliation(s)
- Jiri Bartek
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Sasha Gulati
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Geirmund Unsgård
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Clemens Weber
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | - Petter Förander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Solheim
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Asgeir S Jakola
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abolfotoh M, Bi WL, Hong CK, Almefty KK, Boskovitz A, Dunn IF, Al-Mefty O. The combined microscopic-endoscopic technique for radical resection of cerebellopontine angle tumors. J Neurosurg 2015; 123:1301-11. [DOI: 10.3171/2014.10.jns141465] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The combined microscopic and endoscopic technique has shown significant advantages in the management of various lesions through different approaches. Endoscopic-assisted techniques have frequently been applied to cerebellopontine angle (CPA) surgery in the context of minimally invasive craniotomies. In this paper the authors report on the use of the endoscope in the CPA as a tool to increase the extent of resection, minimize complications, and preserve the function of the delicate CPA structures. They also describe a technique of the simultaneous use of the microscope and endoscope in the CPA and dissection of CPA tumors under tandem endoscopic and microscopic vision to overcome the shortcomings of introducing the endoscope alone in the CPA. The reliability of using the microscope alone in dissecting CPA tumors is evaluated, as is the effectiveness of the combined technique in increasing the resectability of various types of CPA tumors.
METHODS
The authors conducted a retrospective analysis of 50 patients who underwent combined microscopic-endoscopic resection of CPA tumors by the senior author over a period of 3 years (February 2011 to February 2014) at Brigham and Women's Hospital, Harvard Medical School. The reliability of the extent of microscopic removal was evaluated with endoscopic exploration. Additional resection was performed with both microscopic and the combined microscopic-endoscopic technique. Endoscopically verified total resection was validated by intraoperative or postoperative MRI. The function of the cranial nerves was evaluated to assess the impact of the combined technique on their function.
RESULTS
A tumor remnant was endoscopically identified in 69% of the 26 patients who were believed to have microscopic total resection. The utilization of the endoscopic visualization and dissection increased endoscopically verified total removal to 38 patients, and 82% of these patients had no sign of residual tumor on postoperative imaging. The technique was most effective with epidermoid tumors. There were a total of 17 new cranial nerve deficits in 10 patients. Preoperative fifth cranial nerve deficits improved in 52% and hearing improved in 29% of patients after surgery.
CONCLUSIONS
This method provides simultaneous microscopic and endoscopic visualization and dissection techniques through skull-base approaches to CPA tumors. It overcomes some of the shortcomings of endoscopic-assisted surgery, further extends the surgical field, and increases the radicality of tumor resection with good functional outcomes.
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Affiliation(s)
- Mohammad Abolfotoh
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 2Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Wenya Linda Bi
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chang-Ki Hong
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 3Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, Korea; and
| | - Kaith K. Almefty
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
- 4Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Abraham Boskovitz
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ian F. Dunn
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ossama Al-Mefty
- 1Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Pre-operative image-based segmentation of the cranial nerves and blood vessels in microvascular decompression: Can we prevent unnecessary explorations? Clin Neurol Neurosurg 2015; 139:159-65. [PMID: 26476700 DOI: 10.1016/j.clineuro.2015.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 10/01/2015] [Accepted: 10/07/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study was conducted to validate the accuracy of image-based pre-operative segmentation using the gold standard endoscopic and microscopic findings for localization and pre-operative diagnosis of the offensive vessel. PATIENTS AND METHODS Fourteen TN and 6 HS cases were randomly selected. All patients had 3T MRI, which included thin-sectioned 3D space T2, 3D Time of Flight and MPRAGE Sequences. Imaging sequences were loaded in BrainLab iPlanNet and fused. Individual segmentation of the affected cranial nerves and the compressing vascular structure was performed by a neurosurgeon, and the results were compared with the microscopic and endoscopic findings by two blinded neurosurgeons. For each case, at least three neurovascular landmarks were targeted. Each segmented neurovascular element was validated by manual placement of the navigation probe over each target, and errors of localization were measured in mm. RESULTS All patients underwent retro-sigmoid craniotomy and MVD using both microscope and endoscope. Based on image segmentation, the compressing vessel was identified in all cases except one, which was also negative intraoperatively. Perfect correspondence was found between image-based segmentation and endoscopic and microscopic images and videos (Dice coefficient of 1). Measurement accuracy was 0.45 ± 0.21 mm (mean ± SD). CONCLUSION Image-based segmentation is a promising method for pre-operative identification and localization of offending blood vessels causing HFS and TN. Using this method may prevent some unnecessary explorations on especially atypical cases with no vascular contacts. However, negative pre-operative image segmentation may not preclude one from exploration in classic cases of TN or HFS. A multicenter study with larger number of cases is recommended.
