[Adjunctive use of endoscopy during microvascular decompression in the cerebellopontine angle: 27 case reports]

Case report: Fully endoscopic microvascular decompression for glossopharyngeal neuralgia

With the advances in endoscopic technology, endoscopy is widely used in many neurosurgical procedures, such as microvascular decompression, which is an effective method to treat glossopharyngeal neuralgia, trigeminal neuralgia, and facial spasm. The purpose of this study was to determine the efficacy of fully endoscopic microvascular decompression in the treatment of glossopharyngeal neuralgia. We managed a patient with glossopharyngeal neuralgia in our department, whose main clinical manifestation was recurrent left ear and facial pain for 3 years. The patient underwent a fully endoscopic microvascular decompression. The pain in the left ear and face was significantly relieved postoperatively, and there was no recurrence at the 6-month follow-up evaluation. We describe a case of glossopharyngeal neuralgia that was successfully treated by fully endoscopic microvascular decompression, which showed that endoscopy has advantages in microvascular decompression, and fully endoscopic microvascular decompression is an effective method for glossopharyngeal neuralgia.

Efficacy of microsurgical vascular decompression in trigeminal neuralgia

OBJECTIVES

Analysis of the long-term efficacy of microvascular decompression surgery in trigeminal neuralgia.

MATERIAL AND METHODS

A single-center retrospective study included patients undergoing microvascular decompression surgery for trigeminal neuralgia after failure of well-conducted medical or complementary therapy, with visualization of nerve compression syndrome on MRI.

RESULTS

Eighty-seven patients were included. Nerve compression was alleviated without interposition of polytetrafluoroethylene in 79.3% of cases. Postoperative efficacy on pain was immediate in 97.7% of cases. There were no postoperative deaths, and the rate of severe complications was low (2.3%). The efficacy of microvascular decompression surgery was total at 2 years in 90.8% of cases and at 10 years in 92.3%, without resumption of medical treatment. The failure rate was 10.3%; 26.3% of these patients had been previously treated by a lesional technique (P: 0.043) and 33.3% by interposition of polytetrafluoroethylene (P: 0.003).

CONCLUSIONS

With confirmed clinical and radiological diagnosis, microvascular decompression surgery for trigeminal nerve compression was safe, with total effectiveness in the immediate, short and long terms. It should be considered in first line in case of failure or intolerance of well-conducted medical treatment.

A Meta-Analysis of Endoscopic Microvascular Decompression versus Microscopic Microvascular Decompression for the Treatment for Cranial Nerve Syndrome Caused by Vascular Compression

OBJECTIVE

The aim of this study was to compare the efficacy and safety of endoscopic microvascular decompression (E-MVD) and microscopic microvascular decompression (M-MVD) for the treatment for cranial nerve syndrome caused by vascular compression, including primary trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia.

METHODS

A systematic search of the online databases, including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China Biology Medicine disc, and China National Knowledge Infrastructure, was performed from January 1966 to March 2018. The language of the included literature was not limited. Relevant outcomes of perioperative safety and postoperative efficacy were considered for meta-analysis. Single-arm and cumulative meta-analyses were also conducted. All the outcomes were calculated as odds ratios (ORs) with 95% confidence intervals using R language.

RESULTS

A total of 9 studies involving 1093 (E-MVD [543] vs. M-MVD [550]) patients were included for analysis in our study. The recent remission rate (92% vs. 86%; OR, 1.71; P = 0.0089), offending vessel discovery rate (99% vs. 95%; OR 2.76, P = 0.0061), and long-term remission rate (97% vs. 87%; OR 4.59, P = 0.0036) were significantly higher in patients who underwent E-MVD than in those who underwent M-MVD, whereas perioperative complications (23% vs. 35%; OR 0.56, P < 0.0001) were significantly lower in patients who underwent E-MVD.

CONCLUSIONS

This meta-analysis confirms that E-MVD is superior to M-MVD both in perioperative and postoperative efficacy (short- and long-term), and therefore it should be considered as an appropriate treatment choice for patients with neuralgia and hemifacial spasm.

