A clinical analysis on microvascular decompression surgery in a series of 3000 cases

Objective

Despite the microvascular decompression (MVD) has become a definitive treatment for trigeminal neuralgia (TN) and hemifacial spasm (HFS), not all of the patients have been cured completely so far and this sort of operation is still with risk because of the critical operative area. In order to refine this surgery, we investigated thousands MVDs.

Methods

Among 3000 consecutive cases of MVDs have been performed in our department, 2601 were those with typical TN or HFS, who were then enrolled in this investigation. They were retrospectively analyzed with emphasis on the correlation between surgical findings and postoperative outcomes. The differences between TN and HFS cases were compared. The strategy of each surgical process of MVD was addressed.

Results

Postoperatively, the pain free or spasm cease occurred immediately in 88.3%. The symptoms improved at some degree in 7.2%. The symptoms unimproved at all in 4.5%. Most of those with poor outcome underwent a redo MVD in the following days. Eventually, their symptoms were then improved in 98.7% of the reoperative patients. The majority reason of the failed surgery was that the neurovascular conflict located beyond REZ or the offending veins were missed for TN, while the exact offending artery (arteriole) was missed for HFS as it located far more medially than expected.

Conclusion

A prompt recognition of the conflict site leads to a successful MVD. To facilitate the approach, the craniotomy should be lateral enough to the sigmoid sinus. The whole intracranial nerve root should be examined and veins or arterioles should not be ignored. For TN, all the vessels contacting the nerve should be detached. For HFS, the exposure should be medial enough to the pontomedullary sulcus.     

显微血管减压术治疗三叉神经痛和面肌痉挛的技术差别(附37例报告)

目的为了提高手术安全性和疗效,减少术后并发症,探讨显微血管减压术治疗三叉神经痛和面肌痉挛的方法和技术细节差别。方法回顾性分析37例显微血管减压术手术患者,其中三叉神经痛15例,面肌痉挛22例,分析术中体位,切口,骨窗,责任血管压迫等细节,观察二者术后疗效。结果三叉神经痛患者术后疼痛立即完全缓解14例,1例延迟缓解。所有面肌痉挛患者痉挛症状术后即刻消失,无严重并发症。随访半年~2年,1例三叉神经痛患者复发,所有面肌痉挛患者未见复发。结论显微血管减压术是治疗三叉神经痛和面肌痉挛的有效治疗方法,但在术中体位、切口、骨窗、责任血管压迫等具体操作细节方面有细微差别,了解这些差别有助于增加手术安全性,取得更好的疗效。     

家族性原发性颅神经疾病一例报告并文献复习

目的 报告家族性原发性颅神经疾病1例,并对其病因学及治疗学进行探讨. 方法1例家族性原发性颅神经疾病,调查其三代共有5例原发性颅神经疾病患者,包括了三叉神经痛、面肌痉挛、舌咽神经痛等7侧(根)颅神经病变,其中3例采用手术治疗.结果 患者A,右三叉神经痛发病10年后行右三叉神经周围支撕脱术,术后疼痛好转,随访10年至患者去世未再发生严重发作.患者B,右三叉神经痛发病10年后行右三叉神经根显微血管减压术及感觉根选择性部分切断术,术后疼痛消失,随访14年未复发;5年前出现左三叉神经痛,2004年10月行左三叉神经根显微血管减压术,术后疼痛消失,随访44个月未复发.患者C,右舌咽神经痛10年,曾行显微血管减压术及舌咽神经根、迷走神经根丝选择性部分切断术等3次手术,前2次手术无效,第3次手术后有效,半年后出现右三叉神经痛,行右三叉神经根显微血管减压术后治愈.患者D,左面肌痉挛7年,未手术.患者E,右三叉神经痛1年,未手术.结论 家族性原发性颅神经疾病罕见.原发性颅神经疾病出现家族性泛发病例可能与后颅窝容积小、后循环解剖变异、颅神经高易感性、血管迂曲硬化延长等异常发生率高有关,可用颅神经进或出脑干区血管压迫学说解释其病因.颅神经根显微血管减压术可作为首选外科治疗方法.     

