Redo MVD: Nuances of Technique
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What are the indications and techniques for repeat microvascular decompression surgery for Trigeminal neuralgia? I do consider doing an MVD for recurrent pain, if the patient was noted to have a convincingly offending vessel during the initial operation, as well as the fact that he or she received good amount of pain freedom. However, after a relatively extended period of time the pain recurred, and the pain continues to have typical features of trigeminal neuralgia. Redo operations for microvascular decompression surgery are definitely carrying a higher risk than virgin microvascular decompression operations, and the patients should be young, and also have again very typical features of recurrent trigeminal neuralgia. This is a patient of mine who is 62 years old and underwent an MVD operation about a year ago, and then presented with recurrent typical pain and underwent a redo operation. Let's review the findings in this case, the initial operation was done through a linear incision. As you can see, the previous area of the cranial plasty was reopened, and here is the sigmoid sinus on the right side, as well as the transfer sinus. You can see the mastoid bone over the tip of my arrow. After the sharp dissection techniques were used to expose the right side of her trigeminal nerve, you can see, again, the anatomy here more superficially is there seven and eighth cranial nerves. Here's the trigeminal nerve, here is the previous piece of Teflon that is covered the nerve, and it's all at this time, not possible to see around it, to see if there is another compressive vessel, just anterior to the Teflon. Here's the nerve elevated using the dissector. And you can see that the Teflon also is sort of moving over the nerve and just anterior to it. We'll go ahead and dissect the Teflon in order to be able to see if there is a compressive vessel underneath. Now, you can see that actually there is a branch of superior cerebellar artery here that is most likely the offending vessels causing trigeminal neuralgia. However, for me to be able to mobilize this vessel completely, I micro surgically mobilize the piece of the Teflon. And here as you can see the compressive vessel, that is being distracted away through this scar from the nerve. Due to a amount of the scar that is over present in these operations short dissection is the best modality to dissect through the scar. After the compressive vessel was found, you can see pieces of Teflon are placed along the root entry zone of the nerve at the level of the brainstem to complete the mobilization of the artery and authority compression of the nerve.
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