Endoscope-assisted decompression of facial nerve for treatment of hemifacial spasm

Microvascular decompression has become the sole method for a curative treatment of primary hemifacial spasm. Finding the responsible conflicting artery is not always easy as its location can be deeply situated within the cerebellopontine/medullary fissure at the facial root exit zone. Sole or additional offending vessel(s) may be at the meatus of the internal auditory canal (5% of the cases). Identifying the compressive vessel(s) and performing decompression is in most cases possible without cerebellar retraction by classical microsurgical techniques. However, in a number of patients the neurovascular conflict may be hidden in spite of the direct illumination of the operative microscope. Therefore, assistance by endoscopy can be useful and contribute as a minimally invasive approach. The author reports his own experience in a series of 553 patients operated on over the past three decades. A total of 93.6% had complete relief of their spasm (11% after repeated surgery). Relief was delayed in 20.8% of these patients. Recurrence was rare (0.3%). There was no mortality and morbidity was low: deafness occurred in 0.6%. There was no permanent postoperative facial palsy. CSF leakage amounted to 1% in the last period of surgery. In conclusion, the author advocates combining the use of both the endoscopy for exploration and the microscope for decompression.

Trigeminal Neuralgia

Trigeminal neuralgia (TN) is a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve. Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities. Although multiple mechanism involving peripheral pathologies at root (compression or traction), and dysfunctions of brain stem, basal ganglion, and cortical pain modulatory mechanisms could have role, neurovascular conflict is the most accepted theory. Diagnosis is essentially clinically; magnetic resonance imaging is useful to rule out secondary causes, detect pathological changes in affected root and neurovascular compression (NVC). Carbamazepine is the drug of choice; oxcarbazepine, baclofen, lamotrigine, phenytoin, and topiramate are also useful. Multidrug regimens and multidisciplinary approaches are useful in selected patients. Microvascular decompression is surgical treatment of choice in TN resistant to medical management. Patients with significant medical comorbidities, without NVC and multiple sclerosis are generally recommended to undergo gamma knife radiosurgery, percutaneous balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation procedures. Partial sensory root sectioning is indicated in negative vessel explorations during surgery and large intraneural vein. Endoscopic technique can be used alone for vascular decompression or as an adjuvant to microscope. It allows better visualization of vascular conflict and entire root from pons to ganglion including ventral aspect. The effectiveness and completeness of decompression can be assessed and new vascular conflicts that may be missed by microscope can be identified. It requires less brain retraction.

Endoscopic Resection of Vestibular Schwannomas

Objective To report our results and the technical details of fully endoscopic resection of vestibular schwannomas. Design Prospective observational study. Setting A single academic institution involving neurosurgery and neurotology. Participants Twelve consecutive patients who underwent fully endoscopic resection of a vestibular schwannoma. Main Outcome Measures Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons (AAO-HNS) score as well as the Gardener and Robertson Modified Hearing Classification (GR). Facial nerve preservation based on the House-Brackmann (HB) score. Results All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1-2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days. Conclusion A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients.

Endoscopic vascular decompression for the treatment of trigeminal neuralgia: clinical outcomes and technical note

OBJECTIVE

This study sought to describe the operative technique and clinical outcomes in a series of 57 patients with trigeminal neuralgia treated with endoscopic vascular decompression (EVD) alone without the use of microscopy at any point.

METHODS

A prospective observational study was performed on 57 consecutive patients treated with EVD alone for trigeminal neuralgia from October 2005 to October 2010. Patient outcomes were evaluated with respect to pain abatement, complication rate, length of hospital stay, and overall operative time. Pain outcome was graded using the Barrow Neurological Institute pain intensity score (BNI), with BNI 1 considered an excellent result and BNI 2 or 3 considered a good result. Follow-up ranged from 12 to 72 months, with a mean of 32 months. In addition to reporting these cases, our operative technique for EVD is described in detail.

RESULTS

All 57 patients reported severe preoperative pain (BNI 5); 100% of patients achieved immediate postoperative pain control or complete pain relief (BNI 1 to 3), with 82% obtaining an excellent result of BNI 1, and 18% of patients reported good results of BNI 2 or 3. At follow-up, 56 of 57 patients (98%) reported complete relief or well controlled pain (BNI 1 to 3), with 75% obtaining an excellent result of BNI 1; 23% of patients obtained a good result of BNI 2 or 3. The complication rate was 4%, with no mortality. Mean length of hospital stay was 1.6 days, with a range of 1 to 5 days; mean operative time was 133 minutes.

CONCLUSIONS

EVD is a safe and highly effective alternative to the more traditional open microvascular decompression or the more recently developed endoscopically assisted microvascular decompression.