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Postoperative complications of microvascular decompression for hemifacial spasm: lessons from experience of 2040 cases

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Abstract

Microvascular decompression (MVD) is an effective and safe treatment option that offers the prospect of definitive cure for hemifacial spasm (HFS). However, there are potential risks of complications for MVD associated with retromastoid suboccipital craniectomy (RmSOC) and cranial nerves in particular. The purpose of this study was to identify clinical characteristics of possible complications after MVD for HFS and to establish appropriate management concept of these complications. We retrospectively reviewed medical records of 2040 patients who underwent RmSOC with MVD for HFS at Samsung medical center between January 1998 and March 2013. Of 2040 patients, 2027 were followed (99.4 %). Of the 2027 patients, 1841 (90.8 %) exhibited complete relief or minimal symptoms, and 113 (5.6 %) reported improved spasm but had mild remnant symptoms. After operation, the most frequently developed complications were facial nerve palsy (8.19 %), followed by middle ear effusion (4.90 %) and hearing loss (3.63 %). There were two cases of supratentorial subdural hemorrhage, three cases of infarction. MVD was found to be safe and effective treatment for HFS, in consistent with previous reports. Some of the complications such as facial nerve palsy, middle ear effusion, and hearing loss are relatively common. However, they have mild clinical courses that are usually transient.

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The authors declare that they have no conflict of interest.

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    Authors and Affiliations

    1. Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Korea

      Min Ho Lee, Tae Keun Jee, Jeong Ah Lee & Kwan Park

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    1. Min Ho Lee
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    2. Tae Keun Jee
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    3. Jeong Ah Lee
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    4. Kwan Park
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    Correspondence to Kwan Park.

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    Comments

    Marc Sindou and Andrei Brinzeu, Lyon, France

    Authors report the postoperative complications that they observed after micro-vascular decompression (MVD) for hemifacial spasm (HFS), together with putative mechanisms. Results are impressive both in terms of number of patients treated and quality of outcome. Preoperative assessment of the patients, technical means engaged during surgery, and postoperative evaluation were most rigorous. Scope of types of complications is very similar to the ones encountered in literature and our personal practice. As regarding main complications, general consensus to reduce harmful consequences of MVD can be expressed as follows.

    Immediate facial palsies are often related to surgical insults, especially coagulation of—even the tiniest—vessels (vasa nervorum) located at the REZ; these are little propitious to recover. Also, neocompression of the nerve by the inserted material may be responsible; when suspected, early reoperation may be justified. Free-running EMG monitoring of the facial nerve might be of some help to provide warning signals of the nerve suffering in “delicate “ cases, especially when an atheromatous megadolicho-artery (predicted on imaging) is the conflict.

    Decrease in hearing is less prone to happen if trajectory to the ventro-caudal aspect of the facial REZ is infrafloccular without stretching of the eighth nerve. Most reliable warning of BEAP monitoring is an increase in latency of peak V approaching 1 ms. Release of retraction and rectification in trajectory generally obtains prompt reversibility. Loss of hearing can also be due to cochlear ischemia due to manipulation of the anterior superior cerebellar artery and/or its labyrinthine branch. Warning on BEAP is sudden decrease in amplitude of peak I. When vasospasm is observed, topical application of a few droplets of papaverine (10 % in saline) constantly reverses spasm within a minute or so. Because of the very acid pH of papaverine only, a few droplets should be applied. Regular warm saline irrigation is important to avoid drying of the (fragile) neural structures of the CPA. BEAP monitoring at least during the learning curve period, if not constantly, is of valuable practical help.

    CSF leakage may occur and lead to rhinorrhea and meningitis when mastoid air cells are widely opened. Closure of dura and occlusion of cells can be secured by using an aponevrotic patch and fat tissue, respectively. To avoid on-site harmful harvesting with risk of occipital nerve injury, small pieces of fascia lata and fat can be taken from the thigh.

    As shown by the authors, provided careful and meticulous surgical maneuvers are performed, MVD for HFS is the more so as justified as it is at present the sole curative treatment available.

    Min Ho Lee and Tae Keun Jee contributed equally to this work.

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    Lee, M.H., Jee, T.K., Lee, J.A. et al. Postoperative complications of microvascular decompression for hemifacial spasm: lessons from experience of 2040 cases. Neurosurg Rev 39, 151–158 (2016). https://doi.org/10.1007/s10143-015-0666-7

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    • DOI: https://doi.org/10.1007/s10143-015-0666-7

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