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Microvascular Decompression for Trigeminal Neuralgia advanced ...

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Microvascular Decompression for Trigeminal Neuralgia advanced ... Microvascular Decompression for Trigeminal Neuralgia advanced ... Document Transcript

  • Microvascular Decompression for Trigeminal Neuralgiaadvanced levelOverviewMicrovascular decompression (MVD) is a surgicalprocedure that relieves abnormal compression of acranial nerve. It is performed to treat trigeminalneuralgia, vagoglossopharyngeal neuralgia, andhemifacial spasm. These conditions are oftencaused by an artery or vein compressing the nerveroot as it leaves the brainstem. When compressed,normal nerve impulses can recruit nearby nervefibers and send faulty messages. Medications oftenprovide relief to patients with these conditions, butwhen medications become ineffective or causeserious side effects, one treatment option is MVD.What is microvascular decompression(MVD)?MVD is a surgical procedure to relieve thesymptoms (pain, muscle twitching) caused bycompression of a nerve by an artery or vein. MVDinvolves surgically opening the skull (craniotomy)and exposing the nerve at the base of thebrainstem to insert a tiny sponge between thecompressing vessel and the nerve. This spongeisolates the nerve from the pulsating effect and Figure 1. Trigeminal neuralgia can be caused by an arterypressure of the blood vessel. or vein compressing the trigeminal nerve root as itTrigeminal neuralgia is an irritation of the fifth Because MVD involves the use of generalcranial nerve causing severe pain that usually anesthesia and brain surgery, patients with otheraffects one side of the face, normally in the medical conditions or who are in poor health mayforehead, cheek, jaw, or teeth (Fig. 1). To treat not be candidates. MVD is not successful in treatingtrigeminal neuralgia, a sponge is placed between facial pain caused by multiple sclerosis. Because ofthe trigeminal nerve and the superior cerebellar the low risk of hearing loss, MVD may not beartery or a branch of the petrosal vein. By removing suitable for patients who have hearing loss in thethe compression, the painful symptoms are other ear.relieved. What happens before surgery?Who is a candidate? You will typically undergo tests (e.g., blood test,You may be a candidate for MVD if you have: electrocardiogram, chest X-ray) several days before surgery. In the doctors office you will sign consent• trigeminal neuralgia that is not well controlled forms and complete paperwork to inform the with medication and you desire minimal to no surgeon about your medical history (i.e., allergies, facial numbness that may be associated with medicines, anesthesia reactions, previous other treatments such as percutaneous surgeries). Discontinue all non-steroidal anti- stereotactic radiofrequency rhizotomy (PSR) or inflammatory medicines (Naproxin, Advil, etc.) and glycerol injection blood thinners (coumadin, aspirin, etc.) 1 week• facial pain isolated in the ophthalmic division or before surgery. Additionally, stop smoking and in all three trigeminal divisions chewing tobacco before and after surgery because• facial pain recurrence after a previous these activities can cause bleeding problems. Wash percutaneous or radiosurgery procedure your hair with Hibiclens® (chlorhexidine) antiseptic soap for 3 consecutive days prior to surgery. No >1
  • food or drink is permitted past midnight the nightbefore surgery.What happens during surgery?Patients are admitted to the hospital the morning ofthe procedure. You will meet with a nurse who willask your name, date of birth, what procedureyou’re having, and the side of your facial pain. Theywill explain the pre-op process and discuss anyquestions you may have. An anesthesiologist willmeet with you and explain the effects of anesthesiaand its risks. They will place an intravenous (IV)line in your arm and then transport you to theoperating room.There are 5 steps of the procedure. The operationgenerally takes 2 to 3 hours.Step 1: prepare the patientIn the OR room, general anesthesia is administered Figure 2. A skin incision is made behind the earwhile you lie on the operating table. Once asleep, (dashed line) and a 1-inch craniectomy (solid line) is made in the skull.your body is