神经内镜在三叉神经痛和面肌痉挛手术中的应用

目的 探讨神经内镜在三叉神经痛和而肌痉挛手术中的辅助作用。方法 在显微血管减压术中使用神经内镜，观察神经根进出脑干部位及局部血管的分布和走行情况，确认压迫血管；在实施减压后观察神经根松解情况、垫棉的位置和压迫血管移位后的状态。结果 60例三叉神经痛病例中，56例术后疼痛消失，4例疼痛减轻；40例面肌痉挛病例中，37例术后痉挛消失，3例减轻。平均随访3．2年无一例复发。结论 显微血管减压术中辅助使用神经内镜，能提高手术治疗效果，减少并发症发生。     

以三叉神经痛和/或面肌痉挛起病的桥小脑角区肿瘤的手术治疗

目的探讨经枕下乙状窦后入路手术治疗以三叉神经痛和/或面肌痉挛起病的桥小脑角区肿瘤的临床疗效。方法回顾性分析2014年9月至2016年9月收治的21例以三叉神经痛和/或面肌痉挛起病的桥小脑角区肿瘤的临床资料,均采用枕下乙状窦后入路手术切除肿瘤,其中17例同期行微血管减压术。结果肿瘤全切除18例,近全切除3例。术后原有面部疼痛或不自主抽搐症状消失或明显减轻。术后随访3~27个月,临床症状和肿瘤均无复发。结论枕下乙状窦后入路手术治疗以三叉神经痛和/或面肌痉挛起病的桥小脑角区肿瘤的疗效确切,安全性高,并发症少,对于同时存在血管压迫的病例,可同期行微血管减压术治疗。     

Hemifacial spasm caused by cross type vascular compression

Abstract

Objectives: The meatal segment of anterior inferior cerebellar artery usually crosses over the gap between cranial nerves VII and VIII, and may compress the cisternal portion (CP) of the facial nerve. This is defined as cross type compression, which is easy to be neglected and thus leads to poor outcome. Here our experience in treating patients of cross type hemifacial spasm (HFS) is reported.

Methods: Twenty-one patients of HFS due to cross type compression were treated with microvascular decompression (MVD) surgery with the aid of abnormal muscle response monitoring.

Results: In addition to cross type compression at CP, there were typical vascular compressions on the root exit zone and attached segment in 20 cases. After MVD surgery, 17 patients were cured, 3 patients achieved good resolution of spasm, and the other 1 patient got delayed resolution. Three patients had postoperative transient hearing loss and/or tinnitus.

Discussion: Even there are apparently typical vascular compressions at proximal portion of the facial nerve, the surgeon should be aware that cross type compression at the CP may co-exist. With the aid of abnormal muscle response (AMR) monitoring, MVD is efficient for patients due to cross type compression.     

Endoscopic assistance in microvascular decompression of cranial nerves

Microvascular decompression (MVD) is an effective method for treatment of trigeminal neuralgia (TN), hemifacial spasm (HFS), glossopharyngeal neuralgia (GPN). The aim of this study was to assess the role of endoscopic assistance in MVD for the treatment of cranial neuropathies. Since 2009 till 2011 133 patients with cranial neuropathies were treated by MVD in Burdenko Neurosurgical Institute, Moscow. In 22 patients (11 patients with HFS, 10 patients with TN, 1 with GPN) endoscopic assistance was applied during the MVD. We used minimally invasive retrosigmoid approach in a unilateral position. Cerebellopontine angle was explored by 30-degree or 70-degree telescope to visualize the root entry zone of trigeminal, facial or glossopharyngeal nerves and to locate the neurovascular conflict. In 9 patients with HFS and in 1 patient with TN and in another patient with GPN endoscopy discovered offending vessels that were not visible through the microscope. In all cases endoscope was used to exclude another site of compression and to verify decompression and to identify position of teflon and offending vessel after MVD. Immediately after the surgery excellent outcome was observed in 10 patients with HFS (89%), one patient was reoperated 1.5 years after first operation with positive effect. Relief of pain in early postoperative period was observed in patients with TN and GPN. There were no major complications and postoperative mortality in our series. Endoscopic assistance is very effective and helpful technique in MVD of cranial nerves, especially in cases with HFS. In this study the use of the endoscope allowed to identify the site of compression and to confirm the position of teflon after MVD.     

显微血管减压术治疗面肌痉挛51例临床分析

目的 探讨显微血管减压术治疗特发性面肌痉挛疗效.方法 回顾分析显微血管减压术治疗51例面肌痉挛的临床资料,术中确认责任血管并减压.结果 本组均能见到面神经出脑干处有动脉血管压迫,其中AICA26例(51.0%),PICA16例(31.3%),VA4例(7.8%),复合型5例(9.8%).43例(84.4%)术后症状完全缓解,8例术后减轻(15.6%).其中4例(7.8%)3周内停止抽搐,3例(5.8%)3月后抽搐停止,1例(2%)一直未完全缓解.随访1年以上,复发1例(2.0%).结论 显微血管减压是面肌痉挛的首选方法,术中确认责任血管,充分减压和防止副损伤是手术成功的关键.     

