Classic Vascular Compression for Trigeminal Neuralgia

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Hello, ladies and gentlemen. With this video, I would like to discuss technical nuances for microvascular decompression surgery for medically refractory trigeminal neuralgia. This video will review vascular compression in its classical location at the shoulder of the nerve and how this can be mobilized. I'm going to review the case of a six-year-old female who presented with left sided trigeminal neuralgia, and an axial MRI T2 high-resolution MRI of the posterior fossa. You can appreciate that at the tip of the arrow, a vascular loop came in very close contact to the root entry zone of the trigeminal nerve. In the next slice of the MRI, you can see that vascular compression. Due to medical refractory nature of her pain, she underwent a left-sided retromastoid craniotomy. The bony removal is approximately twice the size of a quarter coin. You can see the junction of the transverse sigmoid junction transverse sigmoid dural sinuses. The dura was open along these sinuses, a piece of rubber then was placed underneath the cottonoid, to have the cottonoid slide around the cerebellum. You can see the junction of the tentorium and petrous bone, staying on the side of the petrous bone, the arachnoid membranes over the cerebral pontine angle are opened. You can see the seven and eighth cranial nerves at the lower edge of our dural opening, which are more superficial than the fifth cranial nerve. Here's the root entry zone of the trigeminal nerve. The expected vascular loop, a branch of the superior cerebellar artery, is being mobilized. There was actually two branches causing some discoloration of the nerve. A vein also inferiorly, at the tip of the arrow, is being mobilized away from the nerve. The two branches of the superior cerebral artery are kept in, kept away from the nerve and this area will be packed with shredded pieces of Teflon. And each piece of Teflon is placed between the artery and the nerve, and then pushed distally, to assure the entire intracisternal segment of the nerve, as well as the root exits on, are adequately padded and decompressed. You can see a piece of shredded Teflon was also placed between the vein inferiorly and the nerve, and this allowed a complete decompression of the nerve, without any further evidence of compression.

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