Retractorless Microvascular Decompression for Trigeminal Neuralgia: Technical Nuances and Results in 25 Cases

Introduction: Operative microsurgery of skull base lesions without the use of fixed retractors has gained increased popularity because of less morbidity and brain injury from retractor-induced complications. In microvascular decompression procedures, cerebellar retraction can increase the risk of postoperative hearing loss and cerebellar injury. The authors present a series of patients with trigeminal neuralgia (TN) who underwent a retractorless microvascular decompression (RMVD). The operative nuances and technical pearls are described and assessment of pain relief and postoperative complications are reported.

Methods: A retrospective chart review was performed on 23 patients diagnosed with TN. All patients were treated by way of RMVD through a retrosigmoid approach. Data were extracted regarding patient demographics, presenting symptoms, affected trigeminal branches, intraoperative and postoperative complications, degree of pain relief (based on BNI pain scale), and pain recurrence.

Results: A total of 23 patients (15 females and 8 males) underwent 25 RMVD procedures. One patient had bilateral procedures and one patient had a repeat RMVD for pain free recurrence. There were no complications of hearing loss, facial palsy, trigeminal dysfunction, radiographic or clinical cerebellar injury, or CSF leakage. There were 21 (84%) initial BNI grade I outcomes defined by being completely pain free and not taking medication. There were two “pain free recurrences” defined as initially being scored as BNI grade I for longer than 3 months and then experiencing recurrent symptoms of TN. One patient underwent repeat RMVD and improved to BNI grade I, and the other patient underwent radiosurgery and was lost to follow-up. Three patients had a BNI grade II outcome defined by significant but not total pain relief without the use of medication. One patient was considered a BNI grade V outcome defined by persistent pain with medication use. On final outcome, 18 patients (91%) achieved a BNI grade I–II (78% grade I, 13% grade II), 3 (13%) BNI grade II, 1 (4%) “pain-free recurrence,” and 1 (4%) BNI grade V.

Conclusion: RMVD is a safe and effective strategy for surgical treatment of TN. The avoidance of fixed retractors can minimize the risk of postoperative hearing loss and cerebellar injury.