Retrospective Comparison of Postoperative Complications and Pain by Petrosal Vein Sacrifice in Endoscopic Microvascular Decompression for Trigeminal Neuralgia

Objective: To investigate the risk of petrosal vein (PV) sacrifice during endoscopic microvascular decompression (E-MVD) in trigeminal neuralgia (TGN) and subsequent postoperative complications and pain out comes

Methods: This is a retrospective study based on a 2013 date of adoption of the electronic medical record and a standardized template for operative dictation with specific drop down field for petrosal vein sacrifice coded as none, partial, or complete. A 5-year interval review, from 2013 to 2018, yielded 201 consecutive patients undergoing MVD by a single surgeon for trigeminal neuralgia. PV preservation or sacrifice, and vascular compressive anatomy were noted. Postoperative complications attributable to venous insufficiency as reported in the literature (cerebellar hemorrhage, midbrain and pontine infarction, edema) were gleaned from patient charts. Preoperative and postoperative pain outcomes were measured using the Basic Pain Inventory (BPI)-Facial (aka Penn Facial Pain Scale), administered preoperatively and at 1-month follow-up, were analyzed to determine potential association with PV preservation status.

Results: PV sacrifice was noted for 118/201 (59%) of patients, with 43/201 (21%) undergoing partial sacrifice (denoted by cutting of only one or more branches of the petrosal vein) versus 75/201 (37%) with complete sacrifice No cases of venous infarction, cerebellar swelling, or fatal complications were noted in either cohort. Nonneurologic complications (pulmonary embolus and NSTEMI) (2/201, 1%) were noted in 1.69% (2/118) of patients with PV sacrifice and 0% (0/83) of patients with PV preservation (Fisher’s exact test, p = 0.51). Neurologic deficits (facial palsy, conductive hearing loss, gait instability, memory deficit) (4/201, 2%) occurred in equal proportions in PV preservation and sacrifice groups (2.41 vs. 1.69%; Fisher’s exact test, p > 0.99). Furthermore, statistical analyses found no significant association between PV preservation versus PV sacrifice in 6/7 metrics of subjective pain improvement collected at 1-month follow-up. Comparative rates of headache at 1 month did not differ significantly in PV preservation versus PV sacrifice (26.3 vs. 21.9%; Fisher’s exact test, p > 0.05). Improvement in current pain at 1 month was found to be slightly higher in the PV preservation group versus the PV sacrifice group (−5.5 vs. −1; Mann–Whitney test, p = 0.036).

Conclusion: This negative study counters recent concerns speculation that PV sacrifice during MVD leads to higher postoperative complication rates due to insufficient venous drainage. While potential impact on short-term subjective improvement in pain cannot be fully eliminated, PV sacrifice has no demonstrable relationship with complications following surgery, reinforcing support for its continued use as a safe and justifiable surgical technique when necessary for improved surgical visualization.