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Bohman LE, Pierce J, Stephen JH, Sandhu S, Lee JYK. Fully endoscopic microvascular decompression for trigeminal neuralgia: technique review and early outcomes. Neurosurg Focus 2015; 37:E18. [PMID: 25270137 DOI: 10.3171/2014.7.focus14318] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fully endoscopicmicrovascular decompression (E-MVD) of the trigeminal nerve was initially described more than 1 decade ago, but has not yet gained wide acceptance. The authors present the experience of their first 47 consecutive E-MVDs for trigeminal neuralgia (TN). METHODS All surgeries were performed by a single surgeon (J.Y.K.L.) at the Pennsylvania Hospital at the University of Pennsylvania. Patients prospectively completed pain scales before and after surgery by using the Brief Pain Inventory-Facial outcomes tool. All patients were called on the telephone, and the same outcome tool was administered without reference to their preoperative pain status. RESULTS Forty-seven patients (17 men) were identified and enrolled. Forty (85%) had Burchiel Type 1 TN. Vascular compression was observed at surgery in 42 patients (89%). No surgery was aborted or converted to microscope. One patient suffered permanent hearing loss, for a permanent neurological morbidity rate of 2%. Overall improvement in pain outcomes was excellent, with a median maximum pain intensity preoperatively of 10 and postoperatively of 0 (p< 0.0001). The mean interference with global function scores were 6.2 preoperatively and reduced to 1.0 at last follow-up (p < 0.0001). The mean interference with facial function was 7.3 preoperatively and reduced to 1.2 at last follow-up (p < 0.0001). The mean follow-up period after surgery was 15 ± 8 months. CONCLUSIONS In experienced hands, E-MVD offers superb visualization and illumination and is both safe and effective, at least in the short term. Further longer-term study is needed to compare E-MVD to traditional microscopic MVD.
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Affiliation(s)
- Leif-Erik Bohman
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Filipce V, Ammirati M. Quantitative and qualitative analysis of the working area obtained by endoscope and microscope in pterional and orbitozigomatic approach to the basilar artery bifurcation using computed tomography based frameless stereotaxy: A cadaver study. Asian J Neurosurg 2015; 10:69-74. [PMID: 25972933 PMCID: PMC4421971 DOI: 10.4103/1793-5482.145064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Basilar aneurisms are one of the most complex and challenging pathologies for neurosurgeons to treat. Endoscopy is a recently rediscovered neurosurgical technique that could lend itself well to overcome some of the vascular visualization challenges associated with this pathology. The purpose of this study was to quantify and compare the basilar artery (BA) bifurcation (tip of the basilar) working area afforded by the microscope and the endoscope using different approaches and image guidance. MATERIALS AND METHODS We performed a total of 9 dissections, including pterional (PT) and orbitozygomatic (OZ) approaches bilaterally in five whole, fresh cadaver heads. We used computed tomography based image guidance for intraoperative navigation as well as for quantitative measurements. We estimated the working area of the tip of the basilar, using both a rigid endoscope and an operating microscope. Operability was qualitatively assessed by the senior authors. RESULTS In microscopic exposure, the OZ approach provided greater working area (160 ± 34.3 mm(2)) compared to the PT approach (129.8 ± 37.6 mm(2)) (P > 0.05). The working area in both PT and OZ approaches using 0° and 30° endoscopes was larger than the one available using the microscope alone (P < 0.05). In the PT approach, both 0° and 30° endoscopes provided a working area greater than a microscopic OZ approach (P < 0.05) and an area comparable to the OZ endoscopic approach (P > 0.05). CONCLUSION Integration of endoscope and microscope in both PT and OZ approaches can provide significantly greater surgical exposure of the BA bifurcation compared to that afforded by the conventional approaches alone.
