Sample Report Trigeminal Nerve Decompression
Preoperative Diagnosis: Left trigeminal neuralgia.
Postoperative Diagnosis: Left trigeminal neuralgia.
Procedure Performed: Left retrosigmoid craniotomy, microvascular decompression of left trigeminal nerve and drilling of petrous bone with microscope.
Anesthesia: General endotracheal.
Indications/Consent: The patient is a 48-year-old female with left tic douloureux, most severe in the V1 and V2 distributions, and going on for at least three years. It has gotten to the point where she is not able to get this under control with Tegretol. The pain is severely limiting all of her activities. I discussed with her the many different approaches toward treatment of this, specifically the microvascular decompression, the radiofrequency rhizotomy, the balloon rhizotomy, as well as simple avulsion procedures. We discussed the risks of each of these, the potential recurrence rate of each of these being similar, at about 17%, the risks of stroke, coma, and death as well as cranial nerve abnormalities. This was discussed with the patient in detail and all of her questions were answered. After careful consideration, the patient has requested the following be performed.
Details of Procedure: The patient was taken to the operating room. After induction of general endotracheal anesthesia, a lumbar drain was placed. The patient was given mannitol. She was placed in the lateral decubitus position left side up and right side down. She is an obese woman. All pressure points were padded. An axillary roll was placed and her left shoulder was gently taped down to the side. The hair behind the left ear was shaved and the scalp was shaved and then prepped and draped in the usual septic fashion, and the skin was infiltrated with 1% lidocaine with epinephrine.
A linear, somewhat curved incision was made just posterior to the mastoid process itself, following a posterior groove, and this was opened further with Bovie electrocautery and a cerebellar retractor was placed. A bur hole was placed in the region of the asterion and this appeared to be bordering the transverse sinus. The craniotome was used to make a small bone flap and this required enlarging a little bit anterior to reach the sigmoid sinus. Once exposed, the dura was opened in a cruciate fashion.
The lumbar drain, unfortunately, was not draining adequately; therefore, the cisterna magna was opened using a #1 Penfield dissector and then a small hook and this drained CSF very nicely, which allowed excellent relaxation of the cerebellar hemisphere. It was of interest that at the superiormost portion of the cerebellar hemisphere at the junction with the tentorium there was a tremendous amount of adhesion and this required careful dissection with bipolar electrocautery to finally free this up and free up the number of small veins that drain directly in this region. Once this was accomplished, the retractor was placed.
The cerebellum was gently retracted from a more medial position, enabling us to go down directly to the region of the fifth nerve. The first thing that became apparent was that there was a very large bony protuberance from the petrous bone in the region of the trigeminal nerve. There were also very large veins. These were the superior petrosal veins. Two of these were taken, which enabled better exploration of the trigeminal nerve. There was also a vein underneath the nerve that was not taken.
The superior cerebellar artery was identified along with the bifurcation in the cranial and caudal branches, but these did not pass in the immediate vicinity of the trigeminal nerve. The nerve was explored at the exit point from the pons, and there was no evidence of any pontine artery or any aberrant vessels coming up against the nerve itself.
The drill with a diamond bur was then used to drill down the bony protuberance facing just anterior to the nerve itself. Once this was taken down, the bone eminence was waxed with bone wax. The nerve root was further explored on both sides and no more veins were taken. The retractor was removed. The cerebellar surface appeared to be intact. The wound was irrigated. The surface of the cerebellar hemisphere of the posterior fossa was irrigated copiously and carefully with sterile irrigation solution. There was no evidence of any bleeding.
The dura was closed with interrupted and running 4-0 Prolene. Two dural allografts were sutured into the dura and then with a Valsalva maneuver; there was no leakage of CSF at all. At this time fibrin glue was used over this area and another piece of AlloDerm was cut and placed over the entire exposed dural opening that had been coated with the fibrin glue. More fibrin glue was put over the outer surface and then the bone flap was replaced with three 5-hole Synthes plates. These were the 1.5 system using 4-mm screws. These held the bone graft in excellent position in the center of the opening and it held the AlloDerm graft in place. There was virtually no bleeding. No drain was placed.
The wound was closed in multiple layers using interrupted 0 Vicryl in the deep layers and also superficial layers and then staples were used to close the skin. Sterile dressing was applied. Needle and sponge counts were correct. Estimated blood loss approximately 75 to 100 cc. Replacement was that of crystalloid only. There were no complications. The patient was extubated, was moving all four extremities with no obvious cranial nerve abnormalities, and was taken to the recovery room in stable condition.
