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J Neurol Surg B Skull Base 2022; 83(S 02): e284-e290
DOI: 10.1055/s-0041-1725036
Original Article

Prevention of Superior Petrosal Vein Injury during Microvascular Decompression for Trigeminal Neuralgia: Operative Nuances

Minsoo Kim 
1   Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
2   Department of Medicine, Graduate School, Yonsei University College of Medicine, Seoul, The Republic of Korea
,
Sang-Ku Park
3   Department of Neurosurgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, The Republic of Korea
,
Seunghoon Lee
1   Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
,
Jeong-A Lee
1   Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
,
Kwan Park
1   Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
3   Department of Neurosurgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, The Republic of Korea
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Abstract

Background The superior petrosal vein (SPV) often obscures the surgical field or bleeds during microvascular decompression (MVD) for the treatment of trigeminal neuralgia. Although SPV sacrifice has been proposed, it is associated with multiple complications. We have performed more than 4,500 MVDs, including approximately 400 cases involving trigeminal neuralgia. We aimed to describe our operative technique and nuances to avoid SPV injury.

Methods We have provided a detailed description of our institutional protocol, including the anesthesia technique, neurophysiologic monitoring, patient positioning, surgical approach, and SPV management. The surgical outcomes and treatment-related complications were retrospectively analyzed.

Results No SPVs were sacrificed intentionally or accidentally during our MVD protocol for trigeminal neuralgia. In the 344 operations performed during 2006 to 2020, 269 (78.2%) patients did not require medication postoperatively, 58 (16.9%) tolerated the procedure with adequate medication, and 17 (4.9%) did not respond to MVD. Postoperatively, 35 (10.2%), 1 (0.3%), and 0 patients showed permanent trigeminal, facial, or vestibulocochlear nerve dysfunction, respectively. Wound infection occurred in five (1.5%) patients, while cerebrospinal fluid leaks occurred in three (0.9%) patients. Hemorrhagic complications appeared in four (1.2%) patients but these were unrelated to SPV injury. No surgery-related mortalities were reported.

Conclusion MVD for the treatment of trigeminal neuralgia can be achieved safely without sacrificing the SPV. A key step is positioning the patient's vertex at a 10-degree elevation from the floor, which can ease venous return and loosen the SPV, making it less fragile to manipulation and providing a wider surgical corridor.

Keywords

microvascular decompression - superior petrosal vein - trigeminal neuralgia - complications