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Affiliation(s)
- Venko Filipce
- Department of Neurological Surgery, Dardinger Microneurosurgical Skull Base Laboratory, The Ohio State University Medical Center, Columbus, Ohio
| | - Mario Ammirati
- Department of Neurological Surgery, Dardinger Microneurosurgical Skull Base Laboratory, The Ohio State University Medical Center, Columbus, Ohio
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Microvascular decompression under neuroendoscopic view in hemifacial spasm: rostral-type compression and perforator-type compression. Acta Neurochir (Wien) 2015; 157:329-32; discussion 332. [PMID: 25502988 DOI: 10.1007/s00701-014-2294-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/24/2014] [Indexed: 10/24/2022]
Abstract
We report microvascular decompression (MVD) under neuroendoscopic view in hemifacial spasm (HFS) patients with rostral- and perforator-type compression of the root exit zone (REZ) of the facial nerve. Using either a wireless iPad Mini as a monitor on the microscope or a high-resolution monitor, microscopic and endoscopic views enabled MVD for complete cure of HFS with rostral-type compression (the offender compressing the REZ on the opposite rostral side to the operative approach) or perforator-type compression (the offender tethered to the REZ by the perforator). MVD under neuroendoscopic view may offer more accurate MVD and complete resolution of HFS.
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Setty P, D'Andrea KP, Stucken EZ, Babu S, LaRouere MJ, Pieper DR. Endoscopic Resection of Vestibular Schwannomas. J Neurol Surg B Skull Base 2015. [PMID: 26225307 DOI: 10.1055/s-0034-1543974] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective To report our results and the technical details of fully endoscopic resection of vestibular schwannomas. Design Prospective observational study. Setting A single academic institution involving neurosurgery and neurotology. Participants Twelve consecutive patients who underwent fully endoscopic resection of a vestibular schwannoma. Main Outcome Measures Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons (AAO-HNS) score as well as the Gardener and Robertson Modified Hearing Classification (GR). Facial nerve preservation based on the House-Brackmann (HB) score. Results All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1-2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days. Conclusion A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients.
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Affiliation(s)
- Pradeep Setty
- Section of Neurosurgery, St John Providence Health System, Michigan State Unviersty, Southfield, Michigan, United States
| | - Kenneth P D'Andrea
- Section of Neurosurgery, St John Providence Health System, Michigan State Unviersty, Southfield, Michigan, United States
| | - Emily Z Stucken
- Department of Neurotology, Michigan Ear Institute, Farmington Hills, Michigan, United States
| | - Seilesh Babu
- Department of Neurotology, Michigan Ear Institute, Farmington Hills, Michigan, United States
| | - Michael J LaRouere
- Department of Neurotology, Michigan Ear Institute, Farmington Hills, Michigan, United States
| | - Daniel R Pieper
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, United States
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Sandell T, Ringstad GA, Eide PK. Usefulness of the endoscope in microvascular decompression for trigeminal neuralgia and MRI-based prediction of the need for endoscopy. Acta Neurochir (Wien) 2014; 156:1901-9; discussion 1909. [PMID: 25008460 DOI: 10.1007/s00701-014-2171-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Microvascular decompression (MVD) is a documented effective treatment of trigeminal neuralgia (TN). Lately, reports on endoscopy-assisted microvascular decompression (eaMVD) with better outcome and less risk have emerged. This study was undertaken to verify under which circumstances the endoscope proved essential in identifying the neurovascular conflict (NVC) during eaMVD for TN, and to assess the possibility to predict the need for the endoscope on preoperative magnetic resonance imaging (MRI). METHODS Retrospective analysis of 97 patients with TN undergoing eaMVD at the Oslo University Hospital - Rikshospitalet, 1999-2009. To assess the NVC and anatomical variations, surgical reports were evaluated. MRI was available in 66 patients. The MRIs were evaluated by a blinded neuroradiologist. RESULTS In 27 of the 97 patients (27.8 %), the endoscope was a significant aid in identifying the NVC, due to a bony ridge obscuring the view of the fifth nerve, a very distal vascular compression, or a combination of both. The preoperative MRI over-diagnosed the presence of a bony ridge. However, the MRI-based fraction of microscopically visible trigeminal nerve (FVN) in the cerebellopontine angle cistern proved diagnostic (ROC curve, AUC 0.89, p = <0.001) with an optimal cut-off value of 0.35. Hence, if less than 35 % of the trigeminal nerve is visible on preoperative MRI, the endoscope will be needed to identify the NVC. CONCLUSIONS The endoscope is a valuable tool during MVD for TN, especially under anatomical circumstances such as a bony ridge hiding the direct microscopic view of the NVC. These anatomical circumstances can be predicted with good accuracy on preoperative MRI.
