Trigeminal Neuralgia 2

Trigeminal Neuralgia: Current
Trends in Surgical Research

Reza Jarrahy, M.D.
Division of Skull Base Surgery
Cedars-Sinai Medical Center
Trigeminal Neuralgia Workshop

February 26, 2000
Cedars-Sinai Medical Center
Los Angeles, CA
Research Efforts in TN
• pharmacological research
• neurophysiological research
• clinical research
Clinical Research in TN
• two year effort at Cedars-Sinai Medical
Center
• goals: develop techniques that improve
surgical outcomes in patients
undergoing microvascular
decompression for TN
• prerequisites to introducing new
surgical techniques: the innovative
procedure must...
– … have a sound theoretical basis
– … be reproducible in a controlled setting
(animal laboratory)
– … represent an improvement over the
traditional therapy
procedure must...
(animal laboratory)
traditional therapy
• theory:
– in patients whose neuralgia is caused by
vascular compression of the root of the
trigeminal nerve, there is an anatomical
basis for the disease and the surgical
therapy
– in these patients, surgical success is
directly related to accurate visualization of
the involved anatomical structures
• theory:
– visualization of the posterior fossa with the
operating microscope (the traditional
surgical approach) is restricted due to the
limited capabilities of the instrument...
• theory:
– better images of the posterior fossa during
surgery leads to more comprehensive
identification of all nerve-vessel conflicts,
and therefore more complete repair
• theory:
– endoscopes (long, thin telescopes) are
ideally suited to imaging the trigeminal
nerve and surrounding blood vessels
during surgery for TN
• varying widths, angles of view
• full range of accessories (cameras, light sources,
recorders, processors, irrigation sheaths,
holding arms)
• hypothesis:
– better endoscopic images lead to improved
surgical outcomes...
procedure must...
(animal laboratory)
traditional therapy
• animal experimentation:
– allows for preliminary evaluation of the
effectiveness of the new procedure
– can be reliably reproduced to increase
familiarity with new instruments in a safe
and controlled setting
– provides a means for surgical training
before application in the operating room
• experimental model
– porcine and human skull base anatomy are
very similar
– anatomical relationships are also
analogous
– method
• 30 kg Hampshire-Yorkshire-Duroc swine
• general anesthesia
• left lateral decubitus position
• 2 cm retrosigmoid craniotomy
• incision of dura
• endoscopic exploration of posterior fossa
• identification of cranial nerves
– results
• visualization of cerebellum, lower cranial
nerves (CN IX-XI), acousticofacial bundle (CN
VII-VIII), and trigeminal nerve (CN V)
– results
• panoramic views with addition of angled
endoscopes
• impediments to visualization (e.g., petrous
apex) circumnavigated
– results
• impediments to visualization (e.g., petrous
apex) circumnavigated
– conclusion
• “The dynamic optical qualities of the endoscope should
allow for more careful navigation through the very
constrained cavities of the skull base, for more detailed
appreciation of critical surgical anatomy, and for more
thorough surgical intervention with fewer complications
due to better visualization.”
Jarrahy R, Young J, Berci G, Shahinian HK. Endoscopic skull base surgery II:
a new animal model for surgery of the posterior fossa. J Invest Surg 1999;13:1-6.
procedure must...
(animal laboratory)
traditional therapy
• clinical improvement attributable to a
new technique should be objectively
demonstrated prior to its widespread
acceptance
• posterior fossa endoscopy offers unique
opportunity in this regard:
– it can be used in conjunction with the
microscope to directly compare their
qualities
• endoscope-assisted mvd
– Magnan et al:
• combined endoscopic and microscopic techniques in
MVD for hemifacial spasm in 60 patients
• findings: “When the operating microscope was used
alone, the exact location of the offending vessel was
obvious in only 16 patients (28%). The endoscopic
procedure gave an additional 72% accuracy rate for the
diagnosis of vessel-nerve conflict…”
Magnan J et al, Hemifacial spasm: endoscopic vascular decompression. Otolaryngol

Head Neck Surg 1997;117(4):308-314.
– Magnan et al:
• “Over the past two years, [we] have combined
microsurgery and endoscopy to increase safety
and effectiveness in the… retrosigmoid
approach… In the future, an endoscopic
microvascular decompression seems to be a
possible approach.”
Magnan J et al, Surgical perspectives of endoscopy of the cerebellopontine angle.