Postoperative Diagnosis: Left trigeminal neuralgia.
Procedure Performed: Left retrosigmoid craniotomy, microvascular decompression of left trigeminal nerve and drilling of petrous bone with microscope.
Anesthesia: General endotracheal.
Indications/Consent: The patient is a 48-year-old female with left tic douloureux, most severe in the V1 and V2 distributions, and going on for at least three years. It has gotten to the point where she is not able to get this under control with Tegretol. The pain is severely limiting all of her activities. I discussed with her the many different approaches toward treatment of this, specifically the microvascular decompression, the radiofrequency rhizotomy, the balloon rhizotomy, as well as simple avulsion procedures. We discussed the risks of each of these, the potential recurrence rate of each of these being similar, at about 17%, the risks of stroke, coma, and death as well as cranial nerve abnormalities. This was discussed with the patient in detail and all of her questions were answered. After careful consideration, the patient has requested the following be performed.
Details of Procedure: The patient was taken to the operating room. After induction of general endotracheal anesthesia, a lumbar drain was placed. The patient was given mannitol. She was placed in the lateral decubitus position left side up and right side down. She is an obese woman. All pressure points were padded. An axillary roll was placed and her left shoulder was gently taped down to the side. The hair behind the left ear was shaved and the scalp was shaved and then prepped and draped in the usual septic fashion, and the skin was infiltrated with 1% lidocaine with epinephrine.
A linear, somewhat curved incision was made just posterior to the mastoid process itself, following a posterior groove, and this was opened further with Bovie electrocautery and a cerebellar retractor was placed. A bur hole was placed in the region of the asterion and this appeared to be bordering the transverse sinus. The craniotome was used to make a small bone flap and this required enlarging a little bit anterior to reach the sigmoid sinus. Once exposed, the dura was opened in a cruciate fashion.
The lumbar drain, unfortunately, was not draining adequately; therefore, the cisterna magna was opened using a #1 Penfield dissector and then a small hook and this drained CSF very nicely, which allowed excellent relaxation of the cerebellar hemisphere. It was of interest that at the superiormost portion of the cerebellar hemisphere at the junction with the tentorium there was a tremendous amount of adhesion and this required careful dissection with bipolar electrocautery to finally free this up and free up the number of small veins that drain directly in this region. Once this was accomplished, the retractor was placed.
The cerebellum was gently retracted from a more medial position, enabling us to go down directly to the region of the fifth nerve. The first thing that became apparent was that there was a very large bony protuberance from the petrous bone in the region of the trigeminal nerve. There were also very large veins. These were the superior petrosal veins. Two of these were taken, which enabled better exploration of the trigeminal nerve. There was also a vein underneath the nerve that was not taken.
The superior cerebellar artery was identified along with the bifurcation in the cranial and caudal branches, but these did not pass in the immediate vicinity of the trigeminal nerve. The nerve was explored at the exit point from the pons, and there was no evidence of any pontine artery or any aberrant vessels coming up against the nerve itself.
The drill with a diamond bur was then used to drill down the bony protuberance facing just anterior to the nerve itself. Once this was taken down, the bone eminence was waxed with bone wax. The nerve root was further explored on both sides and no more veins were taken. The retractor was removed. The cerebellar surface appeared to be intact. The wound was irrigated. The surface of the cerebellar hemisphere of the posterior fossa was irrigated copiously and carefully with sterile irrigation solution. There was no evidence of any bleeding.
The dura was closed with interrupted and running 4-0 Prolene. Two dural allografts were sutured into the dura and then with a Valsalva maneuver; there was no leakage of CSF at all. At this time fibrin glue was used over this area and another piece of AlloDerm was cut and placed over the entire exposed dural opening that had been coated with the fibrin glue. More fibrin glue was put over the outer surface and then the bone flap was replaced with three 5-hole Synthes plates. These were the 1.5 system using 4-mm screws. These held the bone graft in excellent position in the center of the opening and it held the AlloDerm graft in place. There was virtually no bleeding. No drain was placed.
The wound was closed in multiple layers using interrupted 0 Vicryl in the deep layers and also superficial layers and then staples were used to close the skin. Sterile dressing was applied. Needle and sponge counts were correct. Estimated blood loss approximately 75 to 100 cc. Replacement was that of crystalloid only. There were no complications. The patient was extubated, was moving all four extremities with no obvious cranial nerve abnormalities, and was taken to the recovery room in stable condition.
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