Surgery for Hemifacial Spasm

  • Raymond F. SekulaJr.Email author
  • Jeffrey R. Balzer
  • Jesse D. Lawrence
  • Penny P. Liu


Hemifacial spasm (HFS) is characterized by unilateral spasms of the facial musculature beginning with the orbicularis oculi muscle and later spreading to other muscles of facial expression. While the disease is not life-threatening, it can profoundly reduce quality of life (Heuser et al., Eur J Neurol 14:335–340, 2007; Samii et al., Neurosurgery 50:712–718, 2002; Sekula et al., Muscle Nerve 48:770–776, 2013). One proposed etiology of disease is vascular compression of the centrally myelinated portion of the facial nerve. In this respect, microvascular decompression (MVD) is the only treatment of HFS that directly addresses etiology of the disease and achieves success in nearly 90 % of initial operations (Miller and Miller, Br J Neurosurg 26:438–444, 2012). The role of electrophysiology and magnetic resonance imaging (MRI) in these patients has become an indispensable tool in identifying surgical candidates.


Neuromonitoring Microvascular decompression Hemifacial spasm Electrophysiology Pathophysiology HFS Operative technique Facial nerve Complications MRI 

Supplementary material

Video 26.1

Setup for microvascular decompression including patient positioning, site marking, and insertion of earpiece for utilization of auditory brainstem-evoked potentials (MOV 223,316 kb)

Video 26.2

Surgeon performing microvascular decompression of the associated segment (AS) of the facial nerve by manipulating the posterior inferior cerebellar artery (PICA) (MP4 37,554 kb)


