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3D Computer graphics simulation to obtain optimal surgical exposure during microvascular decompression of the glossopharyngeal nerve

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Abstract

The affected artery in glossopharyngeal neuralgia (GPN) is most often the posterior inferior cerebellar artery (PICA) from the caudal side or the anterior inferior cerebellar artery (AICA) from the rostral side. This technical report describes two representative cases of GPN, one with PICA as the affected artery and the other with AICA, and demonstrates the optimal approach for each affected artery. We used 3D computer graphics (3D CG) simulation to consider the ideal transposition of the affected artery in any position and approach. Subsequently, we performed microvascular decompression (MVD) surgery based on this simulation. For PICA, we used the transcondylar fossa approach in the lateral recumbent position, very close to the prone position, with the patient’s head tilted anteriorly for caudal transposition of PICA. In contrast, for AICA, we adopted a lateral suboccipital approach with opening of the lateral cerebellomedullary fissure, to visualize better the root entry zone of the glossopharyngeal nerve and to obtain a wide working space in the cerebellomedullary cistern, for rostral transposition of AICA. Both procedures were performed successfully. The best surgical approach for MVD in patients with GPN is contingent on the affected artery—PICA or AICA. 3D CG simulation provides tailored approach for MVD of the glossopharyngeal nerve, thereby ensuring optimal surgical exposure.

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Acknowledgments

We would like to thank Mrs. Sumiko Matsushima for her English language review.

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Authors and Affiliations

  1. Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan

    Tetsuya Hiraishi, Toshio Matsushima, Masatou Kawashima, Yukiko Nakahara, Yuichi Takahashi & Hiroshi Ito

  2. Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Japan

    Tetsuya Hiraishi, Makoto Oishi & Yukihiko Fujii

Authors
  1. Tetsuya Hiraishi
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  2. Toshio Matsushima
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  3. Masatou Kawashima
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  4. Yukiko Nakahara
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  5. Yuichi Takahashi
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  6. Hiroshi Ito
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  7. Makoto Oishi
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  8. Yukihiko Fujii
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Corresponding author

Correspondence to Toshio Matsushima.

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Comments

Paolo Ferroli, Milano, Italy

The authors used a 3D CG simulation to plan the ideal transposition of the offending vessel involved in the physiopathology of glossopharyngeal neuralgia in any position through different approaches. The 3D graphic simulation in the two exemplificative cases that are illustrated was useful to tailor the approach to the pathology and not vice versa. This finding contributes to emphasize the role of modern 3D-guided customized patient-specific approaches and represent the key message of the authors’ work. Simulation, in fact, was able to disclose the advantages of the far lateral approach for PICA conflicts and of retrosigmoid approach for AICA conflicts. Surgery confirmed 3D simulation findings and this seem to prove that the direction that the authors are following is the direction that the entire surgical community should embrace towards a future of “rightly” invasive surgery rather than “mininvasive” or classic neurosurgery. Both classic and mininvasive surgery has the limit of being a standard answer to different patient-specific questions. 3D graphic simulation paves the way to a patient-specific approach that can be different and 3D based even in the same disease as the authors showed in the case of glossopharyngeal neuralgia. Despite the limited conclusions that can be drawn from two exemplificative cases, the authors should be congratulated for having contributed the growing body of knowledge regarding 3D guided neurosurgery.

Steffen K. Rosahl, Erfurt, Germany

Glossopharyngeal neuralgia is a rather rare condition, and unfortunately, this report of two cases by Hiraishi et al. is not likely to attract much attention in the neurosurgical community. The author’s conclusion that approaches to the root zone of the glossopharyngeal nerve should be custom-tailored depending on the offending vessel—PICA or AICA—also does not come as a major surprise.

However, there is a lot more to learn from this article about the possibilities that virtual reality creates for almost all neurosurgical areas today and tomorrow. High-resolution, volumetric imaging has opened a path that will ultimately lead neurosurgical planning—as well as medical imaging as a whole—out of the restrictive valley of two-dimensional image presentation into a world that is much more natural to us: the world of three-dimensional space.

The task to mentally reconstruct and rotate 2D-images in order to reconstruct the tortuous course of vessels like the PICA is all but trivial. Hiraishi et al. show how the intelligent use of software will relieve us of this task. Just like the creation of 3D models helped them to devise the optimal surgical approach in microvascular decompression of the ninth nerve, freely rotatable “virtual operative fields” like theirs will serve similar purposes in planning and guiding approaches to most other lesions. The same 3D images will be injected into the ocular of the microscope and they will be superimposed on the real surgical field. The present article nicely demonstrates the power that this technology can already provide today.

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Hiraishi, T., Matsushima, T., Kawashima, M. et al. 3D Computer graphics simulation to obtain optimal surgical exposure during microvascular decompression of the glossopharyngeal nerve. Neurosurg Rev 36, 629–635 (2013). https://doi.org/10.1007/s10143-013-0479-5

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  • DOI: https://doi.org/10.1007/s10143-013-0479-5

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