Internal Neurolysis (Nerve Combing) for Trigeminal Neuralgia without Neurovascular Compression

Objective The aim of the present study was to describe and evaluate the initial and the long-term clinical outcome of internal neurolysis (IN) for trigeminal neuralgia (TN) without neurovascular compression (NVC). Methods A total of 170 patients diagnosed with TN were treated by posterior fossa exploration, during the period between April 2012 and October 2019. The patients were divided into two groups: Group A (50 patients)was treated by IN and Group B (120 patients) received microvascular decompression (MVD). Surgical outcomes and postoperative complications were compared between the two groups. Pain intensity was assessed by the Barrow Neurological Institute (BNI) pain intensity score and BNI facial numbness score. Pain recurrence was statistically evaluated with Kaplan-Meier analysis. Results Pain was completely relieved in 44 patients (88%) who underwent IN (group A); 3 (6%) experienced occasional pain but did not require medication (BNI 2). In group B, 113 (94%) experienced immediate pain relief after MVD. The median duration of follow-ups was 4 years (6 months to 7.5 years). In Group A, there was a meantime recurrence of 27 months in 3 patients (6%). The recurrence in Group B was of 5.8% during the follow-up period. There were no statistically significant differences in the surgical outcomes between the two groups. All patients with IN experienced some degree of numbness, 88% of the cases resolved in 6 months, on average. Conclusion Internal neurolysis is an effective, safe and durable treatment option for trigeminal neuralgia when NVC is absent.

Hemifacial Spasm Associated with Chiari Type I Malformation: Surgical Considerations and Case Report

Hemifacial spasm (HS) is a movement disorder characterized by paroxysmal and irregular contractions of the muscles innervated by the facial nerve. Chiari malformation type I (CM I) is a congenital disease characterized by caudal migration of the cerebellar tonsils, and surgical decompression of foramen magnum structures has been used for treatment. The association of HS with CM I is rare, and its pathophysiology and therapeutics are speculative. There are only a few cases reported in the literature concerning this association. The decompression of the posterior fossa for the treatment of CM I has been reported to relieve the symptoms of HS, suggesting a relation between these diseases. However, the possible complications of posterior fossa surgery cannot be underrated. We report the case of a 66-year-old patient, in ambulatory follow-up due to right HS, no longer responding to botulinum toxin treatment. Magnetic resonance imaging (MRI) of the skull revealed compression of the facial nerve and CM I. The patient underwent surgery for HS by neurovascular microdecompression of the facial nerve via right lateral suboccipital craniectomy, but presented significant clinical worsening in the postoperative period even though the cerebellum edema related to surgical manipulation was mild. Due to the clinical worsening, the patient underwent a median suboccipital craniectomy with decompression of the foramenmagnum structures. After this second surgery, the patient had progressive improvement and was discharged from the hospital for ambulatory care.

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience / Abordagem retrosigmóidea assistida por endoscopia em espasmo hemifacial: nossa experiência

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.

Resumo Introdução: O uso de descompressão cirúrgica do espasmo hemifacial devido ao loop no canal auditivo interno nem sempre é aceito devido ao risco relacionado ao procedimento cirúrgico. Atualmente, uma nova técnica cirúrgica permite trabalhar em condições seguras. Objetivo: Relatar os resultados que obtivemos com a abordagem retrosigmóidea assistida por endoscopia para a descompressão microvascular do nervo facial em casos de espasmo hemifacial devido a conflito neurovascular. A técnica cirúrgica é descrita. Método: Realizamos um estudo prospectivo em um centro de referência terciária observando 12 pacientes (5M, 7F), com média de idade de 57,5 (intervalo 49-71) anos com espasmo hemifacial submetidos a uma abordagem retrosigmóide assistida por endoscopia para descompressão microvascular. Foram avaliados os achados intraoperatórios, a resolução pós-operatória do espasmo hemifacial e as taxas de complicações. Resultados: A resolução do espasmo hemifacial foi observada em 9/12 (75%) dos casos nas 24 horas após a cirurgia e em 12/12 (100%) dos indivíduos até 45 dias. Uma correlação significativa (p < 0,001) entre a duração do histórico pré-operatório de espasmo hemifacial e o tempo de recuperação pós-operatório foi registrado. Apenas um paciente apresentou uma complicação (meningite), que foi resolvida após administração de antibióticos por via intravenosa sem sequelas. Nenhum caso fístula liquórica, paralisia facial ou deficiência auditiva foi registrado. A recorrência do espasmo hemifacial foi observada em único indivíduo em quem o conflito neurovascular foi causado por um vaso no interior do canal auditivo interno. Conclusões: A técnica da abordagem retrosigmóidea assistida por endoscopia oferece uma ótima visualização do conflito neurovascular através de uma abordagem minimamente invasiva, permite assim uma descompressão precisa do nervo facial com baixas taxas de complicações. Por ser menos invasivo, o procedimento deve ser considerado na cirurgia funcional do ângulo pontocerebelar como tratamento de espasmo hemifacial, especialmente quando o procedimento é feito por um otorrinolaringologista.

