Case Presentation: Trigeminal Neuralgia & Microvascular Decompression - Case 2
History and Physical
77-year-old right-handed gentleman, who experienced a sharp lancinating pain in the right frontal scalp region approximately four months prior to presentation. This pain would radiate from the right frontal scalp (V1 distribution) to the right brow, as well as right temporal region. He experienced anywhere from 6-7 of these pain episodes a day, each one lasting a couple of seconds. The intensity of the pain at onset was 10/10 on visual analog scale. There was no triggering stimuli that initiated these pain episodes.
On examination patient had no neurological deficit with exception of diminished sensitivity to cold, heat, or touch in this region.
He was diagnosed with typical trigeminal neuralgia.
Imaging
MRI scan of his brain demonstrated a vascular structure impinging and compressing the trigeminal nerve at root entry zone on the right.
Surgical Procedure
Having been correctly diagnosed with trigeminal neuralgia, and been refractory to proper medical management , he underwent microvascular decompression of trigeminal nerve by a right retrosigmoid craniectomy with intra-operative neurophysiological monitoring and stereotactic computer aided navigation.
Surgery
The planned bony exposure is marked in green (circle), and important vascular and bony landmarks (mastoid tip, transverse and sigmoid sinuses) are also marked.
View through Surgical Microscope
The planned bony exposure is marked in green (circle), and important vascular and bony landmarks (mastoid tip, transverse and sigmoid sinuses) are also marked.
Trigeminal nerve (TGN) is distorted and compressed by a pulsating superior cerebellar artery (SCA) and its. Brain stem is also marked (BS).
Superior cerebellar artery (SCA) has been mobilized from its constrained position at root entry zone of trigeminal nerve (TGN) and maintained separated by a teflon felt (TF) positioned between the two.
Trigeminal nerve (TGN) is completely separated from the pulsating superior cerebellar artery (SCA). Brain stem is seen in the bottom of the picture (BS)
Microvascular decompression (MVD) is completed by placing a teflon felt (TF) between the trigeminal nerve and the artery to ensure permanent separation of these structures.
Video of Operation
Video of the operation View through the surgical microscope
Hospital Course
Patient did well post-operatively with complete resolution of his facial pain. He was discharged from the hospital and returned to full function.
