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Microvascular decompression for trigeminal neuralgia using the ‘Stitched Sling Retraction’ technique in recurrent cases after previous microvascular decompression

  • Clinical Article - Neurosurgical Techniques
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Abstract

Background

Microvascular decompression is a well-known therapeutic option for trigeminal neuralgia. It is considered safe and effective, and is the surgical treatment of choice for the malady. However, there is no standard technique for it and different authors have proposed different techniques of performing it. In this study, we observe the clinical results of the so-called ‘stitched sling retraction’ technique for recurrent cases of trigeminal neuralgia.

Methods

Twelve consecutive patients with recurrent trigeminal neuralgia after previous microvascular decompression(s) were admitted to our institution form February 2009 to February 2011 and underwent microvascular decompression of the trigeminal nerve using the ‘stitched sling retraction’ technique. In this technique, the offending loop of the superior cerebellar artery is retracted from the nerve and, using a silk thread loop around it, is suspended to the adjacent tentorium.

Results

All patients experienced pain resolution during the immediate post-operative period or within the first 6 months after surgery. They were followed for 24 to 38 months. No recurrence occurred.

Conclusions

The ‘stitched sling retraction’ technique shows promising preliminary results in recurrent cases of trigeminal neuralgia after previous microvascular decompression(s). Since it is a ‘transposing’ technique, it might be associated with less recurrence rates (due to resuming of the neurovascular conflict) than the classic interposing technique, which uses a prosthesis between the offending vessel and the trigeminal nerve.

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Acknowledgments

The authors wish to thank Mrs. Mahnaz Zamani for the artwork.

Conflict of interests

None.

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Authors and Affiliations

  1. Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Ali Tayebi Meybodi, Zohreh Habibi, Mojtaba Miri & Seyed Ali Fakhr Tabatabaie

Authors
  1. Ali Tayebi Meybodi
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  2. Zohreh Habibi
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  3. Mojtaba Miri
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  4. Seyed Ali Fakhr Tabatabaie
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Corresponding author

Correspondence to Ali Tayebi Meybodi.

Additional information

Comment

In this interesting article the authors describe a relatively novel approach for recurrent trigeminal neuralgia (TGN) with arterial compression following previous microvascular decompression(MVD).

The issue of recurrent TGN following MVD is a complex issue; the options in recurrent TGN include medical treatment, percutaneous procedures, stereotatic radiosurgery (SRS) or a re-do of the MVD.

The most important factor in TGN recurrence following MVD is possibly the primary procedure itself. To minimize recurrence, it is necessary to open all the arachnoid at the level of the upper complex of the cerebello-pontine angle (CPA), fully mobilize the offending vessels and fully visualize the V nerve (up to the Meckel cave). Preservation of the petrosal vein when possible is advisable.

In cases of recurrence, the treatment algorithm TGN depends on several different factors: patient age/medical condition, evidence of neurovascular conflict, nature of the conflict (arteria/venous), clinical severity of the recurrence (is it medically responsive ?) and patients' choice.

In our institution we tend to offer percutaneous procedures/SRS when a neurovascular conflict is not present on MRI, in patients in the seventh decade of life or over and in patients with significant medical problems.

Re-do of MVD is limited to patients with clear evidence of neurovascular conflict with medically resistant TGN. Several cases of recurrence are associated with venous compression (recanalization of veins) and a minority is associated with persistent arterial compression.

At times the adhesion between the artery and the spacer used in the original decompression complicate the procedure.

The technique described in this article is a suitable option when a full mobilization of the artery is possible without damaging the surroundings structures.

The good result reported by this group (in recurrences) and a previous report on the sling transposition techniques in MVD for various indications suggest that this technique should be considered for primary procedure when technically possible in cases of arterial compression.

Jibril Osman Farah

Liverpool, UK

Neurosurg Focus. 2013 Sep;35(3)

A novel sling technique for microvascular decompression of a rare anomalous vertebral artery causing cervical radiculopathy.

Tandon A, Chandela S, Langer D, Sen C.

A "sling swing transposition" technique with pedicled dural flap for microvascular decompression in hemifacial spasm.

Ming KH, Yoshimine T, Taki T.

Neurosurgery. 2012 Sep;71(1 Suppl Operative):25–30

Use of the arachnoid membrane of the cerebellopontine angle to transpose the superior cerebellar artery in microvascular decompression for trigeminal neuralgia: technical note.

Skrap M, Tuniz F.

Neurosurgery. 2010 Mar;66(3 Suppl Operative):88–91

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Meybodi, A.T., Habibi, Z., Miri, M. et al. Microvascular decompression for trigeminal neuralgia using the ‘Stitched Sling Retraction’ technique in recurrent cases after previous microvascular decompression. Acta Neurochir 156, 1181–1187 (2014). https://doi.org/10.1007/s00701-014-2092-y

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