January 13, 2016
I'm not yet completely convinced that venous compression can be the only cause of trigeminal neuralgia or other cranial nerve hyperactivity syndromes. Let's review the case of this 50-year old female who presented with right-sided V2 and V3 trigeminal neuralgia. I would like to share with you my intra-operative findings in this case, preoperative MRI demonstrated the presence of some neurovascular structures around the area of the fifth cranial nerve, avascular loops more specifically appear to come in contact with a trigeminal nerve. A right-sided retro mustered craniotomy was completed. You can see the sigmoid sinus, the transverse sinus, their junction and incision of the dural along the dural sinuses. Here's the trigeminal nerve, you can see there's a large vein along the surface of the brain stem, just medial to the root entry zone of the nerve. Before I manipulate the nerve, I meticulously looked around the root entry zone of the nerve and found this artery, which I did not believe is the offending vessel. Furthermore you can see that there's no obvious offending vessel around the shoulder of the nerve or its axilla. You can see the spread Petra. So sinus was protected. Here's the vein on the surface of the brain stem. It appears to be an important vein. It is on the surface of the brain stem and therefore I do not believe it's sacrifice is warranted. I wasn't convinced that this was the cause of her trigeminal neuralgia. You can see the anatomy of the nerve. These veins can occasionally penetrate the nerve and you identified as intraneural veins mobilization of the vein appeared to be on safe. No discoloration of the vein was apparent. I performed a rhizotomy of the nerve using bipolar forceps by pinching the nerve gently specialing along it's inferior two thirds segments and a small piece of Teflon was placed to potentially relieve any neurovascular conflict between the vein and the nerve. I also attempted to return the nerve to its original physiological posture, as you can see in a moment. I do believe that if a venous compression is suspected and clearly arterial compression and neurovascular conflict excluded that the veins that are away from the surface of the brain stem can be safely sacrificed. However those veins that are on the surface of the wrist stem should be left alone. A rhizotomy is also warranted if the vein is not convincingly the source of the neurovascular conflict. This patient did have it good really far for pain after surgery, she do not have any numbness in any of the three distributions of the trigeminal nerve. She also has remained pain free and without any need to use neuropathic medications for about a year post operatively. Thank you.
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