Fully Endoscopic Vascular Decompression of the Trigeminal Nerve

Abstract

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

Key words

Endoscopy - Microvascular Decompression - Trigeminal Neuralgia

References

• 1 Blitzer A. Pharmacotherapy and trigeminal neuralgia.  Anesth Prog. 1969;  16 15-17
• 2 Tovi D, Leivy D M, Krueger E. Trigeminal neuralgia. Current trends in treatment.  N Y State J Med. 1969;  69 564-567
• 3 Doyen E. Surgical therapeutics and operative techniques. Balliere, Tindall, and Cox, Editors London 1917: 599-602
• 4 Dandy W. Concerning the cause of trigmeminal neuralgia.  American Journal of Surgery. 1934;  24 447-455
• 5 Jannetta P J. Arterial compression of the trigeminal nerve at the pons in patients with trigeminal neuralgia.  J Neurosurg. 1967;  26 159-162
• 6 Jannetta P J. Gross (mesoscopic) description of the human trigeminal nerve and ganglion.  J Neurosurg. 1967;  26, Suppl 109-111
• 7 Jannetta P J. The surgical binocular microscope in neurological surgery.  Am Surg. 1968;  34 31-34
• 8 Jannetta P J, Bissonette D J. Management of the failed patient with trigeminal neuralgia.  Clin Neurosurg. 1985;  32 334-347
• 9 Barker F G. et al . The long-term outcome of microvascular decompression for trigeminal neuralgia [see comments].  N Engl J Med. 1996;  334 1077-1083
• 10 McLaughlin M R. et al . Microvascular decompression of cranial nerves: lessons learned after 4400 operations [see comments].  J Neurosurg. 1999;  90 1-8
• 11 Bederson J B, Wilson C B. Evaluation of microvascular decompression and partial sensory rhizotomy in 252 cases of trigeminal neuralgia.  J Neurosurg. 1989;  71 359-367
• 12 Cutbush K, Atkinson R L. Treatment of trigeminal neuralgia by posterior fossa microvascular decompression.  Aust N Z J Surg. 1994;  64 173-176
• 13 Lovely T J, Jannetta P J. Microvascular decompression for trigeminal neuralgia. Surgical technique and long-term results.  Neurosurg Clin N Am. 1997;  8 11-29
• 14 Fries G, Perneczky A. Endoscope-assisted brain surgery: part 2 - analysis of 380 procedures.  Neurosurgery. 1998;  42 226-231; discussion 231 - 232
• 15 Hopf N J, Perneczky A. Endoscopic neurosurgery and endoscope-assisted microneurosurgery for the treatment of intracranial cysts.  Neurosurgery. 1998;  43 1330-1336; discussion 1336 - 1337
• 16 Wackym P A. et al . Endoscope-assisted vestibular neurectomy [see comments].  Laryngoscope. 1998;  108 1787-1793
• 17 Wackym P A, King W A, Weisz D J. Vascular compression of the cochlear nerve identified by endoscopy during acoustic neuroma surgery.  Otolaryngol Head Neck Surg. 1999;  120 535
• 18 Magnan J. et al . Hemifacial spasm: endoscopic vascular decompression.  Otolaryngol Head Neck Surg. 1997;  117 308-314
• 19 Oppel F, Mulch G. Selective trigeminal root section via an endoscopic transpyramidal retrolabyrinhthine approach.  Acta Neurochir Suppl. 1979;  28 565-571
• 20 Prott W. Cisternoscopy of the cerebellopontine angle (author's transl).  Hno. 1974;  22 337-341
• 21 O'Donoghue G M, O'Flynn P O. Endoscopic anatomy of the cerebellopontine angle.  Am J Otol. 1993;  14 122-125
• 22 Bottrill I D, Poe D S. Endoscope-assisted ear surgery.  Am J Otol. 1995;  16 158-163
• 23 Jennings C R, O'Donoghue G M. Posterior fossa endoscopy [editorial].  J Laryngol Otol. 1998;  112 227-229
• 24 King W A, Wackym P A. Endoscope-assisted surgery for acoustic neuromas (vestibular schwannomas): early experience using the rigid Hopkins telescope.  Neurosurgery. 1999;  44 1095-1100; discussion 1100 - 1102
• 25 Rosenberg S I. Endoscopic otologic surgery.  Otolaryngol Clin North Am. 1996;  29 291-300
• 26 Tatagiba M, Matthies C, Samii M. Microendoscopy of the internal auditory canal in vestibular schwannoma surgery.  Neurosurgery. 1996;  38 737-740
• 27 Magnan J. et al . Surgical perspecitives of endoscopy of the cerebellopontine angle.  Am J Otol. 1994;  15 366-370
• 28 Magnan J. et al . Endoscopy of the cerebellopontine angle.  Rev Laryngol Otol Rhinol. 1995;  116 115-118
• 29 Magnan J, Sanna M. Endoscopy in neuro-otology. Vol. 1. New York: Thieme 1999: 7-23
• 30 Linder T E, Simmen D, Stool S E. Revolutionary inventions in the 20th century. The history of endoscopy [see comments].  Arch Otolaryngol Head Neck Surg. 1997;  123 1161-1163
• 31 Eaves F F, Bostwick J, Nahai F. Instrumentation and setum for endoscopic plastic surgery.  Clin Plast Surg. 1995;  22 591-603
• 32 Nishioka N S, Mycek M A. Initial experience with a real-time video processor for enhancing endoscopic image contrast.  Gastrointest Endosc. 1998;  48 62-66
• 33 Liao J J. et al . Reoperation for recurrent trigeminal neuralgia after microvascular decompression.  Surg Neurol. 1997;  47 562-568; discussion 568 - 570
• 34 Lee S H. et al . Recurrent trigeminal neuralgia attributable to veins after microvascular decompression.  Neurosurgery. 2000;  46 356-361; discussion 361 - 362
• 35 Kureshi S A, Wilkins R H. Posterior fossa reexploration for persistent or recurrent trigeminal neuralgia or hemifacial spasm: surgical findings and therapeutic implications.  Neurosurgery. 1998;  43 1111-1117
• 36 Yamaki T. et al . Results of reoperation for failed microvascular decompression.  Acta Neurochir. 1992;  115 1-7
• 37 Rath S A, Klein H J, Richter H P. Findings and long-term results of subsequent operations after failed microvascular decompression for trigeminal neuralgia.  Neurosurgery. 1996;  39 933-938; discussion 938 - 940
• 38 Klun B. Microvascular decompression and partial sensory rhizotomy in the treatment of trigeminal neuralgia: personal experience with 220 patients.  Neurosurgery. 1992;  30 49-52
• 39 Spencer W R. et al . Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope.  Laryngoscope. 1999;  109 791-794
• 40 Jarrahy R, Berci G, HK S. Endoscope-assisted microvascular decompression of the trigeminal nerve. Otolaryngol Head Neck Surg 2000: Accepted for publication
• 41 Andrews R J, Bringas J R. A review of brain retraction and recommendations for minimizing intraoperative brain injury [see comments].  Neurosurgery. 1993;  33 1052-1063; discussion 1063 - 1064