Publication History

Received: 06 November 2020

Accepted: 17 January 2021

Article published online:
01 March 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Antonini G, Di Pasquale A, Cruccu G. et al. Magnetic resonance imaging contribution for diagnosing symptomatic neurovascular contact in classical trigeminal neuralgia: a blinded case-control study and meta-analysis. Pain 2014; 155 (08) 1464-1471
    CrossrefPubMedSearch in Google Scholar
  • 2 Maarbjerg S, Wolfram F, Gozalov A, Olesen J, Bendtsen L. Significance of neurovascular contact in classical trigeminal neuralgia. Brain 2015; 138 (Pt 2): 311-319
    CrossrefPubMedSearch in Google Scholar
  • 3 Wei Y, Zhao W, Pu C. et al. Clinical features and long-term surgical outcomes in 39 patients withtumor-related trigeminal neuralgia compared with 360 patients with idiopathic trigeminal neuralgia. Br J Neurosurg 2017; 31 (01) 101-106
    CrossrefPubMedSearch in Google Scholar
  • 4 Herweh C, Kress B, Rasche D. et al. Loss of anisotropy in trigeminal neuralgia revealed by diffusion tensor imaging. Neurology 2007; 68 (10) 776-778
    CrossrefPubMedSearch in Google Scholar
  • 5 Lutz J, Linn J, Mehrkens JH. et al. Trigeminal neuralgia due to neurovascular compression: high-spatial-resolution diffusion-tensor imaging reveals microstructural neural changes. Radiology 2011; 258 (02) 524-530
    CrossrefPubMedSearch in Google Scholar
  • 6 Mueller D, Obermann M, Yoon MS. et al. Prevalence of trigeminal neuralgia and persistent idiopathic facial pain: a population-based study. Cephalalgia 2011; 31 (15) 1542-1548
    CrossrefPubMedSearch in Google Scholar
  • 7 Sjaastad O, Bakketeig LS. The rare, unilateral headaches. Vågå study of headache epidemiology. J Headache Pain 2007; 8 (01) 19-27
    CrossrefPubMedSearch in Google Scholar
  • 8 Hall GC, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain 2006; 122 (1,2): 156-162
    CrossrefPubMedSearch in Google Scholar
  • 9 Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC. Incidence of facial pain in the general population. Pain 2009; 147 (1–3): 122-127
    CrossrefPubMedSearch in Google Scholar
  • 10 Zakrzewska JM, Wu J, Mon-Williams M, Phillips N, Pavitt SH. Evaluating the impact of trigeminal neuralgia. Pain 2017; 158 (06) 1166-1174
    CrossrefPubMedSearch in Google Scholar
  • 11 Bendtsen L, Zakrzewska JM, Abbott J. et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol 2019; 26 (06) 831-849
    CrossrefPubMedSearch in Google Scholar
  • 12 Broggi G, Broggi M, Ferroli P, Franzini A. Surgical technique for trigeminal microvascular decompression. Acta Neurochir (Wien) 2012; 154 (06) 1089-1095
    CrossrefPubMedSearch in Google Scholar
  • 13 Pathmanaban ON, O'Brien F, Al-Tamimi YZ, Hammerbeck-Ward CL, Rutherford SA, King AT. Safety of superior petrosal vein sacrifice during microvascular decompression of the trigeminal nerve. World Neurosurg 2017; 103: 84-87
    CrossrefPubMedSearch in Google Scholar
  • 14 Choudhari KA. Superior petrosal vein in trigeminal neuralgia. Br J Neurosurg 2007; 21 (03) 288-292
    CrossrefPubMedSearch in Google Scholar
  • 15 Masuoka J, Matsushima T, Hikita T, Inoue E. Cerebellar swelling after sacrifice of the superior petrosal vein during microvascular decompression for trigeminal neuralgia. J Clin Neurosci 2009; 16 (10) 1342-1344
    CrossrefPubMedSearch in Google Scholar
  • 16 Strauss C, Naraghi R, Bischoff B, Huk WJ, Romstöck J. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000; 69 (05) 679-682
    CrossrefPubMedSearch in Google Scholar
  • 17 Koerbel A, Wolf SA, Kiss A. Peduncular hallucinosis after sacrifice of veins of the petrosal venous complex for trigeminal neuralgia. Acta Neurochir (Wien) 2007; 149 (08) 831-832 , discussion 832–833
    CrossrefPubMedSearch in Google Scholar
  • 18 Tsukamoto H, Matsushima T, Fujiwara S, Fukui M. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: case report. Surg Neurol 1993; 40 (01) 31-34
    CrossrefPubMedSearch in Google Scholar
  • 19 Anichini G, Iqbal M, Rafiq NM, Ironside JW, Kamel M. Sacrificing the superior petrosal vein during microvascular decompression. Is it safe? Learning the hard way. Case report and review of literature. Surg Neurol Int 2016; 7 (Suppl. 14) S415-S420
    CrossrefPubMedSearch in Google Scholar
  • 20 Liebelt BD, Barber SM, Desai VR. et al. Superior petrosal vein sacrifice during microvascular decompression: perioperative complication rates and comparison with venous preservation. World Neurosurg 2017; 104: 788-794
    CrossrefPubMedSearch in Google Scholar
  • 21 Xia Y, Kim TY, Mashouf LA. et al. Absence of ischemic injury after sacrificing the superior petrosal vein during microvascular decompression. Oper Neurosurg (Hagerstown) 2020; 18 (03) 316-320