An easy adjustable method of ectatic vertebrobasilar artery transposition for microvascular decompression

Background

Microvascular decompression (MVD) of trigeminal neuralgia (TN) or hemifacial spasm (HFS) caused by an elongated, tortuous or enlarged vertebral or basilar artery has a higher rate of incomplete cure.

Objective

We used an easily applied and adjustable method of vertebrobasilar artery transposition and fixation to improve the immediate surgical outcome of MVD of TN or HFS due to compression by an ectatic vertebrobasilar artery system.

Methods

Vertebral or basilar artery transposition was performed using the vascular sling with a strip of unabsorbable dural tape. The vertebrobasilar artery-sling complex was then fixed to the dura over the petrous bone by aneurysm clip through the dural bridge. The direction and angle of traction on the vertebrobasilar artery was adjustable using different lengths of clip or the horizontal level of the dural bridge.

Results

The sling and clip fixation method has been applied in 7 cases of MVD associated with vertebral or basilar artery compression. All 3 patients with TN and one with HFS had total remission of symptoms right after the procedure; one patient was completely free of spasm within 1 week after MVD and one had achieved 80% improvement of spasm in his last clinical visit 3 months after MVD. There was no major surgical complication in these 7 patients. Surprisingly, refractory hypertension was unexpectedly cured in one patient with TN following the procedure.

Conclusion

The vertebrobasilar artery transposition and fixation method used in the present study provided surgeons an easy and adjustable way to perform MVD safely and effectively.     

3D-TOF-MRA成像对微血管减压术术前诊断的价值

目的观察三维时间飞越法磁共振血管成像(3D-TOF-MRA)结合MR重建技术对微血管减压手术(MVD)的价值。方法对11例三叉神经痛,17例面肌痉挛,1例复发性舌咽神经痛,1例三叉神经痛合并面肌痉挛患者采用MVD治疗。术前应用3D-TOF-MRA结合MR重建技术进行检查,寻找和判别责任血管,以指导临床手术。结果术前3D-TOF-MRA检查30例中,28例证实有明显的责任血管,并在术中得到证实;2例三叉神经痛患者3D-TOF-MRA检查、未发现责任血管,其中1例术中发现为三叉神经出脑干区腹侧受到基底动脉明显压迫,另外1例术中可见小脑上动脉有多支细小动脉攀附于三叉神经出脑干区,给予MVD+选择性三叉神经感觉根切断术后症状完全缓解。30例患者中,术后完全缓解26例,明显缓解4例。结论 3D-TOF-MRA结合MR重建技术对于微血管减压术术前责任血管的判定及手术设计具有重要的应用价值。     

Neuroendoscopy in microvascular decompression for trigeminal neuralgia and hemifacial spasm: Technical note

Abstract

Miocrovascular decompression is an effective treatment for trigeminal neuralgia (TN) and hemifacial spasm (HFS). A complete cure cannot be obtained, and additional adjuncts for extended use of endoscopy are needed. The use of an endoscope combined with the operating microscope can enhance the surgeon’s ability to view deep structures during operation. We study the application of combined microsurgical and endoscopic techniques in 21 cases of HFS and 12 cases of TN. With these techniques the surgeon can explore the ventral aspect of the brainstem and cranial nerves without further retraction, can see the groove caused by compression of the offending artery, and can confirm the proper position of the prosthesis after attachment to the dura by fibrin glue. In HFS the most common offending vessels in 75% of cases were the posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) and in 25% of cases the vertebral artery (VA). In trigeminal neuralgia the offending vessel in 60% of cases was the superior cerebellar artery (SCA), and in 40% of cases the AICA. The overall success rate was 97% with minimal morbidity 3% (facial palsy) and no mortality. The aim of this work is to study advantages and disadvantages of using endoscopy during microvascular decompression for TN and HFS. [Neural Res 2000; 22: 522-526]     

Monitoring of auditory brainstem response (ABR) during microvascular decompression (MVD): results in 400 cases

