Abstract
Background
Microvascular decompression (MVD) for glossopharyngeal neuralgia (GPN) is associated with high complication and incomplete cure rates because of its poor ability to visualize neurovascular conflicts.
Method
Fully endoscopic MVD for GPN was carried out through a retrosigmoid keyhole approach. Neurovascular conflicts were clearly demonstrated with a loop of the posterior inferior cerebellar artery (PICA) under a 30° endoscopic view, and no significant cerebellar retraction was observed. The loop of the PICA was safely decompressed and the perforators were preserved while offering an excellent operative view.
Conclusion
Endoscopic MVD is a reliable and minimally invasive method for GPN.
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References
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This study was approved by our institutional ethics committee, and informed consent was obtained from all patients.
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The authors declare that they have no conflict of interest.
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Summary of 10 key points
1. It is important to carry out preoperative neuroimaging evaluations of an offending artery; 3-T MRI may be reliable for GPN.
2. Assessment of the rhomboid lip type on MRI is mandatory.
3. Precise keyhole placement can be achieved at the junction of the transverse and sigmoid sinuses using the navigation system.
4. The pneumatic holding arm supports stable endoscopic surgery.
5. To obtain an excellent endoscopic view without retraction, adequate cerebellar relaxation by arachnoid dissection around the jugular foramen and CSF release are essential.
6. The use of an angled endoscope provides excellent visualization of structures around the REZ of the CN IX.
7. The use of a single-shaft instrument, including both the curved and malleable type, is needed to manipulate offending arteries through the space between the CN VIII and IX under an angled endoscopic view.
8. The use of Teflon pledgets allows the PICA loop as the offending artery to be inter-positioned without injuring the perforators.
9. Brainstem auditory-evoked potentials are continuously assessed.
10. To prevent postoperative CSF leakage, watertight dural closure and the packing of mastoid air cells using free fascial tissue is necessary.
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ESM 1
A 4-mm, 0° endoscope is inserted and advanced to the jugular foramen. After observing the jugular-type rhomboid lip (jRL), its posterior wall is sharply incised. Cerebrospinal fluid is drained from the cerebellomedullary cistern for relaxation of the cerebellum; thus, a brain retractor is not required. The CN IX, X, XI, VII, and VIII nerve bundles are identified behind the jRL. The jugular-type rhomboid lip adheres tightly to CN IX and CN X, and the space between CN VIII and CN IX, as well as that between CN IX and CN X, is opened sharply. Between CN VIII and CN IX, the REZ of CN IX is visualized under the 30° endoscope. The cranial loop of the posterior inferior cerebellar artery (PICA) compresses the REZ and cisternal portion of CN IX. The arrow indicates the neurovascular conflict on the REZ of the CN IX. Several perforators from the PICA loop are clearly visualized under the endoscopic view. Teflon pledgets are first inter-positioned at the REZ of the CN IX, and then another Teflon pledget is inserted along CN IX to decompress the cisternal portion of CN IX. JF, jugular foramen; jRL, jugular-type rhomboid lip; PICA, posterior inferior cerebellar artery; VI, abducens nerve; VII, facial nerve; VIII, vestibulocochlear nerve; IX, glossopharyngeal nerve; X, vagal nerve; XI, accessory nerve. (WMV 39326 kb).
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Komatsu, F., Kishore, K. & Sengupta, R. How I do it: endoscopic microvascular decompression for glossopharyngeal neuralgia. Acta Neurochir 162, 2833–2835 (2020). https://doi.org/10.1007/s00701-020-04456-w
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DOI: https://doi.org/10.1007/s00701-020-04456-w