Am J Otol 1994;15(3):366-370.
– Division of Skull Base Surgery
• objectives: to determine the efficacy of
endoscopy as an imaging modality in posterior
fossa vascular decompression relative to
microscopy
• design: case series (n = 20) with review of
medical records and intraoperative video
• interventions:
– microvascular decompression via retrosigmoid
craniotomy
– endoscopes used to conduct surveys of nerve-vessel
conflicts prior to microscopic intervention
– endoscopes also used to conduct final surveys of
posterior fossa to evaluate adequacy of microscopic
intervention
Site of No. of Detected by Detected by

Conflict Conflicts Microscope Endoscope
Root entry 31 25 (81%) 6 (19%)

zone
Cistern 14 9 (64%) 5 (36%)
Meckel’s cave 6 3 (50%) 3 (50%)


Root entry 31 25 (81%) 6 (19%)

zone
Cistern 14 9 (64%) 5 (36%)
Meckel’s cave 6 3 (50%) 3 (50%)


Root entry 31 25 (81%) 6 (19%)

zone
Cistern 14 9 (64%) 5 (36%)
Meckel’s cave 6 3 (50%) 3 (50%)


Root entry 31 25 (81%) 6 (19%)

zone
Cistern 14 9 (64%) 5 (36%)
Meckel’s cave 6 3 (50%) 3 (50%)

• results:
– endoscopes were able to identify nerve-vessel
conflicts that were not detected under microscopic
examination
– endoscopic images were particularly useful when
the nerve vessel conflicts were close to the opening
of Meckel’s cave, highlighting the flexibility of the
endoscope
• results:
– In 24% of patients, endoscopic survey following
microscopic placement of insulating Teflon pads
revealed areas of the nerves that were not adequately
decompressed
• conclusions:
– “In this series microscopic exploration of the surgical field
failed to detect roughly one-quarter of the offending
vessels. Likewise…, in one-quarter of cases what was
deemed to be an adequate decompression of the trigeminal
nerve under the microscope proved to be incomplete.
These observations emphasize the value of controlled
application of endoscopic techniques at the
cerebellopontine angle.”
Jarrahy R, Berci G, Shahinian HK. Endoscope-assisted microvascular decompression

of the trigeminal nerve. Accepted for publication in Otolaryngol Head Neck Surg
procedure must...
(animal laboratory)
traditional therapy
• fully endoscopic cranial nerve vascular
decompression surgery...
• fully endoscopic cranial nerve vascular
decompression surgery…
• “The strength of the endoscope in this setting is
its ability to impart to the surgeon more
comprehensive anatomical images than those
that are obtainable under the static
anteroposterior viewing capabilities of the
microscope… Improved visualization has
direct implications for surgical outcome.”
Jarrahy R, Mathiasen RA, Cha ST, Berci G, Shahinian HK. Fully endoscopic vascular
decompression of the trigeminal nerve. Accepted for publication in Arch Otolaryngol
Head Neck Surg

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Trigeminal Neuralgia: Current

Trends in Surgical Research

Trigeminal Neuralgia Workshop

Magnan J et al, Hemifacial spasm: endoscopic vascular decompression. Otolaryngol

Magnan J et al, Surgical perspectives of endoscopy of the cerebellopontine angle.

Site of No. of Detected by Detected by

Root entry 31 25 (81%) 6 (19%)

Cistern 14 9 (64%) 5 (36%)

Meckel’s cave 6 3 (50%) 3 (50%)

Site of No. of Detected by Detected by

Root entry 31 25 (81%) 6 (19%)

Cistern 14 9 (64%) 5 (36%)

Meckel’s cave 6 3 (50%) 3 (50%)

Site of No. of Detected by Detected by

Root entry 31 25 (81%) 6 (19%)

Cistern 14 9 (64%) 5 (36%)

Meckel’s cave 6 3 (50%) 3 (50%)

Site of No. of Detected by Detected by

Root entry 31 25 (81%) 6 (19%)

Cistern 14 9 (64%) 5 (36%)

Meckel’s cave 6 3 (50%) 3 (50%)

Jarrahy R, Berci G, Shahinian HK. Endoscope-assisted microvascular decompression

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