  1. 1.
    Heuser K, Kerty E, Eide PK, Cvancarova M, Dietrichs E. Microvascular decompression for hemifacial spasm: postoperative neurologic follow-up and evaluation of life quality. Eur J Neurol. 2007;14(3):335–40.CrossRefPubMedGoogle Scholar
  2. 2.
    Samii M, Günther T, Iaconetta G, Muehling M, Vorkapic P, Samii A. Microvascular decompression to treat hemifacial spasm: long-term results for a consecutive series of 143 patients. Neurosurgery. 2002;50(4):712–8. discussion 718–9.CrossRefPubMedGoogle Scholar
  3. 3.
    *Sekula RF Jr., Frederickson AM, Arnone GD, Quigley MR, Hallett M. Microvascular decompression for hemifacial spasm in patients >65 years of age: an analysis of outcomes and complications. Muscle Nerve. 2013;48(5):770–6.Google Scholar
  4. 4.
    *Miller LE, Miller VM. Safety and effectiveness of microvascular decompression for treatment of hemifacial spasm: a systematic review. Br J Neurosurg. 2012;26(4):438–44.Google Scholar
  5. 5.
    Jannetta P, Samii M. The cranial nerves. Berlin: Springer; 1981.Google Scholar
  6. 6.
    Babinski J. Hemipasme facial peripherique. Rev Neurol (Paris). 1905;13:443–50.Google Scholar
  7. 7.
    Stamey W, Jankovic J. The other Babinski sign in hemifacial spasm. Neurology. 2007;69(4):402–4.CrossRefPubMedGoogle Scholar
  8. 8.
    Auger RG, Whisnant JP. Hemifacial spasm in Rochester and Olmsted County, Minnesota, 1960 to 1984. Arch Neurol. 1990;47(11):1233–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Nilsen B, Le KD, Dietrichs E. Prevalence of hemifacial spasm in Oslo, Norway. Neurology. 2004;63(8):1532–3.CrossRefPubMedGoogle Scholar
  10. 10.
    Martí-Fàbregas J, Montero J, López-Villegas D, Quer M. Post-irradiation neuromyotonia in bilateral facial and trigeminal nerve distribution. Neurology. 1997;48(4):1107–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Valls-Sole J. Facial palsy, postparalytic facial syndrome, and hemifacial spasm. Mov Disord. 2002;17 Suppl 2:S49–52.CrossRefPubMedGoogle Scholar
  12. 12.
    Gardner WJ. Cross talk—the paradoxical transmission of a nerve impulse. Arch Neurol. 1966;14(2):149–56.CrossRefPubMedGoogle Scholar
  13. 13.
    Nielsen V. Pathophysiology of hemifacial spasm: II. Lateral spread of the supraorbital nerve reflex. Neurology. 1984;34(4):427–31.CrossRefPubMedGoogle Scholar
  14. 14.
    Ferguson JH. Hemifacial spasm and the facial nucleus. Ann Neurol. 1978;4(2):97–103.CrossRefPubMedGoogle Scholar
  15. 15.
    Moller A. Hemifacial spasm: ephaptic transmission or hyperexcitability of the facial motor nucleus? Exp Neurol. 1987;98(1):110–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Moller AR. Cranial nerve dysfunction syndromes: pathophysiology of microvascular compression. In: Barrow DL, editor. Neurosurgical Topics Book 13: surgery of cranial nerves of the posterior fossa. Park Ridge, IL: American Association of Neurologic Surgeons; 1993.Google Scholar
  17. 17.
    Esteban A, Molina-Negro P. Primary hemifacial spasm: a neurophysiological study. J Neurol Neurosurg Psychiatry. 1986;49(1):58–63.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Moller A, Jannetta P. Physiologic abnormalities in hemifacial spasm studied during microvascular decompression operations. Exp Neurol. 1986;93:584–600.CrossRefPubMedGoogle Scholar
  19. 19.
    Montero J, Junyent J, Calopa M, Povedano M, Valls-Sole J. Electrophysiological study of ephaptic axono-axonal responses in hemifacial spasm. Muscle Nerve. 2007;35(2):184–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Tomii M, Onoue H, Yasue M, Tokudome S, Abe T. Microscopic measurement of the facial nerve root exit zone from central glial myelin to peripheral Schwann cell myelin. J Neurosurg. 2003;99(1):121–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Campos-Benitez M, Kaufmann AM. Neurovascular compression findings in hemifacial spasm. J Neurosurg. 2008;109(3):416–20.CrossRefPubMedGoogle Scholar
  22. 22.
    *Hughes MA, Branstetter BF, Taylor CT, Fakhran S, Delfyett WT, Frederickson AM, Sekula RF Jr. MRI findings in patients with a history of failed prior microvascular decompression for hemifacial spasm: how to image and where to look. AJNR Am J Neuroradiol. 2015;36(4):768–73.Google Scholar
  23. 23.
    *Hughes M, Branstetter BF, Frederickson AM, Oskin JE, Yankevich U, Sekula RF. Imaging hemifacial spasm. Neurographics. 2015;5(1):2–8.Google Scholar
  24. 24.
    Nagatani T, Inao S, Suzuki Y, Yoshida J. Perforating branches from offending arteries in hemifacial spasm: anatomical correlation with vertebrobasilar configuration. J Neurol Neurosurg Psychiatry. 1999;67(1):73–7.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Sheth S, Branstetter 4th BF, Escott EJ. Appearance of normal cranial nerves on steady-state free precession MR images. Radiographics. 2009;29(4):1045–55.CrossRefPubMedGoogle Scholar