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Endoscopic Surgery of the Posterior Fossa: Strengths and Limitations. World Neurosurg 2014; 82:322-4. [DOI: 10.1016/j.wneu.2013.08.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 08/29/2013] [Indexed: 11/22/2022]
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Pure endoscopic removal of epidermoid tumors of the cerebellopontine angle. Childs Nerv Syst 2014; 30:1261-7. [PMID: 24481575 DOI: 10.1007/s00381-014-2357-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Epidermoid tumors located in the cerebellopontine angle (CPA) are challenging lesions because they tend to grow slowly in the subarachnoid cisterns around delicate neurovascular structures and often extend into surgical anatomic corners. The aim of this paper is to demonstrate the advantages and limitations of purely endoscopic removal of the CPA epidermoids. METHODS Six patients harboring an epidermoid tumor located in the CPA were treated using an endoscope-controlled microsurgical technique. A retrosigmoid suboccipital approach was used in all patients. The cerebellomedullary cistern and the cisterna magna were opened to allow cerebrospinal fluid drainage and cerebellar drop, thus yielding a wide and straight working channel to the CPA. Then, the tumor and its capsule were removed by the modified microsurgical instruments. RESULT The symptoms caused by mass effect of the lesion resolved after surgery. There were no deaths, but permanent deficits occurred in one patient whose cranial nerves VII/VIII complex was accidentally lesioned. Tumors and their capsules were totally removed in five cases. All patients were discharged 3-5 days after surgery. To date, no recurrences have been observed (follow-up range 14-50 months). CONCLUSION The endoscope-controlled microsurgical technique enables a safe tumor removal even when parts of the lesion are not visible in a straight line in CPA epidermoids. By angled endoscopic lenses, tumor extending into adjacent cranial compartments or surgical anatomic corners can be removed through a single small craniotomy without retracting neurovascular structures.
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Chotai S, Kshettry VR, Ammirati M. Endoscopic-assisted microsurgical techniques at the craniovertebral junction: 4 illustrative cases and literature review. Clin Neurol Neurosurg 2014; 121:1-9. [DOI: 10.1016/j.clineuro.2014.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/24/2014] [Accepted: 03/05/2014] [Indexed: 11/16/2022]
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Abolfotoh M, Dunn IF, Al-Mefty O. Transmastoid retrosigmoid approach to the cerebellopontine angle: surgical technique. Neurosurgery 2014. [PMID: 23190639 DOI: 10.1227/neu.0b013e31827fc87b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The traditional suboccipital craniotomy in the retrosigmoid approach gives limited exposure to the cerebellopontine angle (CPA) structures and necessitates cerebellar retraction, whereas the addition of drilling of the mastoid process with reflection of venous sinuses offers wider exposure of the CPA and avoids cerebellar retraction. We describe the details of the surgical technique and provide radiological measurements substantiating the advantages of this approach. OBJECTIVE To validate the usefulness of partial mastoidectomy in the retrosigmoid approach and to evaluate the complications of this maneuver. METHODS Radiological CPA measurements on computed tomography bone window films were made on the last consecutive 20 patients who underwent CPA surgery via the transmastoid retrosigmoid approach. We measured the distance and angle of work by this approach and compared the measurements with those using the traditional retrosigmoid approach if that would have been used in each case. We also reviewed 432 patients from the records of the senior author to evaluate possible complications of this approach. RESULTS The mean working distance for the transmastoid approach was 23.06 mm, whereas the working distance in the traditional approach was 46.44 mm. The mean increase in the angle of work after drilling of the mastoid was 25.39 degrees, and the simple average of increased distance in lateral exposure was 26.66 mm. CONCLUSION The transmastoid retrosigmoid approach increases the exposure and gives better access to the CPA targets. This approach alleviates cerebellar retraction, facilitates surgery in the supine position, promotes the use of the endoscope, and is associated with negligible complications.
