Abstract
Background
Key hole surgery was recruited for MVD surgery since the maneuver is through the small space between the cerebellum and temporal/occipital bone. However, even small wounds can cause severe postoperative pain if there is significant tissue damage. Attention has been given to the size of the craniotomy rather than to the skin incision or soft tissues such as muscles.
Method
Suboccipital muscle dissection focusing on splitting the splenius capitis muscle was presented. The dura was reapproximated without additional dissection to harvest a fascia graft.
Conclusion
Muscle injury should be minimized to alleviate postoperative pain.
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Summary of ten key points
1. Preoperative evaluation of the mastoid emissary canal and development of mastoid air cells on CT are important for appropriate craniotomy.
2. By using a slight S-shaped incision, the lateral part of the skin can be reflected to make the operative field slightly shallower even if the subcutaneous fat is thick.
3. The semispinalis capitis muscle is innervated by the posterior ramus of the cervical nerve more caudally, and splitting and minimal dissection of this muscle in the suboccipital area should cause minimal atrophy or pain.
4. The oblique superior muscle is divided.
5. To perform the craniotomy needed for this operation, the muscles on the medial side should be dissected further, while the digastric groove can be preserved with the digastric muscle.
6. A rather small craniotomy and the addition of drilling to the medial edge of the sigmoid sinus are safer, minimizing the risk of laceration of the sigmoid sinus.
7. An L-shaped dural incision along the sigmoid sinus and caudal bone edge keeps the dural flap moist and protects the cerebellum.
8. Even when the vertebral artery is concerned, the maneuver can be performed through the same corridor.
9. The wet dura can be approximated with shoe string sutures, and usually, no fascial graft is needed.
10. When a patch graft is needed to close the dura, the tendon of the sternocleidomastoid muscle can be recruited from the skin flap.
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This article is part of the Topical Collection on Functional Neurosurgery - Movement disorders
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The video shows how to minimize muscle damage in detail (MOV 176210 kb).
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Kimura, T. How I do it: minimizing muscle damage in microvascular decompression for hemifacial spasm. Acta Neurochir 163, 1045–1048 (2021). https://doi.org/10.1007/s00701-021-04726-1
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DOI: https://doi.org/10.1007/s00701-021-04726-1