MVD for Geniculate Neuralgia: Alternative Operative Findings

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The pain of geniculate neuralgia can overlap with pain of glossopharyngeal neuralgia. This is a young patient who presented primarily with geniculate neuralgia, however her pain had some minor components of glossopharyngeal neuralgia. Her pain was primarily in her ear. And I would like to share the operative findings with you. She was 52-year-old with a left-sided pain. Here's the initial findings after left-sided retro mastoid craniotomy. You can see this seven and eighth cranial nerves. You can see the ninth cranial nerve with a very sizable vascular loop causing convincing conflict there. You can see the 10th cranial nerve is relatively unharmed. At this juncture, I felt that most likely the pain of this patient could be explained by neurovascular conflict at the level of the ninth cranial nerve. The ninth cranial nerve itself does innervate the ear canal, and therefore, as you can see, there are different kind of vascular conflicts which can lead to geniculate neuralgia, and that is why I have come to believe that inspection of the five, seven and eight, and ninth and tenth cranial nerves are important to assure that this pairing syndrome is adequately addressed intraoperatively. You can also see the labyrinthine artery, which is present between the seven and eighth cranial nerves. I first went ahead and inspected the space between the seven and eighth cranial nerves. You can see that the labyrinthine artery is mobilized, however, inspection of the shoulder of the seventh and eighth cranial nerves did not reveal any impressive findings. I did not persist in retracting the eighth nerve as this may lead to intractable vestibular dysfunction. The vesicles of nervous intermedius often can be just between the superior vestibular nerve and the facial nerve. Here, you can see the vascular loop between the ninth cranial nerve. As was the brainstem was decompressed I then went ahead and mobilized the labyrinthine artery very gently and decompress this artery against the space between the seven and eighth cranial nerves. Again, it's important for this artery to remain intact to assure that hearing is preserved. So in conclusion, this patient underwent microvascular decompression of the ninth and 10th cranial nerves, as well as mobilization of the labyrinthine artery. No obvious nervous intermedius vesicles were found. This patient has benefited from complete relief of her pain.

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