Abordaje asterional mínimamente invasivo para descompresión microvascular en neuralgia del trigémino / Minimally invasive asterional approach for microvascular decompression in trigeminal neuralgia

Resumen Objetivo: La neuralgia del trigémino (NT) es un trastorno neuropático susceptible de tratamiento quirúrgico. El objetivo es presentar los hallazgos quirúrgicos y resultados obtenidos en 26 pacientes con NT, tratados mediante un abordaje asterional mínimamente invasivo para descompresión vascular trigeminal. Métodos: Estudio longitudinal descriptivo. Se intervino mediante abordaje asterional a 26 pacientes. Se registró el historial médico, hallazgos quirúrgicos, respuesta al tratamiento y complicaciones. Se les dio seguimiento durante 36 meses. Resultados: Diecinueve casos se asociaron a compresión vascular, cinco casos a aracnoiditis y los dos restantes se relacionaron con esclerosis múltiple y neuralgia postherpética. El dolor se controló significativamente en todos los pacientes durante el postoperatorio inmediato. A 36 meses de seguimiento, en 25 pacientes se alcanzó un control total o aceptable del dolor. A largo plazo 22 pacientes evolucionaron sin complicaciones permanentes. Conclusiones: La cirugía de descompresión microvascular a través de un abordaje asterional mínimamente invasivo para el tratamiento de la NT es una alternativa con resultados similares al abordaje retrosigmoideo clásico, pero que suma las bondades de una técnica quirúrgica que se rige con los principios de la mínima invasión. Se requieren esfuerzos constantes para optimizar las técnicas quirúrgicas en el tratamiento de la NT.

Abstract Objective: Trigeminal neuralgia (TN) is a neuropathic disorder that can be treated surgically. This study aimed to present the surgical findings and the clinical outcomes of 26 patients with TN treated by minimally invasive asterional surgery. Methods: Longitudinal descriptive study. Twenty-six patients with TN underwent minimally invasive asterional surgery. The medical history, surgical findings, therapeutic response, and complications were registered. They were followed for 36 months. Results: Nineteen cases were associated with vascular compression; five were associated with arachnoiditis. The two remaining cases were associated with multiple sclerosis and post-herpetic neuralgia. The pain was substantially reduced in all patients in the immediate postoperative period. At 36 months, in 25 patients, total or acceptable pain control was achieved. In the long term, 22 patients evolved with no permanent complications. Conclusion: The microvascular decompression surgery by an asterional approach is an alternative with similar results to the classic retrosigmoid approach to treat TN, but that adds the benefits of the principles of minimally invasive surgery. Constant efforts need to be made to optimize minimally invasive surgical techniques for TN.

Microvascular Compressicaude by Slinging a Tortuous Vertebrobasilar Artery to the Petrous Dura in Hemifacial Spasm: Technical Note

Objective In cases of hemifacial spasm caused by a tortuous vertebrobasilar artery (TVBA), the traditional treatment technique involves Teflon (polytetrafluoroethylene), which can be ineffective and fraught with recurrence and neurological complications. In such cases, there are various techniques of arteriopexy using adhesive compositions, 'suspending loops' made of synthetic materials, dural or fascial flaps, surgical sutures passed around or through the vascular adventitia, as well as fenestrated aneurysmal clips. In the present paper, we describe a new technique of slinging the vertebral artery (VA) to the petrous dura for microvascular decompression (MVD) in a patient with hemifacial spasm caused by a TVBA. Method A 50-year-old taxi driver presented with a left-sided severe hemifacial spasm. A magnetic resonance imaging (MRI) scan of the brain showed a large tortuous left-sided vertebral artery impinging and compressing the exit/entry zone of the 7th and 8th nerve complex. After a craniotomy, a TVBAwas found impinging and compressing the entry zone of the 7th and 8th nerve complex. Arachnoid bands attaching the artery to the nerve complex and the pons were released by sharp microdissection. Through the upper part of the incision, a 2.5 1 cmtemporal fascia free flap was harvested. After the fixation of the free flap, a 6­0 prolene suture was passed through its length several times using the traditional Bengali sewing and stitching techniques to make embroidered quilts called Nakshi katha. The'prolenated' fascia was passed around the compressing portion of the VA. Both ends of the fascia were brought together and stitched to the posterior petrous dura to keep the TVBA away from the 7th and 8th nerves and the pons. Result The patient had no hemifacial spasm immediately after the recovery from the anesthesia. A postoperative MRI of the brain showed that the VA was away from the entry zone of the 7th and 8th nerves.