rolled over on its side and your head isplaced in a 3-pin skull fixation device, whichattaches to the table and holds your head inposition during the procedure. Next, the areabehind your ear is prepped with antiseptic. A hair-sparing technique may be used, where only a 1/4-inch wide area along the proposed skin incision isshaved.Step 2: perform a craniectomyA 3-inch curved skin incision is made behind theear. The skin and muscles are lifted off the boneand folded back. Next, a 1-inch opening is made inthe occipital bone with a drill (Fig. 2). The bone isremoved to expose the protective covering of thebrain called the dura. The dura is opened withsurgical scissors and folded back to expose thebrain.Step 3: expose the nerveRetractors placed on the brain gently open acorridor to the trigeminal nerve at its origin with thebrainstem. The surgeon exposes the trigeminalnerve and identifies any offending vessel causingcompression (Fig. 3). The vessel and nerve areoften restricted by thickened connective tissue thatmust be dissected free with scissors and knife.Step 4: insert a spongeThe surgeon cuts an appropriate size of teflonsponge and inserts it between the nerve and thevessel (Fig. 4). Sometimes a vein is adherent to the Figure 3. The superior cerebellar artery is adherentnerve and causing compression. In these cases, the to the trigeminal nerve causing compression andvein is cauterized and moved away. painful trigeminal neuralgia attacks.Step 5: closureOnce the sponge is in place, the retractor isremoved and the brain returns to its naturalposition. The dura is closed with sutures and madewatertight with tissue sealant. Since the boneopening is very small, it is not replaced. Instead, atitanium plate covers the skull opening and is >2
  • secured with tiny screws (Fig. 4). The muscles andskin are sutured back together. A soft adhesivedressing is placed over the incision.What happens after surgery?After surgery, you’ll be taken to the recovery roomwhere vital signs are monitored as you awake fromanesthesia. Next, you are transferred to theintensive care unit (ICU) for close observationovernight. You may experience some nausea andheadache after surgery; medication can controlthese symptoms. When your condition stabilizes,you’ll be transferred to a regular room where you’llincrease your activity level (sitting in a chair,walking). In 1 to 2 days you’ll be released from thehospital and given discharge instructions.Patients taking anticonvulsant or pain medicationfor trigeminal neuralgia prior to surgery will beweaned off the medications according to a scheduleto decrease risk of withdrawal and side effects.Discharge instructions:Discomfort• After undergoing a craniotomy, headaches are expected; after surgery, pain may be managed Figure 4. A sponge is inserted between the nerve with narcotic medication. Because narcotic pain and the blood vessel causing compression. pills are addictive, they are used for a limited period (2 to 4 weeks). Also, their regular use may cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).• Ask your surgeon before taking nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve). NSAIDs may cause bleeding and interfere with bone healing.Restrictions• Do not drive after surgery until discussed with your surgeon and avoid sitting for long periods of time. Figure 5. A circular titanium plate secured with screws• Do not lift anything heavier than 5 pounds covers the craniectomy made in the skull. (e.g., 2-liter bottle of soda), including children.• Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and Bathing/Wound Care loading/unloading the dishwasher, washer, or • You may shower and shampoo 3 to 4 days after dryer. surgery unless otherwise directed by your• Do not drink alcoholic beverages. surgeon. • Sutures or staples, which remain in place whenActivity you go home, will need to be removed 7 to 14• Gradually return to your normal activities. days after surgery. Ask your surgeon or call the Fatigue is common. office to find out when.• An early exercise program to gently stretch the neck and back may be advised. When to Call Your Doctor• Walking is encouraged; start with short walks If you experience any of the following: and gradually increase the distance. Wait to • A temperature that exceeds 101º F participate in other forms of exercise until • An incision that shows signs of infection, such discussed with your surgeon. as redness, swelling, pain, or drainage. >3