  26. 26.
    Borges A, Casselman J. Imaging the trigeminal nerve. Eur J Radiol. 2010;74(2):323–40.CrossRefPubMedGoogle Scholar
  27. 27.
    Zeng Q, Zhou Q, Liu Z, Li C, Ni S, Xue F. Preoperative detection of the neurovascular relationship in trigeminal neuralgia using three-dimensional fast imaging employing steady-state acquisition (FIESTA) and magnetic resonance angiography (MRA). J Clin Neurosci. 2013;20(1):107–11.CrossRefPubMedGoogle Scholar
  28. 28.
    Jo KW, Kong DS, Hong KS, Lee JA, Park K. Long-term prognostic factors for microvascular decompression for trigeminal neuralgia. J Clin Neurosci. 2013;20(3):440–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Garcia M, Naraghi R, Zumbrunn T, Rösch J, Hastreiter P, Dörfler A. High-resolution 3D-constructive interference in steady-state MR imaging and 3D time-of-flight MR angiography in neurovascular compression: a comparison between 3T and 1.5T. AJNR Am J Neuroradiol. 2012;33(7):1251–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Sekula Jr RF, Frederickson AM, Branstetter 4th BF, Oskin JE, Stevens DR, Zwagerman NT, Grandhi R, Hughes MA. Thin-slice T2 MRI imaging predicts vascular pathology in hemifacial spasm: a case–control study. Mov Disord. 2014;29(10):1299–303.CrossRefPubMedGoogle Scholar
  31. 31.
    Savino PJ, Sergott RC, Bosley TM, Schatz NJ. Hemifacial spasm treated with botulinum A toxin injection. Arch Ophthalmol. 1985;103(9):1305–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Kraft SP, Lang AE. Cranial dystonia, blepharospasm and hemifacial spasm: clinical features and treatment, including the use of botulinum toxin. CMAJ. 1988;139(9):837–44.PubMedPubMedCentralGoogle Scholar
  33. 33.
    *Barker FG II, Jannetta PJ, Bissonette DJ, Shields PT, Larkins MV, Jho HD. Microvascular decompression for hemifacial spasm. J Neurosurg. 1995;82(2):201–10.Google Scholar
  34. 34.
    Wang A, Jankovic J. Hemifacial spasm: clinical findings and treatment. Muscle Nerve. 1998;21(12):1740–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Sekula Jr RF, Bhatia S, Frederickson AM, Jannetta PJ, Quigley MR, Small GA, Breisinger R. Utility of intraoperative electromyography in microvascular decompression for hemifacial spasm: a meta-analysis. Neurosurg Focus. 2009;27(4):E10.CrossRefGoogle Scholar
  36. 36.
    *Thirumala P, Frederickson AM, Balzer J, Crammond D, Habeych ME, Chang YF, Sekula RF, Jr. Reduction in high-frequency hearing loss following technical modifications to microvascular decompression for hemifacial spasm. J Neurosurg. 2015;123(4):1059–64.Google Scholar
  37. 37.
    Thirumala PD, Carnovale G, Habeych ME, Crammond DJ, Balzer JR. Diagnostic accuracy of brainstem auditory evoked potentials during microvascular decompression. Neurology. 2014;83(19):1747–52.CrossRefPubMedGoogle Scholar
  38. 38.
    Thirumala PD. Hearing outcomes after loss of brainstem auditory evoked potentials during microvascular decompression. J Clin Neurosci. 2015;22(4):659–63.CrossRefPubMedGoogle Scholar
  39. 39.
    *Thirumala PD, Krishnaiah B, Habeych ME, Balzer JR, Crammond DJ. Clinical impact of residual lateral spread response after adequate microvascular decompression for hemifacial spasm: a retrospective analysis. Br J Neurosurg. 2015;29(6):818–22.Google Scholar
  40. 40.
    Moller AR, Jannetta PJ. On the origin of synkinesis in hemifacial spasm: results of intracranial recordings. J Neurosurg. 1984;61(3):569–76.CrossRefPubMedGoogle Scholar
  41. 41.
    Moller AR, Jannetta PJ. Hemifacial spasm: results of electrophysiologic recording during microvascular decompression operations. Neurology. 1985;35(7):969–74.CrossRefPubMedGoogle Scholar
  42. 42.
    Yamashita S, Kawaguchi T, Fukuda M, Watanabe M, Tanaka R, Kameyama S. Abnormal muscle response monitoring during microvascular decompression for hemifacial spasm. Acta Neurochir (Wien). 2005;147(9):933–7. discussion 937–8.CrossRefGoogle Scholar
  43. 43.
    Kong DS, Park K, Shin BG, Lee JA, Eum DO. Prognostic value of the lateral spread response for intraoperative electromyography monitoring of the facial musculature during microvascular decompression for hemifacial spasm. J Neurosurg. 2007;106(3):384–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Sindou MP. Microvascular decompression for primary hemifacial spasm. Importance of intraoperative neurophysiological monitoring. Acta Neurochir (Wien). 2005;147(10):1019–26. discussion 1026.CrossRefGoogle Scholar
  45. 45.
    Hatem J, Sindou M, Vial C. Intraoperative monitoring of facial EMG responses during microvascular decompression for hemifacial spasm. Prognostic value for long-term outcome: a study in a 33-patient series. Br J Neurosurg. 2001;15(6):496–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Kiya N, Bannur U, Yamauchi A, Yoshida K, Kato Y, Kanno T. Monitoring of facial evoked EMG for hemifacial spasm: a critical analysis of its prognostic value. Acta Neurochir (Wien). 2001;143(4):365–8.CrossRefGoogle Scholar