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Affiliation(s)
- Mohammad Abolfotoh
- Neurosurgery Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Galzio RJ, Di Cola F, Raysi Dehcordi S, Ricci A, De Paulis D. Endoscope-assisted microneurosurgery for intracranial aneurysms. Front Neurol 2013; 4:201. [PMID: 24391623 PMCID: PMC3866583 DOI: 10.3389/fneur.2013.00201] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/30/2013] [Indexed: 11/17/2022] Open
Abstract
Background: The endovascular techniques has widely changed the treatment of intracranial aneurysms. However surgery still represent the best therapeutic option in case of broad-based and complex lesions. The combined use of endoscopic and microsurgical techniques (EAM) may improve surgical results. Objective: The purpose of our study is to evaluate the advantages and limits of EAM for intracranial aneurysms. Methods: Between January 2002 and December 2012, 173 patients, harboring 206 aneurysms were surgically treated in our department with the EAM technique. One hundred and fifty-seven aneurysms were located in the anterior circulation and 49 were in the posterior circulation. Standard tailored approaches, based on skull base surgery principles, were chosen. The use of the endoscope included three steps: initial inspection, true operative time, and final inspection. For each procedure, an intraoperative video and an evaluation schedule were prepared, to report surgeons’ opinions about the technique itself. In the first cases, we always used the endoscope during surgical procedures in order to get an adequate surgical training. Afterwards we became aware in selecting cases in which to apply the endoscopy, as we started to become familiar with its advantages and limits. Results: After clipping, all patients were undergone postoperative cerebral angiography. No surgical mortality related to EAM were observed. Complications directly related to endoscopic procedures were rare. Conclusion: Our retrospective study suggests that endoscopic efficacy for aneurysms is only scarcely influenced by the preoperative clinical condition (Hunt–Hess grade), surgical timing, presence of blood in the cisterns (Fisher grade) and/or hydrocephalus. However the most important factors contributing to the efficacy of EAM are determined by the anatomical locations and sizes of the lesions. Furthermore, the advantages are especially evident using dedicated scopes and holders, after an adequate surgical training to increase the learning curve.
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Affiliation(s)
- Renato J Galzio
- Department of Neurosurgery, University of L'Aquila , L'Aquila , Italy
| | - Francesco Di Cola
- Department of Neurosurgery, University of L'Aquila , L'Aquila , Italy
| | | | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore City Hospital , L'Aquila , Italy
| | - Danilo De Paulis
- Department of Neurosurgery, San Salvatore City Hospital , L'Aquila , Italy
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An endoscopic-assisted technique for retrosellar access during the extended retrosigmoid approach: a cadaveric feasibility study and quantitative analysis of retrosellar working area. Neurosurg Rev 2013; 37:243-51; discussion 251-2. [PMID: 24346377 DOI: 10.1007/s10143-013-0514-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/04/2013] [Accepted: 10/27/2013] [Indexed: 10/25/2022]
Abstract
The retrosigmoid approach has been advocated for certain petroclival tumors but provides limited access to any retrosellar extension of tumor, necessitating a two-stage operation. Our purpose was to demonstrate preliminary feasibility of an endoscopic-assisted technique to provide retrosellar access during the extended retrosigmoid approach and compare microscopic and endoscopic retrosellar working area. Standard retrosigmoid craniectomy and partial petrosectomy respecting inner ear structures were performed on six embalmed cadaveric heads. Two balloons were inflated to simulate a 15 mm petroclival tumor. Retrosellar clival and brainstem working area and ipsilateral oculomotor nerve and posterior cerebral artery (PCA) working distance were measured using the endoscope and microscope. Artificial tumors were implanted and resected using the endoscopic-assisted technique to assess feasibility. The endoscope provided significantly greater mean working area/distance on the clivus (201.6 vs 114.8 mm(2), p < 0.01), brainstem (223.5 vs 121.2 mm(2), p < 0.01), ipsilateral oculomotor nerve (10.8 vs 6.4 mm, p < 0.01), and ipsilateral PCA (13.7 vs 8.9 mm, p = 0.01). Petrous dissection to create a 10 × 10 mm working channel and artificial tumor resection was feasible in all dissections. The superior petrosal vein required ligation in 9 (75%) cases. Air cells were exposed in 1 (8%) case. The described endoscopic-assisted technique can provide retrosellar access during the extended retrosigmoid approach to access petroclival tumors with retrosellar extension. Risks include superior petrosal vein sacrifice, bleeding that can impair visualization, injury to the trigeminal nerve during endoscopic insertion/manipulation or injury to the brainstem while working in the medial limits of exposure. Further work is necessary to determine clinical feasibility, safety, and efficacy.
