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How I do it: two-step transposition technique during endoscopic microvascular decompression for trigeminal neuralgia

  • How I Do it - Functional Neurosurgery - Pain
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Abstract

Background

Endoscopic microvascular decompression (eMVD) provides excellent visualization and minimally invasive surgical treatment of trigeminal neuralgia (TN). The transposition technique is desirable for long-term outcomes of TN.

Method

A two-step transposition technique is performed during eMVD for TN due to the arch-shaped superior cerebellar artery (SCA). First, the cerebellomesencephalic segment of the SCA is pulled out using oxycellulose balls. Second, the retracted lateral pontomesencephalic segment of the SCA is detached from the trigeminal nerve and is transposed for fixation at the tentorium cerebelli.

Conclusion

The two-step transposition technique offers simple, reliable decompression for TN due to the arch-shaped SCA.

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References

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa-ward, Nagoya, Aichi, 454-8509, Japan

    Fuminari Komatsu & Yoko Kato

  2. Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, Japan

    Yuichi Hirose

Authors
  1. Fuminari Komatsu
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  2. Yoko Kato
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  3. Yuichi Hirose
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Fuminari Komatsu. First draft of the manuscript was written by Fuminari Komatsu, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Fuminari Komatsu.

Ethics declarations

Ethics approval

The institutional ethics committee approved this study (No. HM18-447), and the study was conducted in accordance with the guidelines of the 1964 Declaration of Helsinki.

Consent to participate

Informed consent was obtained from all individual participants included in this study.

Consent for publication

The participants have consented to the submission of the report to the journal.

Conflict of interest

The authors declare no competing interests.

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Summary of 10 key points

1. Preoperative 3D fusion imaging is useful to assess neurovascular conflicts between CN V and the arch-shaped SCA.

2. CN V, the lateral pontomesencephalic segment of the SCA, and the cerebellomesencephalic segment of the SCA are exposed.

3. Perforators from the SCA must be observed to assess the feasibility of transposition.

4. Oxycellulose balls are applied to lift the cerebellomesencephalic segment of the SCA and to pull on the lateral pontomesencephalic segment of the SCA.

5. Damage to CN IV must be avoided during manipulation of the cerebellomesencephalic segment of the SCA.

6. After the angle of the arch-shaped SCA becomes shallow, the lateral pontomesencephalic segment of the SCA is more easily transposed.

7. Application of fibrin glue alone is easy and sufficient for fixing the transposed SCA.

8. Preservation of blood flow in the transposed artery is confirmed.

9. No prostheses that may cause recurrent TN are required for this technique.

10. Complete decompression from the offending arteries is confirmed.

This article is part of the Topical Collection on Functional Neurosurgery—Pain

Supplementary Information

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Supplementary file1 (MP4 147573 KB) Video 1. Pure eMVD is performed for TN due to the arch-shaped SCA. The caudal trunk of the SCA makes a deep caudal loop, and the bottom of the loop extends inferiorly beyond the inferior margin of CN V. The medial aspect of the root entry zone of CN V is severely compressed by the distal part of the arch-shaped SCA (the caudal trunk at the lateral pontomesencephalic segment). The cerebellomesencephalic segment of the SCA and CN IV are identified dorsomedial to the SPV. For the two-step transposition technique, oxycellulose balls approximately 5 mm in diameter are first applied between the upper brainstem and the cerebellomesencephalic segment of the SCA. The cerebellomesencephalic segment of the SCA is lifted from the upper brainstem using oxycellulose balls. The arch-shaped SCA is then pulled out posteriorly, and the angle of the arch-shaped SCA becomes significantly shallower. The arch-shaped SCA is easily mobilized because the physical strain due to the deep loop is greatly reduced. As the second step, the pontomesencephalic segment of the SCA is transposed upward and fixed to the tentorium cerebelli with fibrin glue. Preservation of blood flow in the transposed artery and secure decompression of CN V are confirmed. AICA, anterior inferior cerebellar artery; CM, cerebellomesencephalic segment of the superior cerebellar artery; CT, caudal trunk of the superior cerebellar artery; LP, lateral pontomesencephalic segment of the superior cerebellar artery; NVC, neurovascular conflict; OB, oxycellulose ball; RT, rostral trunk of the superior cerebellar artery; SPV, superior petrosal vein; TC, tentorium cerebelli; CN IV, trochlear nerve (cranial nerve IV); CN V, trigeminal nerve (cranial nerve V). Arrows, arch-shaped superior cerebellar artery

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Komatsu, F., Kato, Y. & Hirose, Y. How I do it: two-step transposition technique during endoscopic microvascular decompression for trigeminal neuralgia. Acta Neurochir 164, 823–826 (2022). https://doi.org/10.1007/s00701-021-05080-y

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  • DOI: https://doi.org/10.1007/s00701-021-05080-y

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