  • • If you are taking an anticonvulsant, and notice 2. McLaughlin MR, Jannetta PJ, Clyde BL, Subach drowsiness, balance problems, or rashes. BR, Comey CH, Resnick DK: Microvascular• Decreased alertness, increased drowsiness, decompression of cranial nerves: Lessons weakness of arms or legs, increased headaches, learned after 4400 operations. J Neurosurgery vomiting, or severe neck pain that prevents 90:1–8, 1999. lowering your chin toward the chest. LinksWhat are the results? Facial Pain Association, www.endthepain.orgMVD is highly successful in treating trigeminal American Pain Society, www.ampainsoc.orgneuralgia (95% effective) with a relatively low risk Facial Neuralgia Resources, facial-neuralgia.orgof pain recurrence (20% within 10 years). Themajor benefit of MVD is that it causes little or no Glossaryfacial numbness compared to percutaneous craniotomy: opening made in the skull.stereotactic rhizotomy (PSR). cerebellum: part of the brain responsible for balance and muscle control for movement.For a comparison of MVD to other treatments, see diplopia: double vision.Comparison of Treatment Results for Facial Pain. dysesthesia: troublesome or bothersome numbness.What are the risks? dura mater: a tough, fibrous, protective coveringNo surgery is without risks. General complications of the brain.of any surgery include bleeding, infection, blood hemifacial spasm: an irritation of the seventhclots, and reactions to anesthesia. Specific cranial nerve (facial nerve) causing involuntarycomplications related to a craniotomy may include contraction of the muscles on one side of thestroke, seizures, venous sinus occlusion, swelling of face, also known as tic convulsif. Can sometimesthe brain, and CSF leak. The most common cause pain behind the ear and loss of hearing.complication related to MVD is nerve damage, glossopharyngeal nerve: a nerve originating inwhich varies depending on the nerve being treated; the brain that supplies feeling and movement tothese include hearing loss, double vision, facial the tongue and throat.numbness or paralysis, hoarseness, difficulty glossopharyngeal neuralgia: an irritation of theswallowing (dysphagia), and unsteady gait. ninth cranial nerve causing pain at the back of the throat. multiple sclerosis: a chronic degenerative diseaseSources & links of the central nervous system in which the myelinIf you have more questions, please contact the (sheath) surrounding the nerves is destroyed.Mayfield Clinic at 800-325-7787 or 513-221-1100. neuralgia: nerve pain. neurogenic keratitis: inflammation of the cornea.Support percutaneous: by way of the skin (e.g., injection).Through the Trigeminal Neuralgia Association, local rhizotomy: cutting or destroying of a group ofsupport groups are available. The support group cells.provides an opportunity for patients and their tic douloureux: French for trigeminal neuralgia.families to share experiences, receive support, and trigeminal nerve: a nerve originating in the brainlearn about advances in treatments, pain control, that supplies feeling and movement to the face.and medications. If you would like information The trigeminal nerve has three divisions:about the Greater Cincinnati Trigeminal Neuralgia ophthalmic, maxillary, and mandibular.Support Group, please call the Mayfield Clinic at trigeminal neuralgia: an irritation of the fifth513-569-5290. For support outside Greater cranial nerve causing severe pain that usuallyCincinnati, please contact the Trigeminal Neuralgia affects one side of the face normally in theAssociation at 800-923-3608. forehead, cheek, jaw, or teeth.Sources1. Taha JM, Tew JM Jr: Comparison of surgical updated > 2.2010 treatments for trigeminal neuralgia: reviewed by > John M. Tew, MD Reevaluation of radiofrequency rhizotomy. Nancy McMahon, RN Neurosurgery 38:865-871, 1996. This information is not intended to replace the medical advice of your doctor or health care provider. For more information about our editorial policies and disclaimer of liability visit www.mayfieldclinic.com/policies.htm, or write to attn: Tom Rosenberger, Mayfield Clinic & Spine Institute, 506 Oak Street, Cincinnati, OH 45219 513.221.1100 • 800.325.7787 © Mayfield Clinic 2007. All rights reserved. >4