In recent years, microvascular decompression (MVD) has been well established as a definitive surgical procedure in the management of hemifacial spasm (HFS) and trigeminal neuralgia (TN). With careful microsurgical technique, MVD can be performed accurately without significant morbidity. However, some incidence of postoperative hearing disturbance has been reported as one the annoying complications. In order to avoid complications of the 8th nerve, we have been using intraoperative monitoring of auditory brainstem response (ABR) for the past 5 years. This report presents the results of ABR monitoring in our personal series of 400 MVD cases. Our clinical results consist of 225 HFS and 175 TN, who underwent recording of ABR before, during and after MVD, including audiometry before and after the operation. There are 107 males and 293 females with the age ranging between 22 and 79, averaging 55 years old. Under routine general endotracheal anesthesia, the patient was placed in a lateral position and a small retromastoid opening was made. Pieces of teflon tape and fibrin glue was used to transpose, reposition and fixate the offending vessels. We used CADWELL 5200 and recorded ABR with needle electrode and click sound averaging 1500 times. ABR recordings were performed on admission, at the beginning of the operation, during nerve decompression and wound closure and at the time of discharge. The interpeak latency of waves I-V and the wave V amplitude during nerve decompression or wound closure were compared with those on admission.(ABSTRACT TRUNCATED AT 250 WORDS)     

A charcot-marie-tooth type 1B kindred associated with hemifacial spasm and trigeminal neuralgia

Introduction: Charcot-Marie-Tooth (CMT) phenotypes can be distinguished by electrophysiology and genetic analysis but few can be identified by their clinical characteristics. Distinctive phenotypes are useful in identifying affected individuals and providing additional clues about the mechanism of the neuropathy. Cranial neuropathies are uncommon features of CMT, and few reports of familial hemifacial spasm (HFS) and trigeminal neuralgia (TN) have been published. Methods: Sixty-three members of a large CMT 1B kindred were assessed for signs of peripheral neuropathy and cranial neuropathies then tested for the G163R mutation in the myelin protein zero (MPZ) gene. Results: Of 27 individuals with the G163R mutation in MPZ, 10 had HFS or TN. Co-existing HFS and TN were found in 3 of these and 4 had bilateral HFS or TN. Conclusions: This kindred exhibits a distinct CMT phenotype characterized by the development of HFS or TN decades after clinical signs of hereditary neuropathy are manifest. Muscle Nerve, 2019     

Effect of botulinum neurotoxin treatment in the lateral spread monitoring of microvascular decompression for hemifacial spasm

Introduction: Botulinum neurotoxin (BtNtx) treatment for hemifacial spasm (HFS) prior to microvascular decompression (MVD) is hypothesized to be a factor in the variability of intraoperative neurophysiological monitoring (IONM) during this procedure. Methods: We analyzed 282 MVDs performed at the University of Pittsburgh Medical Center between January 1, 2000 and December 31, 2007. We retrospectively compared the lateral spread response (LSR) in the mentalis muscle when stimulus‐triggered electromyography (EMG) was elicited from the facial nerve. Previous BtNtx treatment was the grouping factor. Results: Baseline LSR amplitudes during MVD (prior BtNtx: mean = 341.47 μV; no BtNtx: mean = 241.81 μV) were significantly different between groups (df = 1,281; t = ?2.463; P = 0.014). Comparisons of latency and current threshold at baseline, as well as HFS disappearance or LSR persistence after the procedure, did not achieve statistical significance. Conclusions: HFS patients treated with BtNtx prior to MVD demonstrated higher LSR baseline amplitudes during IONM. This could be related to muscle poly‐reinnervation after recovery from repeated BtNtx use. Muscle Nerve, 2011     

Delayed Cranial Nerve Palsy after Microvascular Decompression for Hemifacial Spasm

Objective

Microvascular decompression (MVD) for hemifacial spasm (HFS) is a safe and effective treatment with favorable outcomes. The purpose of this study was to evaluate the incidence of delayed cranirve ( VI, VII, and VIII ) palsy following MVD and its clinical courses.

Methods

Between January 1998 and December 2009, 1354 patients underwent MVD for HFS at our institution. Of them, 100 patients (7.4%) experienced delayed facial palsy (DFP), one developed sixth nerve palsy, and one patient had delayed hearing loss.

Results

DFP occurred between postoperative day number 2 and 23 (average 11 days). Ninety-two patients (92%) completely recovered; however, House-Brackmann grade II facial weakness remained in eight other patients (8%). The time to recovery averaged 64 days (range, 16 days to 9 months). Delayed isolated sixth nerve palsy recovered spontaneously without any medical or surgical treatment after 8 weeks, while delayed hearing loss did not improve.

