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Repeat MVD for Trigeminal Neuralgia

January 16, 2015


Repeat microvascular decompression surgery for trigeminal neuralgia has a role in the management of this pain syndrome. However, the indications are rather rare, and I'm going to review some of the rationale and techniques here. I offer repeat microvascular decompression surgery for my patients who have previously undergone an MVD operation and were noted to have convincingly compressive vascular loop during the initial operation. These patients usually have a period of pain freedom after which they have recurrent pain. Their recurrent pain is very typical of their original trigeminal neuralgia. These patients are typically younger and they are looking for procedures that could be sort of safe later in their lives in terms of a percutaneous procedure or radiosurgery, and therefore a repeat microvascular decompression surgery is very reasonable and most likely has a more durable effect. These repeat operations do carry slightly higher risk and due to the scar, there are lengthier and they require more patience with sharp dissection techniques. Let's go ahead and review the case of a patient of mine, who is a 55 year old male who has been suffering from recurrent V2 and V3 right-sided trigeminal neuralgia, and he underwent an MVD operation about 4 years ago. And per his op report was noted to have a convincingly compressive vessel along the shoulder of the nerve. So he subsequently underwent a repeat right-sided retromastoid operation. You can see before surgery on the right-side, there's evidence of the Teflon patch and implant and potentially some other post-operative changes in this area. However, it is unclear where the vascular compression could be. Here is reopening of his previous linear incision. You can see the patient is placed in a lateral position and the shoulder is moved out of the way to assure adequate working zone around the operative area. A lumbar puncture is performed to relieve some CSF. Here is the previous reopening the cranioplasty has removed. You can see that tenacious amount of scar along the epidural space. Subsequently the previous dural opening was reopened and you can see the cerebellum. Sharp dissection techniques were used to be able to expose the nerve. Here's the seven and eight cranial nerves. Here's the piece of Teflon overlying the nerve, and here is our attempt to be able to use in sharp dissection techniques, mobilize as much of the Teflon safely away from the nerve as possible. Here as you can see a vascular loop along the superior aspect of the Teflon that is being mobilized away. We continue mobilizing the Teflon in this case that is very much adhering into the nerve. Significant manipulation of the nerve should be avoided, and if there is some Teflon very adherent, it should be left on the nerve. In this circumstance, I suspected that the Teflon itself could have been the cause of recurrent pain in this area. As you can see, I was able to eventually move most of the Teflon away and be able to inspect the nerve just underneath and above the area of the Teflon implant. I was actually unable to find a compressive vessel. However, most likely, the Teflon itself was the cause of the pain through inflammation, although this is a controversial topic in management of trigeminal neuralgia. For this particular patient, removal of the Teflon and bringing the nerve to its physiological posture and preventing the Teflon to potentially cause compression and pain was effective and caused relieve of the pain of this patient, and this patient has remained pain-free for the past three years. Thank you.

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