  47. 47.
    Joo WI, Lee KJ, Park HK, Chough CK, Rha HK. Prognostic value of intra-operative lateral spread response monitoring during microvascular decompression in patients with hemifacial spasm. J Clin Neurosci. 2008;15(12):1335–9.CrossRefPubMedGoogle Scholar
  48. 48.
    *Thirumala PD, Shah AC, Nikonow TN, Habeych ME, Balzer JR, Crammond DJ, et al. Microvascular decompression for hemifacial spasm: evaluating outcome prognosticators including the value of intraoperative lateral spread response monitoring and clinical characteristics in 293 patients. J Clin Neurophysiol. 2011;28(1):56–66.Google Scholar
  49. 49.
    Wang X, Thirumala PD, Shah A, Gardner P, Habeych M, Crammond D, Balzer J, Burkhart L, Horowitz M. Microvascular decompression for hemifacial spasm: focus on late reoperation. Neurosurg Rev. 2013;36(4):637–43. discussion 643–4.CrossRefPubMedGoogle Scholar
  50. 50.
    Wang X, Thirumala PD, Shah A, Gardner P, Habeych M, Crammond DJ, Balzer J, Horowitz M. Effect of previous botulinum neurotoxin treatment on microvascular decompression for hemifacial spasm. Neurosurg Focus. 2013;34(3):E3.CrossRefPubMedGoogle Scholar
  51. 51.
    House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2):146–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Huh R, Han IB, Moon JY, Chang JW, Chung SS. Microvascular decompression for hemifacial spasm: analyses of operative complications in 1582 consecutive patients. Surg Neurol. 2008;69(2):153–7. discussion 157.CrossRefPubMedGoogle Scholar
  53. 53.
    Polo G, Fischer C, Sindou MP, Marneffe V. Brainstem auditory evoked potential monitoring during microvascular decompression for hemifacial spasm: intraoperative brainstem auditory evoked potential changes and warning values to prevent hearing loss—prospective study in a consecutive series of 84 patients. Neurosurgery. 2004;54(1):97–104. discussion 104–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Currier RD, Dejong RN. The lateral medullary (Wallenberg’s) syndrome. Med Bull (Ann Arbor). 1962;28:106–13.Google Scholar
  55. 55.
    Currier R, Dejong R. Some comments on Wallenberg’s lateral medullary syndrome. Neurology. 1961;11:778–91.CrossRefPubMedGoogle Scholar
  56. 56.
    Lister JR, Rhoton Jr AL, Matsushima T, Peace DA. Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery. 1982;10(2):170–99.PubMedGoogle Scholar
  57. 57.
    Chadwick GM, Asher AL, Van Der Veer CA, Pollard RJ. Adverse effects of topical papaverine on auditory nerve function. Acta Neurochir (Wien). 2008;150(9):901–9. discussion 909.CrossRefGoogle Scholar
  58. 58.
    Kim B, Lee JA, Kong DS, Park K. Delayed facial palsy following microvascular decompression in hemifacial spasm. J Korean Neurosurg Soc. 1999;28:1332–6.Google Scholar
  59. 59.
    Kuroki A, Itagaki S, Nagai A. Delayed facial palsy after microvascular decompression for hemifacial spasm. Facial Nerve Res. 1991;11:147–50.Google Scholar
  60. 60.
    Lovely TJ, Getch CC, Jannetta PJ. Delayed facial weakness after microvascular decompression of cranial nerve VII. Surg Neurol. 1998;50(5):449–52.CrossRefPubMedGoogle Scholar
  61. 61.
    Rhee DJ, Kong DS, Park K, Lee JA. Frequency and prognosis of delayed facial palsy after microvascular decompression for hemifacial spasm. Acta Neurochir (Wien). 2006;148(8):839–43. discussion 843.CrossRefGoogle Scholar
  62. 62.
    Furukawa K, Sakoh M, Kumon Y, Teraoka M, Ohta S, Ohue S, Hatoh N, Ohnishi T. Delayed facial palsy after microvascular decompression for hemifacial spasm due to reactivation of varicella-zoster virus. No Shinkei Geka. 2003;31(8):899–902.PubMedGoogle Scholar
  63. 63.
    Ryu H, Yamamoto S, Miyamoto T. Atypical hemifacial spasm. Acta Neurochir (Wien). 1998;140(11):1173–6.CrossRefGoogle Scholar
  64. 64.
    Jannetta PJ. Surgical treatment of cranial rhizopathies. Paper presented at Congress of Neurological Surgeons, Montreal, QC, Canada; 1996.Google Scholar
  65. 65.
    Pollack IF, Pang D, Kocoshis S, Putnam P. Neurogenic dysphagia resulting from Chiari malformations. Neurosurgery. 1992;30(5):709–19.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Raymond F. SekulaJr.
    • 1
    Email author
  • Jeffrey R. Balzer
    • 1
  • Jesse D. Lawrence
    • 1
  • Penny P. Liu
    • 2
  1. 1.Department of Neurological Surgery, University of Pittsburgh Medical CenterUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Division of Neuroanesthesia, Department of AnesthesiologyTufts Medical CenterBostonUSA

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