    CrossrefPubMedSearch in Google Scholar
  • 22 Lee S, Park SK, Lee JA. et al. A new method for monitoring abnormal muscle response in hemifacial spasm: a prospective study. Clin Neurophysiol 2018; 129 (07) 1490-1495
    CrossrefPubMedSearch in Google Scholar
  • 23 Park SK, Joo BE, Lee S. et al. The critical warning sign of real-time brainstem auditory evoked potentials during microvascular decompression for hemifacial spasm. Clin Neurophysiol 2018; 129 (05) 1097-1102
    CrossrefPubMedSearch in Google Scholar
  • 24 Joo BE, Park SK, Cho KR, Kong DS, Seo DW, Park K. Real-time intraoperative monitoring of brainstem auditory evoked potentials during microvascular decompression for hemifacial spasm. J Neurosurg 2016; 125 (05) 1061-1067
    CrossrefPubMedSearch in Google Scholar
  • 25 McLaughlin MR, Jannetta PJ, Clyde BL, Subach BR, Comey CH, Resnick DK. Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 1999; 90 (01) 1-8
    CrossrefPubMedSearch in Google Scholar
  • 26 Rhoton Jr AL. The cerebellopontine angle and posterior fossa cranial nerves by the retrosigmoid approach. Neurosurgery 2000; 47 (3, suppl): S93-S129
    CrossrefPubMedSearch in Google Scholar
  • 27 Lee S, Park SK, Joo BE, Lee JA, Kong DS, Park K. A surgical strategy to prevent delayed epidural hematoma after posterior fossa surgery using lateral suboccipital retrosigmoid approach. J Clin Neurosci 2018; 52: 156-158
    CrossrefPubMedSearch in Google Scholar
  • 28 Jannetta PJ, McLaughlin MR, Casey KF. Technique of microvascular decompression. Technical note. Neurosurg Focus 2005; 18 (05) E5
    CrossrefPubMedSearch in Google Scholar
  • 29 Zhong J, Li ST, Zhu J. et al. A clinical analysis on microvascular decompression surgery in a series of 3000 cases. Clin Neurol Neurosurg 2012; 114 (07) 846-851
    CrossrefPubMedSearch in Google Scholar
  • 30 Zhong J, Zhu J, Sun H. et al. Microvascular decompression surgery: surgical principles and technical nuances based on 4000 cases. Neurol Res 2014; 36 (10) 882-893
    CrossrefPubMedSearch in Google Scholar
  • 31 Basamh M, Sinning N, Kehler U. Individual variations of the superior petrosal vein complex and their microsurgical relevance in 50 cases of trigeminal microvascular decompression. Acta Neurochir (Wien) 2020; 162 (01) 197-209
    CrossrefPubMedSearch in Google Scholar
  • 32 Dumot C, Sindou M. Veins of the cerebellopontine angle and specific complications of sacrifice, with special emphasis on microvascular decompression surgery. A review. World Neurosurg 2018; 117: 422-432
    CrossrefPubMedSearch in Google Scholar
  • 33 Feng B, Zheng X, Wang X, Wang X, Ying T, Li S. Management of different kinds of veins during microvascular decompression for trigeminal neuralgia: technique notes. Neurol Res 2015; 37 (12) 1090-1095
    CrossrefPubMedSearch in Google Scholar
  • 34 Gajski D, Dennis AR, Arnautović KI. Microsurgical decompression of trigeminal neuralgia caused by simultaneous double arterial (SCA and AICA) and petrosal vein complex compression. J Neurol Surg B Skull Base 2018; 79 (Suppl. 05) S428-S430
    Thieme ConnectPubMedSearch in Google Scholar
  • 35 Hong W, Zheng X, Wu Z. et al. Clinical features and surgical treatment of trigeminal neuralgia caused solely by venous compression. Acta Neurochir (Wien) 2011; 153 (05) 1037-1042
    CrossrefPubMedSearch in Google Scholar
  • 36 Inoue T, Hirai H, Shima A, Suzuki F, Fukushima T, Matsuda M. Diagnosis and management for trigeminal neuralgia caused solely by venous compression. Acta Neurochir (Wien) 2017; 159 (04) 681-688
    CrossrefPubMedSearch in Google Scholar
  • 37 Degn J, Brennum J. Surgical treatment of trigeminal neuralgia. Results from the use of glycerol injection, microvascular decompression, and rhizotomia. Acta Neurochir (Wien) 2010; 152 (12) 2125-2132
    CrossrefPubMedSearch in Google Scholar
  • 38 Ko AL, Ozpinar A, Lee A, Raslan AM, McCartney S, Burchiel KJ. Long-term efficacy and safety of internal neurolysis for trigeminal neuralgia without neurovascular compression. J Neurosurg 2015; 122 (05) 1048-1057
    CrossrefPubMedSearch in Google Scholar
  • 39 Pamir MN, Peker S. Microvascular decompression for trigeminal neuralgia: a long-term follow-up study. Minim Invasive Neurosurg 2006; 49 (06) 342-346
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Pollock BE, Stien KJ. Posterior fossa exploration for trigeminal neuralgia patients older than 70 years of age. Neurosurgery 2011; 69 (06) 1255-1259 , discussion 1259–1260
    CrossrefPubMedSearch in Google Scholar
  • 41 Tyler-Kabara EC, Kassam AB, Horowitz MH. et al. Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. J Neurosurg 2002; 96 (03) 527-531
    CrossrefPubMedSearch in Google Scholar