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Venous Compression in TN: Strategies

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Here is another example of venous compression, potentially leading to trigeminal neuralgia. This is a 53-year-old male who presented with left-sided V2 and V3 trigeminal neuralgia. MRI examination was relatively unremarkable. You can see the location of the Petrous bone and the tentorium. Arachnoid bands were generously dissected. You can see the presence of multiple branches of this superior petrosal vein. One of them was sacrificed to allow careful inspection of the root entry zone of the trigeminal nerve. The seven and eighth cranial nerve complex is also evident, more superficially and inferiorly. A large vein was coursing just in the axilla of the nerve. This vein was gently immobilized. The shoulder of the nerve was also carefully inspected to exclude any branches of the superior cerebellar artery. You can see that most likely this vein is contiguous with the other vein located at the shoulder, since this vein is very intimately associated with the anterior surface of the brain stem. I do believe its sacrifice is risky. You cannot be safely immobilized, therefore, rhizotomy is the most reasonable strategy for controlling the pain. I use fine forceps to squeeze the nerve gently, as you will see in a moment. Here's the maneuver for the rhizotomy. Two or three squeezes are quite effective. Here is the final view of the operative corridor. Thank you.

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