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Setty P, Volkov AA, D'Andrea KP, Pieper DR. Endoscopic vascular decompression for the treatment of trigeminal neuralgia: clinical outcomes and technical note. World Neurosurg 2013; 81:603-8. [PMID: 24140999 DOI: 10.1016/j.wneu.2013.10.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 09/04/2013] [Accepted: 10/12/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study sought to describe the operative technique and clinical outcomes in a series of 57 patients with trigeminal neuralgia treated with endoscopic vascular decompression (EVD) alone without the use of microscopy at any point. METHODS A prospective observational study was performed on 57 consecutive patients treated with EVD alone for trigeminal neuralgia from October 2005 to October 2010. Patient outcomes were evaluated with respect to pain abatement, complication rate, length of hospital stay, and overall operative time. Pain outcome was graded using the Barrow Neurological Institute pain intensity score (BNI), with BNI 1 considered an excellent result and BNI 2 or 3 considered a good result. Follow-up ranged from 12 to 72 months, with a mean of 32 months. In addition to reporting these cases, our operative technique for EVD is described in detail. RESULTS All 57 patients reported severe preoperative pain (BNI 5); 100% of patients achieved immediate postoperative pain control or complete pain relief (BNI 1 to 3), with 82% obtaining an excellent result of BNI 1, and 18% of patients reported good results of BNI 2 or 3. At follow-up, 56 of 57 patients (98%) reported complete relief or well controlled pain (BNI 1 to 3), with 75% obtaining an excellent result of BNI 1; 23% of patients obtained a good result of BNI 2 or 3. The complication rate was 4%, with no mortality. Mean length of hospital stay was 1.6 days, with a range of 1 to 5 days; mean operative time was 133 minutes. CONCLUSIONS EVD is a safe and highly effective alternative to the more traditional open microvascular decompression or the more recently developed endoscopically assisted microvascular decompression.
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Affiliation(s)
- Pradeep Setty
- Section of Neurosurgery, St. John Providence Hospital and Medical Centers, Michigan State University, Southfield, Michigan, USA.
| | - Andrey A Volkov
- Section of Neurosurgery, St. John Providence Hospital and Medical Centers, Michigan State University, Southfield, Michigan, USA
| | - Kenneth P D'Andrea
- Section of Neurosurgery, St. John Providence Hospital and Medical Centers, Michigan State University, Southfield, Michigan, USA
| | - Daniel R Pieper
- Department of Neurosurgery, William Beaumont School of Medicine, Oakland University, Rochester, Michigan, USA
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Broggi M, Acerbi F, Ferroli P, Tringali G, Schiariti M, Broggi G. Microvascular decompression for neurovascular conflicts in the cerebello-pontine angle: which role for endoscopy? Acta Neurochir (Wien) 2013; 155:1709-16. [PMID: 23884611 DOI: 10.1007/s00701-013-1824-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/10/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microvascular decompression (MVD) is the surgical intervention designed to resolve neurovascular conflicts (NCs) in the cerebellopontine angle (CPA). Today, endoscopy is commonly used in many neurosurgical procedures. This study aims to retrospectively assess the usefulness of endoscopy during MVD, focusing on microscopic endoscopic-assisted (MEA) MVD. METHODS Between January 2010 and December 2012, 141 patients underwent MVD procedures: 119 (84.5 %) were affected by idiopathic trigeminal neuralgia (TN), 20 (14 %) by hemifacial spasm (HFS), 1 by glossopharyngeal neuralgia (GN) and 1 by TN and GN simultaneously; 128 (91 %) MVD were first time procedures, while 13 (9 %) were recurrences (10 TN, 3 HFS). Visualization techniques used were: pure microscopic in 89 (63 %) cases, fully endoscopic in 12 (8.5 %) and MEA in 40 (28.5 %). The MEA technique was used when the conflict was not clearly identified under microscopic view or it was not certainly resolved. RESULTS Overall, a NC was found in 130 (92 %) cases, while 11 patients had no intraoperative evidence of NC. Considering specifically the 40 MEA cases, 12 (8.5 % overall) conflicts not clearly visible with the microscope were revealed and solved, a complete conflict resolution was confirmed in 13 (9 % overall) cases, while an incomplete conflict resolution was shown in four cases (3 % overall). CONCLUSION Pure microscopic MVD remains the technique of choice. The endoscope is a useful adjunctive imaging tool in confirming NCs identified by the microscope, revealing conflicts missed by the microscopic survey alone and verifying adequate nerve decompression.
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Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milano, Italy.
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