Conclusion

Delayed cranial nerve (VI, VII, and VIII) palsies can occur following uncomplicated MVD for HFS. DFP is not an unusual complication after MVD, and prognosis is fairly good. Delayed sixth nerve palsy and delayed hearing loss are extremely rare complications after MVD for HFS. We should consider the possibility of development of these complications during the follow up for MVD.     

A new method for monitoring abnormal muscle response in hemifacial spasm: A prospective study

Objective

To examine a new abnormal muscle response (AMR) monitoring method during microvascular decompression (MVD) for hemifacial spasm.

Surgical Management of Medically Refractory Trigeminal Neuralgia

The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis–related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.     

异常肌反应在面神经显微血管减压术中的应用

目的 探讨异常肌反应(abnormal muscle response,AMR)监测在面神经显微血管减压术(microvascular decolnpression,MVD)中鉴别责任血管、评估减压效果以及判断预后方面的作用.方法 241例典型面肌痉挛患者接受了面神经MVD术中AMR的实时监测,并在术后1周进行疗效评估,分析术中AMR变化与手术预后之问的关系.结果 所有241例患者均在术中记录到典型AMR波形,术后第1周217例(90.0%)患者症状完全缓解.AMR消失组175例,其中165例(94.3%)症状缓解;AMR未消失组66例,52例(78 8%)症状缓解.统计学分析显示AMR消失组的疗效明显好于AMR未消失组(P<0.05).结论 术中AMR监测可辅助判断责任血管,评估减压效果,对提高手术疗效具有较高的应用价值.

Abstract：

Objective Abnormal muscle response( AMR) to the electrical stimulation of a branch of facial nerve is a specific electrophysiological feature of primary hemifacial spasm ( HFS) .Although the correlation between intraoperative AMR findings and postoperative results in patients with HFS has been investigated before, the AMR monitoring has not been employed widely during the microvascular decompression (MVD) surgery.The aim of this study was to evaluate the value of AMR monitoring during MVD, and the correlation between the AMR changes and the clinical outcome.Method This study included 241 cases of MVD.Intraoperative AMR monitoring was performed for each subject.The patients were divided into two groups based on whether the AMR wave disappeared or not following decompression of the facial nerve.Results The AMR disappeared after MVD in 175 patients.Among these 175 patients, 165(94.3% ) patients were relieved from HFS 1 week after HFS.Out of the 66 patients in whom the AMR persisted after MVD, 52(78.8%) patients were relieved.The correlation between intraoperative AMR abolition and HFS relief was statistically significant ( P < 0.05 ) .Conclusions Intraoperative AMR monitoring is an effective assistant for a successful MVD for the patient with HFS.It may be helpful in predicting outcomes in short term and identifying offending vessels,so it should be monitored routinely during MVD.     

Vascular compression of cranial nerves. I. History of the microvascular decompression operation

Abstract

The development of the microvascular decompression (MVO) operation is reviewed. It is stressed that a few innovative neurosurgeons discovered the role of vascular compression of cranial nerves V and VII in trigeminal neuralgia (TGN) and hemifacial spasm (HFS) and developed an operation, later to be known as the 0VO operation. While the understanding of the pathophysiology. of these disorders has improvedl the surgIcal procedure has undergone little change since Gardner described the operation about 1960. [Neural Res 1998; 20: 727–731]     

电生理监测在面肌痉挛微血管减压术中的作用

目的 评价异常肌反应(Abnormal muscle response,AMR)监测在面肌痉挛微血管减压术(Microvascular decompression,MVD)中的作用.方法 回顾性分析在我科接受治疗的241例典型面肌痉挛患者临床资料并检索数据库中关于AMR监测与面肌痉挛MVD手术疗效关系的临床研究文章,采用RevMan 5.1荟萃分析软件进行分析,对AMR变化程度与术后疗效关系采用优势比(Odds ratio,OR)进行评价.结果 A组(AMR完全消失或波幅下降超过80％),B组的手术有效率分别为96.2％,82.1％,组间差异具有统计学意义(P＜0.05);荟萃分析显示AMR消失组的术后治愈率是AMR未消失组的3.53倍[OR=3.53,95％置信区间95％CI(2.28,5.48)].结论 面肌痉李微血管减压术中行AMR监测可有效指导手术,提高手术治愈率,应将AMR作为MVD术中常规监测项目.